diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1023_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1023_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f60a0cc795bf0bf3f7a38f7a42436718462be92e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1023_en.txt
@@ -0,0 +1,5 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1029_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1029_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c28e9eda77ef500ad2de10f49172e18b3cb6c313
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1029_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1041_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1041_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0a624c9de480545e2757db2803a54c07c6ffb5e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1041_en.txt
@@ -0,0 +1,5 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1052_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1052_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d426149f7014e41bc23533bc5265b4da44ca2e8e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1052_en.txt
@@ -0,0 +1,2 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1083_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1083_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..478ab327d11c49a261ebecb42754ed1a485d3353
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1083_en.txt
@@ -0,0 +1,57 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1109_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1109_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bba50f8bf8311675145b8412aae1dce773cb4fb5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1109_en.txt
@@ -0,0 +1,3 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1117_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1117_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..116b763ee6024703556e5d4bc56b782db7d0a4df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1117_en.txt
@@ -0,0 +1 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1145_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1145_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..26a070cbf3c69b65955a6bc28bf397e083b2c714
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1145_en.txt
@@ -0,0 +1,16 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1158_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1158_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5ca09b824ca70238301dc2ff51fabcb21933b7ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1158_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1171_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1171_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea0401da7185819d95b356a2c44749f126242d61
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1171_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1198_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1198_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af2dffd12ce6a674ae2624defdc20b1134a8982e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1198_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1210_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1210_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a72c34287cbd708b506489d82fa7626e2ff2146d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1210_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1211_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1211_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3c606d3711b21b95a67c3021f18b2788e75965ea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1211_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1213_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1213_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b228ddfa8dbd0664b0eb05a884e61e706659101d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1213_en.txt
@@ -0,0 +1,4 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1232_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1232_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ddf855c88c97083753f93acc4efa91ad10de3f78
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1232_en.txt
@@ -0,0 +1,8 @@
+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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1244_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1244_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..011eb2b5de17bfa52038809629d41c1994290a56
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1244_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1247_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1247_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eaaaa04c373aac15f18241a36446160f334170ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1247_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1267_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1267_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..41497207c5c8d5676676e0746666708be1fd8526
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1267_en.txt
@@ -0,0 +1,6 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1268_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1268_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3a1ec4cae736c5657cccfd9f1f198425ed97771
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1268_en.txt
@@ -0,0 +1,6 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1276_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1276_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6796a96af84f8370a21db0843349df43a2321590
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1276_en.txt
@@ -0,0 +1,6 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1297_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1297_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e8f79b365951165a44f0af15b7f5e6c0819c656c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1297_en.txt
@@ -0,0 +1,6 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1299_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1299_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2cbf5d365891f045b743188ef9d0e61336c35df7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1299_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1318_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1318_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5821fc2195634c3b7db845dc37b531e4e4f727bd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1318_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1324_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1324_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2e8832dc950482c25b4e782615d9e33f90907760
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1324_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1327_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1327_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f830ce965a4254a82d9b6ba13da4fbe64c9aa4a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1327_en.txt
@@ -0,0 +1,8 @@
+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
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1355_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1355_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd1e3360280d96bbb16a7288b5d4d13d73301c05
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1355_en.txt
@@ -0,0 +1,10 @@
+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 [, ].
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1362_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1362_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1bb8f03f0c2fa2bc2f176afa6fdb8b002c34d10b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1362_en.txt
@@ -0,0 +1,7 @@
+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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1366_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1366_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f60fccda08330bf4230b9b3b55cb3e5d190169aa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1366_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1368_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1368_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..baab3d2a3a1b295a94ae47e53d7bb69ca3d243df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1368_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_140_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_140_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..418064ba00cb33edf216dce86e47e0bdd2134917
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_140_en.txt
@@ -0,0 +1,2 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1431_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1431_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd19e75e14acde90b63b0c763fd30f394fe06b75
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1431_en.txt
@@ -0,0 +1,9 @@
+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 (,)
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1450_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1450_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42f0eb055f8217cf3509a88d05d0fca70cfaa92b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1450_en.txt
@@ -0,0 +1 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1466_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1466_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..016b18156b14ec80ff63230db366f49ba77d28eb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1466_en.txt
@@ -0,0 +1,4 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1472_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1472_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ed1ab03792cc71c13518339d2a1b5a025c3fd206
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1472_en.txt
@@ -0,0 +1,9 @@
+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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1477_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1477_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9eb951111eed46680b66fc9e88d7043b153db818
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1477_en.txt
@@ -0,0 +1,7 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1486_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1486_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1d50344b31f4c512d1b3ef98b335558b813f9a8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1486_en.txt
@@ -0,0 +1 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1491_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1491_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..813bbb528b89f51467461863d51d5bf60d831b32
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1491_en.txt
@@ -0,0 +1,7 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1507_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1507_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b8e8304f9af35e747c6a65ada1548396f8703926
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1507_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1509_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1509_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..34d24fe134c888d35e1b6075a029d31a6f2baa7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1509_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1530_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1530_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5166a4c2b1031883db52752ecf1583d7631108eb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1530_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1560_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1560_en.txt
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index 0000000000000000000000000000000000000000..07a5881f43c8c1a2a5bc7aa89e6e13a333603bc3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1560_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1562_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1562_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eb5327fcd434c493fc5f19c5068f9c6e30888eff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1562_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1567_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1567_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..33422d268aef78829492279c3ba452349f3ac313
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1567_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1585_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1585_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..773d0b9710756410803b2b77a2ca42f4f4e726b9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1585_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1607_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1607_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..974ff294ee489049df845195de86c378ff936b10
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1607_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1609_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1609_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eb8c7f6f9bd936e861c32d16bb881a7b422454fe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1609_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1616_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1616_en.txt
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index 0000000000000000000000000000000000000000..b18ae867013ee889de9bdeb53eee892ca3f18668
--- /dev/null
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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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1639_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1639_en.txt
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index 0000000000000000000000000000000000000000..318326a11a4e8da29073f9978bc32f87c890b795
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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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1647_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1647_en.txt
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index 0000000000000000000000000000000000000000..2bae9d1186ee7472d716652cab5908c39b10f9e2
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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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1657_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1657_en.txt
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index 0000000000000000000000000000000000000000..4769c5234cca1f6b0b758b894f85f1f442433e2d
--- /dev/null
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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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1684_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1684_en.txt
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index 0000000000000000000000000000000000000000..2f47ed0fb8385967860868a0833d582552d5aac7
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@@ -0,0 +1,7 @@
+A 35-year-old female was referred to our department in October 2021 because of thyroid dysfunction for 2 months. Her past and family histories were unremarkable. In the local hospital, thyroid function tests demonstrated high levels of free tri-iodothyronine (FT3) 10.18 pmol/L (3.1–6.89 pmol/L), free thyroxine (FT4) 25.8 pmol/L (11–22 pmol/L), and thyroid-stimulating hormone (TSH) 8.6 mU/L (0.27–4.2 mIU/L). Thyroid ultrasound revealed a solid, slightly hyperechoic nodule in the left lobe of the thyroid (9.6 × 7.8 × 10.1 mm). Based on this funding, the patient was diagnosed with Graves’ disease and given methimazole (MMI, 5 mg bid). After 20 days, her thyroid function test was rechecked: FT3 was 7.97 pmol/L, FT4 was 19.8 pmol/L, and TSH was 10.49 mU/L. A local hospital suspected the patient had TSHoma. Further inquiries did not find a family history of thyroid dysfunction.
+On examination at our hospital, her body mass index (BMI) was 22.8 kg/m2, her blood pressure and heart rate were 116/79 mmHg and 105 bpm, respectively, and her body temperature was 37 °C. Physical examination showed a degree 2 enlarged thyroid gland with no oculopathy or symptoms of acromegaly (Supplementary Figure ).
+Endocrine function tests showed an elevated TSH level of 12.26 mU/L with high levels of FT3 8.99 pmol/L and FT4 19.78 pmol/L. Sex hormone-binding globulin (SHBG) was 93.3 nmol/L (34.3–147 nmol/L). Thyroglobulin antibody (TGAb) was 271.70 IU/mL (0–115 IU/mL), thyroid peroxidase antibody (TPOAb) was 455.91 IU/mL (0–5.61 IU/mL), and thyroid receptor antibody (TRAb) was negative . The α-subunit was not measured. After polyethylene glycol (PEG) precipitation, the TSH level was 9.1 to 3.48 mU/L, GH was 4.82 μg/L (0–8 μg/L), and IGF-1 insulin-like growth factor-1 (IGF-1) was 661.00 ng/mL (115–307 ng/mL, Table ). An oral glucose tolerance test (OGTT) showed that the GH level decreased from 4.82 to 2.65 μg/L (Supplementary Figure ). During a 24-h octreotide suppression test (0.1 mg subcutaneously every 4 hours during the first 12 h), TSH declined from 8.09 to 1.518 mIU/l, GH decreased from 4.31 to 0.24 mIU/l, and the suppression ratios of TSH and GH were 81.2 and 94.4%, respectively . Other endocrine hormone levels were within the normal range: adrenocorticotropic hormone (ACTH) was 35.86 ng/mL (7.2–63.3 ng/L), cortisol was 304.2 nmol/L (66–579.4 nmol/L), PRL was 19.03 ng/mL, luteinizing hormone (LH) was 50.83 mIU/mL (follicular phase 239–66 mIU/mL; mid-cycle 9.06–72.24 mIU/mL; luteal phase 0.90–9.33 mIU/mL; postmenopausal 10.39–64.57 mIU/mL), follicular stimulating hormone (FSH) was 15.15 mIU/mL (follicular phase 3.03–8.08 mIU/mL; mid-cycle 2.55–16.69 mIU/mL; luteal phase 1.38–5.47 mIU/mL; postmenopausal 26.72–133.41 mIU/ml), estradiol was 238.00 pg/mL (follicular phase 21–251 pg/mL; mid-cycle 38–649 pg/mL; luteal phase 21–312 pg/mL; postmenopausal < 10–144 pg/mL), Testo (testosterone) was 1.29 nmol/L (0.38–1.97 nmol/L), and dehydroepiandrosterone (DHEA) was 121.3 μg/dL (139.7–484.4 μg/dL). Renal and liver function was within the normal range. Due to a drug deficiency in our center, the T3 test and thyrotropin-releasing hormone (TRH) stimulation were not applicable. Mutations in the TSH receptor and thyroxine receptor-β (THR-β) genes were not found.
+Her initial brain magnetic resonance imaging (MRI) revealed a quasi-circular equal signal shadow in the sellar region and a pituitary macroadenoma (18 × 16 × 16 mm) adjacent to the siphon of the left internal carotid artery . The T2-weighted signal intensity was isointense. In addition, the Knosp and Hardy classifications of the pituitary tumor were grade 1 and 2, respectively. Additionally, the cavernous sinus invasion score (CSIS) was grade 1, the sphenoid sinus invasion score (SSIS) was grade 0, the suprasellar extension score (SSES) was grade 1, and the cumulative score was grade 2 . The visual field revealed a visual field defect in the left eye. In thyroid echography, enlarged thyroid and hyperechoic nodules in the left lobe of the thyroid (11 × 8.3 × 11 mm, TI-RADS class 3) were observed. An ultrasound-guided fine-needle biopsy of the thyroid nodules showed benign lesions.
+Based on these findings, this patient was finally diagnosed with TSH PitNET and acromegaly. After our multidisciplinary united team consultation, the patient was preoperatively treated with octreotide (OCT, 0.1 mg, s.c., tid). TSH, FT3, and FT4 levels decreased to the normal range in 5 days. Then, the pituitary mass was endoscopically removed via an endoscopic transsphenoidal resection. Surgical pathology confirmed a macroadenoma.
+Histologically, the tumor was composed of plurimorphic cells with a distinct cell border, abundant granulated cytoplasm, and round or oval nuclei. On light microscopy, histopathology revealed the plurihormonal adenoma with strong nuclear immunoreactivity with Pit-1 antibody . Immunohistochemistry revealed strong immunoreactivity for GH and diffuse positivity for TSH and PRL . The tumor had negative staining for ACTH, FSH, LH, and ER. In p53 staining, scattered p53-positive cells were observed . The Ki-67 index was < 1% . In GH and TSH immunohistochemical double staining, many GH cells and a minority of TSH cells were observed (Supplementary Figure B). Immunofluorescence double staining for GH and TSH positivity was found in different cell populations (Supplementary Figure A). In GH and PRL immunohistochemical and immunofluorescence double staining, GH was the most diffusely positive hormone, and PRL reactivity was scattered (Supplementary Figure C, D). Electron microscopy revealed that the tumor consisted of plurimorphous cells . Some adenoma cells (black arrow) were densely granulated. Secretory granules were spherical or ovoid and measured 300–450 nm. Many adenoma cells contained elongated or geometrically shaped secretory granules, suggesting crystallization within their substance, a phenomenon seen in densely granulated somatotropic adenomas. The thyrotropin cells (red arrow) had a predominantly spherical or ovoid nucleus, scattered lysosomes and mitochondria, prominent Golgi apparatus, and numerous secretory granules measuring 100 to 200 nm. The cell membrane was peripherally clustered with numerous small secretory granules that outlined the cell boundary.
+After surgery, TSH decreased slightly below the normal range (0.299 mIU/l), and FT3 and FT4 levels were normal at 2.75 pmol/L and 9.9 pmol/L, respectively. GH and IGF-1 levels were 0.16 μg/mL and 274 ng/mL 1 week after the surgery . Except for high TGAb and TPOAb levels, TSH, FT3, FT4, GH, and IGF-1 levels decreased to the normal range 1 month after surgery. The OGTT test successfully suppressed GH below 0.4 μg/mL (basal GH, 7.62 μg/mL; maximal suppression, 0.4 μg/mL, Supplementary Figure ). However, although no clinical symptoms of hyperthyroidism were observed in this patient, FT3 and FT4 levels increased, and TSH levels were slightly below the normal range 3 months after surgery . Considering previously consistently elevated TGAb, TPOAb, and TRAb levels and an enlarged thyroid nodule, the patient was suspected of having Hashimoto’s thyroiditis. Interestingly, her thyroid function normalized over 10 days without medical treatment . Four months after the surgery, her thyroid function showed increased TSH, TRAb, TPOAb, and TGAb levels and decreased FT4 levels. Hashimoto’s thyroiditis further destroyed the thyroid cells and led to hypothyroidism in this patient. Indeed, central hypothyroidism was also possible. Six months after the surgery, the patient was given levothyroxine sodium tablets (L-T4, 37.5 μg/day), and her FT4, TSH, and TRAb returned to the normal range . The MRI revealed no particular abnormalities after the surgery. The patient achieved basal clinical and biochemical remission during follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1690_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1690_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5d20a7d0beb8a156cf3c62736168a7fa76ad266f
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@@ -0,0 +1,3 @@
+Osteomas A 10- years old school-girl has been refered to the Department of Oral Surgery in University Dental Clinical Centre of Kosova of complaining for appearance of the formation in the upper lip which has been progresively grown in past three years . The anamnesis reported an asymptomatic increase of the mass in upper lip in previous 3 years. Clinical examination shows the 2 x1,5 cm firm, nodular well circumscribed and non-tender lesion present in the region corresponding frenulum of the upper lip which was clinically suspected to be as lipoma. The overlying mucosa was without physiological changes. No regional lymphadenopathy was not observed. No anamnestic features related to systemic disease were registered.
+The Surgery was performed in the operating theater regarding to the standard infection control guidelines for surgery using Chlorhexidine solution 1% for intra- and extraoral surgical field disinfection and covered with sterile surgical drapes. Appropriate local analgesia was secured using 4 ml of 2o/o Lidocaine with l:800,000 Adrenaline (Alkaloid, Skopje) for appropriate anesthesia of ramii alveolaris superior anterior and nervus nasopalatinus scarpae.
+The surgery was realized with intraoral approach. Total exision of the well encapsulated mass approximately 2 cm in size was done and macroscopy with no invasion on the adjacent structures , followed by suturing as shown in . Histopathology of the tumoral tissue shows Tumor tissue displaying cystic and ductal structures , Hematoxylin & Eosin, 2.5x) lined by keratinizing squamous , Hematoxylin & Eosin, 5x) and cuboidal Hematoxylin & Eosin, 5x) epithelium. The patient was examined one week later and suture has been removed. The follow-up examination one year later shows no signs of its recurrence . Considering the possibility of tumor recidivation, patient will be in routine control every 12 months in the next two years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1698_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1698_en.txt
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index 0000000000000000000000000000000000000000..91b5e42de6c2c32b6170d6ee549e534d7b8afd6b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1698_en.txt
@@ -0,0 +1,7 @@
+A 38-year-old woman from Hunan Province, China presented with stiffness of the left hip in abduction, flexion, and external rotation after falling from a 2-meter-tall tree on her left knee 1.5 mo prior.
+Pain and swelling of the left knee, and fixed abduction and flexion of the left hip occurred immediately after falling. Rather than going to the hospital, the patient applied a traditional Chinese medicine herbal ointment of unknown composition. The left knee improved within 2 wk but the left hip remained stiff, so she could only walk with the aid of a stick. Due to the lack of improvement in the left hip, an X-ray was performed at a local clinic at 1.5 mo after the fall, which showed dislocation of her left hip. She was subsequently transferred to our hospital.
+The patient had a free previous medical history.
+The patient experienced compensatory scoliosis to the left, and the pelvis was lower on the left side. The left hip showed elastic fixation in 40° of flexion, 45° of abduction, and 30° of external rotation . The pressure point was examined near the hip joint, and the range of motion of the hip was limited. The Trendelenburg test was positive. The patient could only walk with the aid of a stick and was not able to load any weight on her left leg. The neurovascular status of the left leg was good.
+Radiographs at admission revealed dislocation of the left hip and femoral head impaction fracture without any injury of the left knee . Computed tomography showed obturator hip dislocation. The femoral head shifted to the inferior and anterior side of the obturator foramen, with impaction fracture at the superolateral aspect of the left femoral head without associated fracture of the acetabulum .
+The treatment options for old unreduced obturator dislocation of the left hip and impaction fracture of the ipsilateral femoral head were discussed with the patient. She decided to undergo open reduction only, and refused further intervention such as bone grafting or total hip arthroplasty because of her low income, even though she was informed that the incidence of posttraumatic arthritis and avascular necrosis would be high with treatment by delayed reduction alone.
+The surgery was performed 3 d after admission. After general anesthesia, the patient was placed in the supine position on a radiolucent operating table and the left leg was prepared and draped freely. Open reduction for obturator hip dislocation was performed using the Smith-Peterson approach. Intraoperatively, the femoral head was locked with the superior ramus of the pubis and embedded in the pelvis, so a subtrochanteric Schanz screw parallel to the femoral neck was used as a joystick to help unlock and reduce the femoral head. The acetabulum was completely filled with fibrous tissue, which was separated and removed. After reduction, the anterosuperior aspect of the femoral head showed collapse and articular damage . The hip was completely stabilized without re-dislocation in a full passive range of motion. Intraoperative fluoroscopy was used to evaluate the concentric alignment of the left hip. The hip anterior capsule, subcutaneous tissue, and skin were sutured sequentially. The suction drain was removed 24 h after surgery. After surgery, 6-wk skin traction was applied and the patient was kept in bed for an additional 2 wk. Prophylactic cefazolin was used from 30 min before surgery to 24 h postoperatively. Oral rivaroxaban was applied for 6 wk to prevent deep venous thromboembolism. The patient started toe-touch weight-bearing with crutches 2 mo after surgery. Postoperative X-rays showed satisfactory reduction of the hip .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1712_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1712_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d0cf6e10420146ef682caef8294527ca1088d3b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1712_en.txt
@@ -0,0 +1,7 @@
+An 81-year-old woman, who had a history of resection of a benign eccrine spiradenoma from the parietal scalp 12 years earlier, presented with a large swelling on the same region that had been growing over the preceding 5 years without any neurological deficit. Radiological examinations demonstrated that the lesion was a single, large cystic mass invading bilateral parietal bones and attached to but not occluding the superior sagittal sinus (SSS) . Whole-body positron emission tomography revealed no lymph node or distant metastases.
+The lesion was excised along with surrounding scalp and bone, and detached from the SSS. The dura mater covering the SSS was electrocoagulated. Reconstruction of the removed skull and scalp was then performed using titanium mesh and a pedicled skin flap from the occipital region which was replaced by a skin graft from the femoral area . Histopathological examination revealed the features of low-grade eccrine SC. Two distinct cell types were observed, comprising eosinophilic cuticular cells surrounded by poroid cells with a high nuclear-cytoplasmic ratio forming palisading or solid nests, accompanied by glandular lumens and ducts. Overall cytoplasmic atypia, some mitotic figures and partial loss of the two-cell structures were also observed . Cytokeratin 7 was broadly expressed, and Ki-67 labeling index was approximately 30% . Close follow-up was continued considering the risk of recurrence.
+Thirty-three months after the first surgery, solid tumor was seen to have recurred in the SSS and a second resection was performed . The tumor was totally excised, again preserving the SSS, adjacent dura and pedicled scalp flap . Histopathological diagnosis was similar to the previous lesion, other than the loss of the large cyst formation. No adjuvant therapy was administered, in consideration of the lack of evidence of efficacy, the age of the patient, and a recent history of ischemic brainstem infarction prior to the second surgery.
+Twelve months after the second surgery, a heterogeneous contrast-enhancing mass was observed in the epidural region with extracranial extension pushing against the titanium mesh. The SSS was compressed but not occluded, and the scalp skin was about to rupture . No metastatic lesion was evident on whole-body examination.
+The third operation was performed with resection of the skin flap, titanium mesh, and surrounding bone edge. The tumor invading the SSS could not be resected due to marked bleeding. An artificial bone flap made from polyethylene was used for the cranioplasty instead of metallic material, which would reduce the scattered radiation dose to the surrounding tissue. Scalp reconstruction was performed with a new pedicled skin flap from the left temporal region . The histopathological diagnosis was compatible with the first lesion. Two months after the third surgery, the patient received 6 MV X-ray EBRT using simultaneous integrated boost (SIB) volumetric-modulated arc therapy (VMAT) with the prescribed dose of 50 Gy in 25 fractions to the planning target volume margin (residual gross tumor invading the SSS + 5 mm, tumor cavity + 3 mm) as well as SIB with 57.5 Gy to the residual gross tumor margin. The median dose to the gross tumor volume was 60.4 Gy. The residual tumor rapidly shrank and had vanished by 3 months after completion of the EBRT .
+Twenty months after the third surgery, the patient developed left hemiparesis and a recurrent tumor was observed with intracerebral extension arising from the SSS forming a cystic lesion . The patient concurrently developed rectal carcinoma with lower gastrointestinal bleeding. Palliative endoscopic partial resection of the cystic lesion was performed, followed by stereotactic radiotherapy using CyberKnife® (Accuray Incorporated, Sunnyvale, CA) with 42.2 Gy in 10 fractions to the margin of the residual cyst wall and the tumor involving the SSS . Histopathological examination demonstrated that the features of low-grade SC had been sustained .
+The patient was transferred to another hospital and died 7 months after the last treatment, 7 years after the first surgery, with no apparent swelling of the scalp.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1714_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1714_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e35acedef7db69aa47749df3a7b666bad3b4ef4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1714_en.txt
@@ -0,0 +1,3 @@
+This was a 30-year-old female who presented at the outpatient clinic with a three-month history of progressive low back pain and leg neuropathic pain. She reported paresthesia of both lower limbs predominantly on the right side reaching up to the inguinal regions. The paresthesia was more prominent at night, and it was refractory to medical therapy. She denied any weakness, bowel or bladder dysfunction, or upper limb affection. Her past history was unremarkable. She was born to non-consanguineous parents, and she had no family history of similar condition, related neurological diseases, or neoplasia. Her general physical examination was unremarkable. Her neurological examination revealed mild clasp-knife spasticity in both lower limbs (particularly on the right side), bilateral extensor plantar response, brisk knee and ankle reflexes, sensory level at L1 with involvement of the saddle-shaped area (for pin-prick sensations).
+The patient underwent lumbosacral magnetic resonance imaging (MRI) of the spine with contrast, and it revealed a T1 isointense, T2 hyperintense (A) intradural extramedullary lesion at the conus medullaris at L1 level with strong homogenous enhancement on contrast adminstration.
+The patient underwent surgical laminectomy at L1, and the tumor was completely removed successfully without any residual (B to G). Histopathological examination by the hematoxylin and eosin (H&E) and immunohistochemistry of the excised mass revealed clusters of epithelioid cells arranged in a Zellballen pattern and separated by prominent fibrovascular stroma. The cells were oval to polygonal with abundant granular cytoplasm and large nuclei. There were no mitotic figures or features of nuclear atypia. The histopathological features were suggestive of paraganglioma. The postoperative follow-up was uneventful. The patient recovered completely, and she is pain-free to date.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1728_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1728_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c81d74cb6c4afab124b1a123d928eeae15a206d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1728_en.txt
@@ -0,0 +1,15 @@
+An Italian Caucasian 28-year-old woman was transported by ambulance to the emergency room (ER) on 27 July 2019, due to sudden and progressive dyspnoea, epigastric pain, and palpitations occurring while she was at the beach. The patient denied relevant pathological medical history except for short-lasting episodes of palpitations. She was on no regular medication and denied substance abuse.
+Early medical examination in the ER revealed paleness, cold sweat, epistaxis, and signs of pulmonary oedema due to a new-onset atrial fibrillation with rapid ventricular response (170 b.p.m.); blood pressure (BP) was 230/110 mmHg and SpO2 was 96%.
+Blood tests revealed leucocytosis, hyperglycaemia (309 mg/dL—normal range 70–110 mg/dL) and troponin T elevation (151 ng/L—normal range 0–14 ng/L). Blood gas analysis showed metabolic acidosis. Electrocardiogram revealed ST-segment depression in the lower lateral leads. Transthoracic echocardiogram (TTE) was performed too, showing 33% left ventricular ejection fraction (LVEF) with diffuse akinesia.
+The patient was sedated, intubated and mechanically ventilated. Polypharmacological therapy, including amiodarone, bisoprolol, nitroglycerine, furosemide, ticagrelor, acetylsalicylic acid, heparin, ceftriaxone, and pantoprazole was started.
+The patient was subsequently transferred to a II level emergency department. At her arrival, she presented with anisocoria, BP was 220/100 mmHg, heart rate was 160, and SpO2 was 74%. Blood gas analysis showed persistent severe metabolic acidosis with elevated lactate levels (5.8 mmol/L—normal value <2 mmol/L). A new TTE was performed, showing 20–30% LVEF. Chest X-ray revealed bilateral symmetrical and diffuse alveolar opacities .
+Given the sustained hypertension (mean arterial pressure 140 mmHg), despite sedation and maximal pharmacological therapy, resulting in progressive haemodynamic impairment with low ejection fraction, severe pulmonary oedema, and metabolic acidosis, the patient underwent urgent venoarterial extracorporeal membrane oxygenation (VA ECMO) in the cath lab. Coronary angiography did not show any coronary artery stenosis. A percutaneous left ventricular assist device (IMPELLA) was implanted. Three endomyocardial biopsies were obtained, subsequently turning out to be negative for myocarditis but suggestive of catecholamine-induced cardiomyopathy. The patient was then admitted to the cardiothoracic intensive care unit.
+In the following day, she developed thrombocytopenia (platelet count of 33000 plt/mm3—normal range 150 000–450 000 plt/mm3) and acute kidney injury requiring renal replacement therapy (RRT).
+On 29 July, sedation was transiently stopped. Neurological evaluation revealed right hemiplegia. Cerebral computed tomography (CT) scan showed hypodense (ischaemic) bilateral parieto-occipital areas and a hypodense subcortical area in the left frontal lobe . Abdominal CT scan revealed a 5 cm tumour of the left adrenal gland compatible with pheochromocytoma .
+On 30 and 31 July, ECMO and IMPELLA were respectively removed, due to a gradually recovery of the LVEF. Hypertensive crisis and episodes of atrial fibrillation were treated with urapidil, esmolol, and amiodarone. CT scan was repeated confirming the previous findings.
+As it was not possible to determine urinary metanephrines due to the ongoing RRT, on 1 August, plasmatic catecholamines were dosed, showing increased adrenaline and noradrenaline levels and therefore confirming pheochromocytoma diagnosis.
+On 2 August, magnetic resonance imaging of the brain confirmed the presence of bilateral parieto-occipital ischaemic lesions of recent onset. Ischaemic lesions of the right cerebellum, right centrum semiovale and left frontal subcortical region where also found. Intense vasogenic oedema accompanied these lesions , thus suggesting the diagnosis of posterior reversible encephalopathy syndrome (PRES).
+On 5 August, the patient was transferred from the cardiothoracic intensive care unit to the Department of Shock and Trauma of the same hospital. Neurological evaluation showed persistence of the right hemiplegia. She was still sedated, intubated and mechanically ventilated. Sedation with sufentanil, propofol, and dexmedetomidine improved BP control. Moreover, antihypertensive therapy with doxazosin 16 mg/day and labetalol by continuous intravenous infusion was started, leading to rapid BP and heart rate control. Due to persistent oligo anuria, RRT was continued.
+The following days, haemodynamic stability was reached: labetalol infusion was stopped and doxazosin administration was reduced up to 4 mg × 2/day.
+On 13 August, left videolaparoscopic adrenalectomy was performed. Histological analysis confirmed the diagnosis of pheochromocytoma. The same day, doxazosin treatment was stopped. On 14 August, the patient was extubated. She was discharged from our department on 22 August. She was conscious; no residual focal deficit could be detected at neurological examination. She was breathing spontaneously. RRT had been stopped due to autonomous diuresis.
+On 25 August, she was discharged from hospital. TTE was repeated before discharge, revealing complete recovery of left ventricular systolic function (LVEF 58%). Grade I diastolic dysfunction persisted, as suggested by E/A reversal (ratio < 1.0).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_172_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_172_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..280a88b5651f9aaae30e6b113acc835bf1529cf6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_172_en.txt
@@ -0,0 +1,3 @@
+A 68-year-old Asian man with no smoking history was diagnosed with right lower lobe lung adenocarcinoma with multiple osseous metastases but without brain metastasis in October 2014 when he presented with severe back pain. Molecular study of a tissue biopsy revealed EGFR mutation L858R, sensitive to EGFR TKIs. Treatment with gefitinib, a first-generation TKI, was initiated in November 2014. The patient tolerated therapy well and exhibited an excellent clinical response until November 2015 when he started to experience progressive worsening of lower back pain and bilateral lower extremity weakness. Imaging studies demonstrated disease progression, and thus re-biopsy of the right lower lobe lesion was performed to search for a T790M mutation, the most common molecular abnormality responsible for resistance to targeted therapy. Somewhat surprisingly, biopsy sample mutation studies again demonstrated EGFR L858R but without a T790M mutation. The patient declined systemic cytotoxic chemotherapy and palliative radiation to the lumbar spine metastasis, but continued with gefitinib.
+The patient transferred his care to our center at the end of January 2016. Unfortunately, he continued to deteriorate clinically and developed intractable lower back pain and bilateral lower extremity weakness, but no incontinence. Repeat magnetic resonance imaging (MRI) of the spine showed metastases at multiple levels involving the thoracic, lumbar, and sacral spines without compromise of the central canal or compression of the spinal nerve roots. The patient received urgent palliative radiation of 35 Gy in 14 fractions from T7-S2 spine, demonstrating a favorable symptomatic response. The patient was subsequently hospitalized for persistent confusion, generalized fatigue, anorexia, and failure to thrive. Neurological examination revealed mental status changes, but no focal neurological deficits. MRI of the brain demonstrated extensive leptomeningeal carcinomatosis , which was believed to be the cause of his symptomatology. In view of the previous failed attempt to identify a T790M mutation via tissue biopsy, a liquid biopsy was undertaken which revealed an EGFR T790M mutation. Osimertinib 80 mg p.o. daily was initiated despite lack of solid clinical evidence for the utility of this agent in LM.
+The patient responded rapidly, displayed substantial clinical improvement within 2 weeks of starting therapy, and became symptom-free after 3 months of treatment. Six months after initiation of osimertinib, repeat MRI of the brain revealed marked reduction of LM . Unfortunately, the patient developed hearing loss, confusion, and short-term memory loss approximately 1 year later in February 2017. Computerized tomography of the abdomen showed a few enlarged retroperitoneal lymph nodes, consistent with metastasis. MRI of the brain demonstrated progression of LM involving the cerebellar vermis, right occipital lobe as well as bilateral temporal and parietal lobes. The patient declined further systemic chemotherapy and expired after a short time interval.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_174_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_174_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..db1f36b06fdd41014195011f429db82c88fd84ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_174_en.txt
@@ -0,0 +1 @@
+An otherwise healthy 3 years and 10 months-old, 99 cm, 14 kg Hispanic boy presented to our Emergency Department after multiple visits to other facilities during the same week with a chief complaint of abdominal pain. The pain was described as postprandial and crampy, and the child’s mother endorsed his aversion to fatty foods and carbonated beverages. She denied emesis, jaundice, icterus, pruritus, or symptoms of altered mental status. Physical examination was unremarkable. Laboratory studies showed only borderline elevated total bilirubin. A plain abdominal x-ray was obtained, which revealed a radiodense mass in the right upper quadrant . The patient was diagnosed with calcified gallstone. This was confirmed with an abdominal ultrasound, which further showed that the 1.2 × 0.8 × 0.7 cm stone was impacted in the neck of the gallbladder . Elective cholecystectomy was performed using the standard four-port laparoscopic technique, with the finding of a large pigmented stone in the gallbladder neck.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1754_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1754_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c252f5c578327094bdaf211eaf891458cbe72f34
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1754_en.txt
@@ -0,0 +1 @@
+A 60-year-old woman with systemic lupus erythematosus (SLE) and epilepsy experienced gradual anhedonia over 2 weeks and insomnia for 3 days without any discernable psychological causes. She had two episodes of repetitive neuropsychiatric SLE (NPSLE) in the past, which required methylprednisolone pulse therapy 12 years ago and 2.5 years ago (7 months and 2 months of hospitalization, respectively). During her first hospitalization, she was diagnosed with epilepsy. She had been managing both her SLE and epilepsy well for years with prednisolone 3 mg/day, azathioprine 50 mg/day, hydroxychloroquine 200 mg/day, valproate 500 mg/day, and perampanel 6 mg/day. Although she had gone shopping with her family the day before admission, her consciousness deteriorated abruptly, and she was transferred to a university hospital. At the emergency department, her Glasgow Coma Scale was E4V1M2. Her temperature was 38.6°C, and her blood pressure was 179/89 mmHg. Comprehensive examinations, including blood and cerebrospinal fluid analyses, cranial MRI, and culture examinations, revealed no significant findings. On day 2, the patient exhibited symptoms including stupor, mutism, staring, rigidity, and withdrawal. She remained in a semi-sitting position for long periods without reacting. Her consciousness deteriorated to E1V1M1, requiring a benzodiazepine challenge under EEG monitoring. The initial low-amplitude basic activity with rare α waves on EEG improved remarkably to 40–60 μV α waves promptly after diazepam was administered intravenously , and her status improved to E4V5M6. Although she relapsed on day 3, a second benzodiazepine challenge restored her from E1V1M1 (stupor) to E4V5M6 within minutes and this was video recorded (Video ; Figure ). She was subsequently treated with lorazepam 1.5 mg/day orally. After confirming the need for ongoing lorazepam medication with the help of the video recording, she was discharged without recurrence on day 13. Her cognitive function was assessed with a score of 30 on the Mini-Mental State Examination (MMSE) during her outpatient visit on day 27, and there were no subsequent relapses.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_175_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_175_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..59968b590bb77ac72d15e76e6f9b5fcdcf3ffc07
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_175_en.txt
@@ -0,0 +1,2 @@
+A 32-year-old female had a fall from a two-wheeler and sustained an injury to the left knee. She presented to us with knee pain and an inability to bear weight. She had diffuse pain over the knee with a contusion on the anterior knee. She had posterior tibial sag and the posterior drawer test was positive. The varus and valgus stress tests were comparable with the opposite knee. The range of movement was from 0° to 90° with further movement painful. The dial test was negative at 30° and 90°.
+The radiograph and the computed tomography scan were suggestive of posterior tibial rim fracture along with PCL avulsion fracture from the tibial insertion . The patient was planned for open reduction and fixation. The patient was operated on under regional anesthesia in a prone position with a tourniquet over the proximal thigh. A lazy S-shaped skin incision was placed over the popliteal fossa with a horizontal limb over the fossa and vertical limbs over the lateral distal femur and proximal medial tibia . The dissection was between the medial gastrocnemius and semimembranosus as suggested by Burke and Schaffer. Deep into this plane, the popliteus muscle was seen and elevated from the proximal tibia. The posterior capsule of the knee joint was identified along with the avulsed tibial fragment. The fragment was initially stabilized with a K wire . Then, four high tensile sutures (Fiber wire No. 2, Arthrex, Naples, Florida) were passed through the posterior capsule and PCL at their tibial insertion on the avulsed fragment . A knotless fixation was planned with two swivel lock PEEK anchors (4.9 mm, Arthrex, Naples, Florida). Two drill holes were made and the drill holes were tapped for the passage of anchors. The sutures that were passed through the capsule and PCL were then passed through the anchors, with two sets of sutures through each anchor. The anchor along with the sutures was threaded through the posterior tibial cortex with sutures in tension and the K wire was removed . The reduction was checked under the image and the tourniquet deflated. The wound was washed and closed in layers. A posterior knee plaster was applied with a proximal tibial posterior padding to prevent posterior sagging. The patient was started on isometric quadriceps exercises from day 1 and non-weight-bearing crutch walking was also started. At 2 weeks, the plaster was removed and sutures were also removed. A brace was applied with proximal leg PCL support and non-weight bearing was allowed along with isometric quadriceps and ankle range of movement exercises. At 4 weeks, partial weight bearing was allowed progressing to full weight bearing by 8 weeks. The patient was started on an open chain range of movement exercises of the knee and active straight leg rising. Night-time bracing was continued for 2 months. At 6-month and 1-year follow-up, the patient had no complaints and she achieved her full range of movement . There was no posterior tibial sag.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1762_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1762_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4436b30a8e7d2ec5f62a6be51016d463f62c45c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1762_en.txt
@@ -0,0 +1,3 @@
+A 29-year-old African-American male with a past medical history of advanced AIDS and non-compliance with medications was presented with acute onset of chest pain. The pain was associated with shortness of breath. Physical activity worsened the intensity of the pain. He denied any nausea, vomiting or diaphoresis. Physical examination was unremarkable. Laboratory work up on admission showed a troponin T level of 5.0 ng/ml (upper limit of normal = 0.10 ng/ml), white blood cell (WBC) count of 2.0 K/uL and eosinophil count 1.52 K/uL (upper limit of normal = 0.4 k/uL), hemoglobin level of 9 g/dL and platelets count of 250,000/μL and absolute CD4 count of 12/mm3. Renal, liver and clotting profiles were all normal. The electrocardiogram (EKG) initially showed T wave inversions in the anterior leads, which were not present on prior EKGs. The troponin T level rose to a peak of 35.8 ng/ml and a repeat EKG revealed changes consistent with inferior wall myocardial ischemia. The 2D echocardiogram revealed decreased ejection fraction estimated at 30–35% with no wall motion abnormalities. Workup for hypercoagulable state including anticardiolipin antibodies, protein C, protein S, factor V Leiden and homocysteine levels tests were all negative.
+Of interest, throughout the year prior to admission, the percentage of eosinophil was noted to be persistently and abnormally high. In that same period, the patient was leukopenic with WBC count ranging between 0.8 K/ul and 3 K/ul. In addition, Immunoglobulin E level was found to be elevated at 9330 IU/ml (normal <100 IU/ml). Fluorescence in situ Hybridization (FISH) peripheral blood analysis was negative for FIP1L1-PDGFRB translocation. Bone marrow biopsy showed slightly hypercellular tri-lineage hematopoiesis with no evidence of any pathological/clonal hematologic disorder. The anti-neutrophil cytoplasm antibodies (ANCA), anti-nuclear antibodies (ANA), rheumatoid factor, myeloperoxidase antibody, proteinase 3 antibody, anti-cyclic citrullinated peptides (CCP) were negative. Serologic studies for infection, hepatitis, toxoplasmosis, autoimmune, and paraneoplastic disease were negative. Stool analysis and blood films were negative for parasites.
+On the basis of his elevated troponins and echocardiographic findings, he was initially managed for non-ST elevation myocardial infarction (NSTEMI) with aspirin, statin, clopidogrel, beta blockers and heparin. Angiography showed that our patient had a mild non-obstructive disease. A cardiac magnetic resonance imaging (CMR) was done [Figures and ] and it showed a pattern typical of eosinophilic endomyocarditis. He was started on daily methylprednisolone 1 mg/kg intravenously. On steroid treatment, the eosinophilic count decreased dramatically and his clinical state ameliorated rapidly. A repeat echocardiogram on day 10 revealed an increase in ejection fraction and systolic function confirming the therapeutic benefit of the steroid therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1772_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1772_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f15621984e6ea876e4a70b3d1203abe2a7e46daf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1772_en.txt
@@ -0,0 +1,5 @@
+An 80-year-old man was admitted to our institute for lower urinary tract symptoms (LUTS) in April 2018. International Prostate Symptom Score (IPSS) of the patient was evaluated as 30, while Quality of life (QoL) was scored as 5 points and Eastern Cooperative Oncology Group (ECOG) performance status was 0. Digital rectal examination revealed a grade III enlarged prostate, with palpable hard nodules on the surface obviously and the central sulcus disappeared. The value of serum prostate- specific antigen (PSA) was 145.6 ng/mL (normal value: 0–4 ng/mL), testosterone (T) was 354.5 ng/dl (normal value: 193–740 ng/dl), hemoglobin (Hb) was 119 g/l (normal value: 130–175 g/l), serum creatinine (SCr) was 67 μmol/l (normal range: 57–111 μmol/l). The pelvic enhanced magnetic resonance imaging (MRI) showed that a high possibility of prostate cancer, and the seminal vesicles and pelvic bones were invaded . Single-photon emission computed tomography (SPECT) indicated tumor had metastasized to multiple bones including the right ilium and the right sacroiliac joint . Transrectal ultrasound-guided biopsy revealed poorly differentiated AdPC after pathological examination, with a Gleason score of 9 (4 + 5), PSA (+), synaptophysin (-), chromogranin A (-) and Ki67 (15%) . The clinical stage was determined as stage IV (T3b N0 M1b) and this patient agreed to accept the ADT comprising bicalutamide (50 mg, once a day) combined with goserelin (10.8 mg, once every three months) since April 2018. The patient had a good response to the aforementioned therapy with the LUTS improved (IPSS 15, QoL 3) and serum PSA level decreased to 0.077 ng/mL (normal value: 0–4 ng/mL). Meanwhile, subsequent pelvic enhanced MRI and SPECT suggested the volume of the primary tumor and metastases was significantly reduced at the follow-up in June 2019.
+However, 6 months later, the patient gradually presented with gross hematuria, urination pain, anemia, tachycardia and pale lips, and thus was admitted to our institute again in December 2019. Hb decreased continuously from 115 g/l to 79 g/l in four days after admission, and showed no obvious improvement even after blood transfusions. At that point, serum PSA was 0.416 ng/mL (normal value: 0–4 ng/mL), T was 4.33 ng/dl (normal value: 193–740 ng/dl), SCr was 86 μmol/l. Although SPECT indicated no significant change in bone metastases , the pelvic enhanced MRI suggested that the primary prostate cancer tumor was enlarged with bladder invasion and the parailiac lymph nodes were involved . An emergency contrast-enhanced computed tomography (CT) of the chest and abdomen further suggested that the tumor had metastasized to thoracic vertebra without urinary obstruction and ureterohydronephrosis. To sum up, the disease has progressed to the more aggressive CRPC stage.
+In consideration of the relative stable PSA level and the rapid progression of the disease, we tested the serum NSE with a value of 170.8 ng/mL (normal value: 0–17 ng/mL). All these results indicated a possible formation of t-NEPC. Therefore, a secondary biopsy of the enlarged primary tumor was performed. The results of pathology showed small-cell neuroendocrine carcinoma . The immunohistochemical staining contained features of t-NEPC, which had an intensive Ki67 expression (70%), was negative for PSA staining and positive for synaptophysin and CD56 ( and ). Furthermore, a genetic testing of the blood sample showed germ-line mutations of RB1 and FOXA1 , both of which are tightly associated with the formation of t-NEPC.
+The effect of conservative treatments (eg, continuous bladder irrigation, fluid infusion and blood transfusion) for hematuria was limited. To control the bleeding of the primary tumor and relieve symptoms, the patient was treated with superselective prostate artery embolization (PAE) after multi-disciplinary consultations in January 2020. During the surgery, digital subtraction angiography (DSA) revealed extravasation of contrast medium from branches of right prostatic artery . Then, superselective PAE was performed to terminate the bleeding. Polyvinyl alcohol particles (PVA) were successfully injected into the right prostatic artery . We also found that a large amount of contrast medium overflowed at the terminal of the left prostatic artery . However, the left internal pudendal artery was selected to be embolized with infusion of PVA, gelatin sponge and spring coil due to the malformation of the left prostatic artery . Finally, the hematuria was controlled immediately with no obvious discomfort after operation.
+After analyzing all test results and conducting a comprehensive evaluation, we have realized that the patient was not suitable for platinum-based chemotherapy due to his weak constitution. For this reason, to further control the disease and relieve pain of the patient, palliative radiotherapy (intensity modulated radiation therapy, IMRT) to the pelvic tumor (60.2 Gy/2.15 Gy/28 fractions), the lymph drainage area (50.4 Gy/1.8Gy/28 fractions) and bone metastases (30Gy/3Gy/10 fractions) was performed in the Department of Tumor Radiotherapy of our institution in February 2020. The LUTS were relieved effectively after the palliative radiotherapy. The tumor biomarkers decreased after the superselective PAE and the radiation therapy (NSE from 170.8 ng/mL to 32 ng/mL; PSA from 0.416 ng/mL to 0.058 ng/mL). Moreover, enhanced MRI in May 2020 showed that the primary tumor was smaller than that in December 2019 . Unfortunately, the patient could not withstand the pain of the disease and then refused the follow-up treatments. He eventually died of cachexia and multiple organ failure at home on July 12, 2020.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1779_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1779_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fdd509793755f8be95fc63eb1000903a40b00641
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1779_en.txt
@@ -0,0 +1,3 @@
+A 53-year-old Chinese lady, with a history of hypertension, diabetes mellitus and chronic depression, presented with an 8 month duration of severe medial right knee pain associated with varus knee deformity. Pain was exacerbated on walking and standing. She was initially treated conservatively with a course of non-steroidal inflammatory drugs, intra-articular visco-supplementation, physiotherapy and weight loss regime. Despite a two-year trial of non-surgical therapy, she continued to experience a deterioration in her symptoms with limitation ofher functional status requiring a quadstick as a walking aid. Clinical examination revealed bilateral genu varum. Range of motion was limited to 0 to 110° with no fixed flexion deformity found bilaterally. Significantly, there was medial joint line tenderness and absence of lateral joint line and patellofemoral tenderness. Minimal effusion was found in the right knee. No limb length discrepancy or varus knee thrust was found. Bilateral weight-bearing knee and long limb radiographs were performed . Significant medial compartment radiographic osteoarthritic changes were noted in the right knee, corresponding to Kellgren-Lawrence grade 3 osteoarthritis. These changes included loss of medial joint space, varus knee deformity and the presence of marginal osteophytes. The femoral-tibial angle measured was 175° and the anatomical lateral distal femoral angle was 86°. We performed a diagnostic knee arthroscopy and then proceeded to an opening wedge high tibial osteotomy using the Tomofix plate after a failed two year trial of conservative therapy . Arthroscopic findings include medial compartment Outer bridge grade 4 lesion with degenerate radial tear of the posterior horn of the medial meniscus. The lateral compartment had no cartilage or meniscal tear. Intra-operative correction with the opening wedge osteotomy was guided with the use of radiographic imaging. Post-operatively, she was started on a rehabilitation programme, progressing to partial weight bearing at about 6 weeks.
+However, she continued to experience pain over the osteotomy site up till 6 months post operatively. Pain was exacerbated on standing and ambulation. Repeat radiographs showed minimal callus formation over previous osteotomy site . She was treated conservatively with continued protected weight bearing. However, her symptoms deteriorated and she developed a fix flexion deformity of her right knee. A computed tomogram performed 8 month postoperatively revealed non-union of the osteotomy site with hardware failure and loss of correction . Three proximal screws were broken and 1 screw had back-out. The proximal tibia was angulated laterally in varus and anteriorly increasing the tibial plateau slope. Inflammatory markers were not elevated.
+The patient subsequently underwent revision plating with autologous bone graft. The surgical approach was similar to the index surgery. Intra-operatively, findings were consistent with CT scan results. The screws were completely removed together with the Tomofix plate. Bone edges were freshened and the alignment was corrected under radiographic imaging guidance. Autologous cancellous iliac crest bone grafts were harvested and compacted into the osteotomy site. A proximal tibial locking plate was placed on the posteromedial aspect and locking screws were used to secure the fixation. The previous plate was medial. Intraoperative cultures sent were negative for infection. Post-operatively, the patient progressed from non-weight bearing to partial weight bearing at 3 months and full weight-bearing at 6 months post-operatively. She no longer experienced pain at the osteotomy site and repeat radiographs performed at 1 year post-operatively showed union . She was able to ambulate without any walking aids and no longer has any limitations in her daily activities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1781_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1781_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1aa438127bd30b32fbeafef5fe8e466cd95db622
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1781_en.txt
@@ -0,0 +1,5 @@
+A 46-year-old Chinese man complained of four hands 7 d after SCI. The two supernumerary hands were painless but complicated with actual limb pain.
+The patient suffered from tetraplegia caused by an accident on April 9, 2018. He underwent major surgery consisting of cervical posterior unilateral open-door expansive laminoplasty on 16 April 2018. Seven days after the accident, the patient felt the presence of an additional pair of hands that originated at the wrist joints and extended medially, with equal length to the paralyzed hands. He complained that he could feel but could not see the additional limbs. According to the patient’s description, the two supernumerary hands that were placed across his abdomen were not painful and persisted throughout the day . However, he felt a burning-like pain on both actual forearms, which measured 7 points (right side) and 5 points (left side) on the visual analogue scale. He experienced a more intense feeling of the existence and movement of the supernumerary hands, and stronger actual limb pain when he tried to control his limbs or someone touched his body.
+The patient had no significant medical history, psychiatric history, and history of substance misuse, except for type 2 diabetes mellitus, which was diagnosed 5 years previously and treated with regular injections of insulin.
+According to the American Spinal Injury Association (ASIA) standards for neurological classification of SCI, the patient was classified as having an incomplete lesion (ASIA impairment scale B) with a neurologic level at C4. The ASIA evaluation for neurological function was performed 18 d after injury, and the motor score for the upper and lower limbs was 0, and the total score for light touch and pin prick, for both sides, was 31. Bulbocavernosus reflex was positive.
+Computed tomography scan of the cervical spine on the day of the accident did not show vertebral body fracture or SCI. Three days later, magnetic resonance imaging showed an abnormal signal at C3-6 cervical spinal cord on T2-weighted magnetic resonance imaging . No concomitant brain injury was observed on head computed tomography scans, and all cognitive evaluations suggested no abnormalities. Follow-up cervical spine X-ray was performed .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1796_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1796_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42d8c4242ea7a9688263ae750edd79e52ac6cd1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1796_en.txt
@@ -0,0 +1,7 @@
+A 58-year-old female patient was admitted to our center because of low back pain without precipitating causes.
+Magnetic resonance imaging (MRI) showed a type A aortic dissection involving the aortic arch and extending to the ascending aorta up to the end of the left common iliac artery with an anomalous right subclavian artery (ARSA) .
+The patient underwent orthotopic heart transplantation (Bicaval technique) 28 mo ago for dilated cardiomyopathy with a left ventricular ejection fraction of 23%. Her immunosuppressive protocol including tacrolimus (0.5 mg, qod), mycophenolate mofetil (0.5 g, q12h), and prednisone (20 mg, bid). The donor was a 24-year-old man with no reported medical history.
+The patient also had hypertension and diabetes mellitus.
+Blood pressure on admission was 147/104 mmHg, and body mass index (BMI) was 30.1 kg/m2.
+The value of D-dimer was 0.84 mg/L, and G and GM tests were negative.
+On September 3, 2020, MRI showed a type A aortic dissection involving the aortic arch and extending to the ascending aorta up to the end of the left common iliac artery with an ARSA . The echocardiogram showed mild aortic valve insufficiency. The patient was diagnosed with type A aortic dissection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_17_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_17_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b28ca1687de6762c35e97306b7def33a7bd6bd5d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_17_en.txt
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+A 58-year-old Caucasian male presented with acute kidney injury (AKI) and proteinuria in June 2016. He had originally been diagnosed with melanoma along the right flank in the 1980s that was treated with wide excisional removal. He was followed closely for over three decades with no signs of metastatic disease until he was noted to have a mass near his prior melanoma excisional scar in summer 2014. A biopsy at that time revealed an epithelioid neoplasm with morphology and phenotype highly suggestive of melanoma that was positive for the BRAF V600E mutation. A Positron Emission Tomography/Computed Tomography (PET/CT) at that time showed numerous bilateral pulmonary nodules, and a subsequent right upper lobe wedge resection did confirm metastatic melanoma. In May 2015, he was initiated on ipilimumab (3 mg/kg) and nivolumab (1 mg/kg) every 3 weeks for management of his metastatic melanoma. His course was complicated by grade 3 dermatitis, colitis, and hepatitis, which were treated with courses of prednisone. Therapy was ultimately discontinued in October 2015, after receiving a total of three cycles intermittently, as a result of worsening hepatitis confirmed by liver biopsy. Because of persistent bilateral lung metastases and left pleural metastases, the patient was initiated on dabrafenib 150 mg twice daily and trametinib 2 mg twice daily in December 2015, which he remained on until his presentation to nephrology in June of 2016. He had no personal or family history of chronic kidney disease (CKD). He denied exposure to nephrotoxic agents. He was only taking amlodipine 10 mg for hypertension and had been receiving immunotherapy with dabrafenib and trametinib since December 2015. He denied tobacco use, illicit drug use, and toxic environmental exposure. His blood pressure was 172/89 mm/Hg and had 2+ edema bilaterally. The remainder of his physical examination was normal, and laboratory results indicated a creatinine level of 2.4 mg/dL with a urinary protein-to-creatinine ratio of 2 g/g. His urinalysis showed dysmorphic erythrocytes and red blood cell casts. Renal ultrasonography was normal. Serologic testing was negative for Antineutrophil cytoplasmic autoantibody (ANCA), PR-3, Myeloperoxidase (MPO), and Anti-glomerular basement membrane (anti-GBM) antibody. Complement levels were normal. A renal biopsy was performed in September of 2016 showing focal crescentic (2 of 15 glomeruli with cellular crescents), proliferative, and sclerosing glomerulonephritis with diffuse linear staining of glomerular capillary loops dominant for IgG (3+), IgA (2+), kappa (2+), and lambda (1+) minimal changes . Ultrastructural examination of three glomeruli demonstrated areas with open capillary loops and preserved foot processes. Other areas demonstrated diffuse effacement of foot processes with variable thickening and wrinkling of glomerular basement membranes. No immune complex disease or tubuloreticular structures were identified.
+Repeat anti-GBM testing remained negative, and the patient’s creatinine eventually rose to a peak of 3.8’mg/dL. He had no signs or symptoms of lung hemorrhage. Dabrafenib and trametinib were discontinued, and he was subsequently initiated on oral cyclophosphamide (2 mg/kg/day) and pulse intravenous methylprednisolone (1000 mg daily for 3 consecutive days) followed by 1 mg/kg/day of prednisone. Serum creatinine improved to 2.5 mg/dL, and the active urinary sediment resolved. Immunosuppression with cyclophosphamide was discontinued after 4 months of therapy, and he was weaned off prednisone by 6 months.
+The patient was off all immunotherapy for his malignancy, and his renal function remained relatively stable over the ensuing 12 months. By June 2018, a PET/CT of the chest showed evidence of metastatic melanoma to the left upper and medial lobes of the lung. The patient was placed back on nivolumab, which seemed to stabilize his oncologic disease. Unfortunately, 4 weeks after reinitiating nivolumab, his creatinine jumped from 2.8 to 5.8 mg/dL and home hemodialysis was initiated. The patient remains stable on home hemodialysis and was more recently taken off nivolumab and placed back on dabrafenib and trametinib for progressive metastatic pulmonary disease, which has led to significant symptom control.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1805_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1805_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c436c741876ad514043b4809a5f5386f3e260d81
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1805_en.txt
@@ -0,0 +1,11 @@
+A 52-year-old overweight white woman with hypertension and a 3-years history of chronic kidney disease stage II K-DOQI was referred to our Nephrology department for worsening renal function and resistant hypertension.
+Laboratory analysis showed a mild asymptomatic anemia, serum creatinine 1.9 mg/dl, with non-selective nephrotic proteinuria, Bence-Jones proteinuria, and extremely elevated serum kappa free light chains (FLC). Total calcemia was persistently normal and no bone lesions or full-blown nephrotic syndrome were present. Although coagulation profile was persistently not evaluable, probably due to the interfering monoclonal protein, bleeding time was in the normal range .
+A bone marrow biopsy revealed a complete metaplasia of clonal plasma cells with > 90% of clonal plasma cells and cytogenetic analysis (FISH) confirmed the diagnosis of micromolecular kappa MM with high-risk chromosomal abnormalities, R-ISS 3. All clonal plasma cells carried translocation t(14;16) on IGH/MAF gene. Complete immunoparesis was also noticed, while CRAB criteria were not reported.
+Patient showed increased NT-proBNP and high-sensitivity troponin (hs-cTnT) suggesting cardiac involvement. ECG showed tachycardia, first degree AV block and right axial deviation with right conduction delay. Unexpectedly, Congo-red stain on abdominal fat was negative for amyloid deposition. Transthoracic echocardiogram (TTE) revealed a 4.4 × 2.8 cm right atrial mass projecting through the tricuspid valve orifice, and a second 1.5 cm mass located at the right ventricle (RV) apex. Function and motility of both ventricles were preserved, and no sign of left ventricular (LV) hypertrophy was present (interventricular septum 10 mm, LV posterior wall 8 mm). No significant valvular regurgitations were identified.
+A computed tomography (CT) pulmonary angiogram showed RV thrombi, a large thrombus involving the pulmonary trunk and its two main right and left branches, as well as the segmental basal branches of the left lung. A partial thrombosis was described in the inferior vena cava from its intrahepatic tract to the origin of the renal veins (extended for about 7,5 cm) . Complete thrombosis of the left renal vein was also detected. Remarkably, the patient reported only mild asthenia, normal blood pressure, no dyspnea, and 99% oxygen saturation in room air. Since she was hemodynamically stable, unfractionated heparin was promptly started but, according to the thrombosis extension and the high risk of embolization, the patient was referred to cardiac surgery.
+Through a midline-sternotomy approach, a bilateral pulmonary thrombus was removed en-bloc with attached casts of the lobar branches across an incision in the pulmonary artery.
+Both masses from the right chambers were removed through the right atrium , while the thrombus into the inferior vena cava was too firmly attached to the vessel wall to be extracted. Cardiopulmonary bypass was terminated without inotropic supports. After surgery, patient restarted anticoagulation therapy with unfractionated heparin, subsequently substituted by warfarin.
+Meantime, a kidney biopsy was performed and light microscopy showed a moderately increased glomerular mesangial matrix without endo or extracapillary proliferation. No morphological lesions such as mesangial nodules or nodular glomerulosclerosis were recognized and none of the glomeruli were sclerotic. There was a grade 1 interstitial fibrosis (IF < 25%) with small areas of lymphocytic infiltrate. Also, rare inflammatory hyaline casts were found in the tubules in the absence of concurrent cast-nephropathy. Vascular compartment was practically normal according to patient’s age . Congo red staining was once again negative. Immunofluorescence (IF) on fresh frozen unfixed tissue was not contributory, with only weak (± or 1 +) staining for C3 and kappa FLC . Differently, IF on fixed tissue demonstrated an intense (3 +) linear staining for kappa FLC along the glomerular and tubular basement membranes, while IgG, lambda, and C3 staining were negative . Electron microscopy showed segmentary “ground pepper-like” deposits in the subendothelial space and the glomerular basement membranes (GBM). Similar deposits were observed along the tubular basement membrane (TBM). Extensive podocyte foot process effacement was seen with no sub-epithelial or mesangial electron-dense deposits . The final diagnosis was “kappa light chain deposition disease (LCDD)”.
+The patient fully recovered from surgery. A new TTE showed preserved function of both ventricles (EF 58%, TAPSE 20 mm, RV-RA gradient 25 mmHg) or major valvular disease. No new intracardiac masses were detected (video, Additional file 1).
+A 3-months follow-up CT showed the persistence of only a partially calcified thrombus in the right pulmonary artery’s distal branches, warfarin was continued.
+After 4 cycles of VTD protocol (Bortezomib, Thalidomide, Dexamethasone), the patient presented a very-good partial hematologic remission. Afterwards, she received autologous hematopoietic stem cell transplantation, with a stable complete hematologic remission and a progressive improvement of proteinuria and renal function .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1824_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1824_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..821caa0b9e32561a2f18d08b6c3d44db56c59e88
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1824_en.txt
@@ -0,0 +1,6 @@
+A 21-year-old male college student presented with no previous medical history or any drug intake. During a tackle at rugby practice, his forehead collided with the forehead of an opponent. Immediately after the collision remained asymptomatic and continued to play. However, several hours later of the same day, the patient started experiencing a mild headache with a gnawing pain all over the head. On the 2nd day, he took part in another rugby practice. However, during the rugby practice, experienced several episodes of transient left lower extremity paralysis reporting the event to the team trainer that suspected a concussion and immediately ordered him to stop playing. On the 3rd day of illness, he reported to the team doctor, who instructed him to visit our hospital.
+The patient did not have headache or posterior neck pain. His Glasgow coma scale score was 4-5-6 and he did not have pupillary abnormalities, nystagmus, eye movement disorder, tetraplegia, sensory disturbance, or balance disorder. The finger-nose test did not reveal any abnormality in the patient. Similarly, his blood tests showed no abnormalities. His electrocardiogram showed sinus rhythm and a pulse rate of 56/min.
+Computed tomography of the head did not show intracranial hemorrhage, but low absorptive changes were observed in the medial right frontal lobe. Magnetic resonance angiography (MRA) showed occlusion of the right ACA. T1-VISTA revealed an intramural hematoma (hyperintense intramural signal) that was consistent with the occluded artery [ and ]. Carotid artery echocardiography showed no abnormality. Based on the above-mentioned results, the patient was diagnosed with acute cerebral infarction due to traumatic ACA dissection.
+He was admitted urgently on the 3rd day of illness and underwent thorough neurological examination and blood pressure monitoring. Since the CVI was caused by dissection, there is a possibility that an aneurysm may form in the future that could cause a cerebral hemorrhage. Therefore, the patient was not administered antithrombotic therapy. After admission, the patient was closely monitored for blood pressure, which was not high enough to require antihypertensive medication. He remained clear and conscious with no recurrence of headache or lower extremity paralysis. It was decided to evaluate his vessel with a minimally invasive MRI. If the MRI showed cerebral infarct enlargement or aneurysm formation, a digital subtraction angiography (DSA) was scheduled for a more detailed evaluation. T1-VISTA was repeated on the 10th illness day; it did not show recanalization of the occluded artery and no aneurysm had formed . On the 11th day of illness, he was discharged home with a modified Rankin scale score of 0. After discharge, he underwent a follow-up MRI.
+T1-VISTA performed 1 month after the SRHI (i.e., on the 31st day of illness) showed recanalization of the occluded artery, but no aneurysmal changes were observed . In addition, the intramural hematoma had extended to the periphery of the artery. T1-VISTA performed 3 months after the SRHI (i.e., on the 82nd day of illness) showed maintained recanalization, but it did not show aneurysm formation or any other morphological abnormality of the artery. It also showed that the size of the intramural hematoma had decreased .
+Our plan was to perform DSA if there were any changes in vessel morphology over time and to consider the need for additional treatment. In this case, he was able to be followed the changes in vascular morphology using MRI and T1-VISTA. Based on the above clinical and radiological course, we decided that the patient would continue to be followed conservatively and that detailed examination with DSA was unnecessary.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1825_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1825_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5fb95469e503c0a04ff7a993e6f3faeb71074751
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1825_en.txt
@@ -0,0 +1,4 @@
+A 49-year-old Chinese female was admitted to the Department of Vascular Surgery on the 13th of May, 2013 presenting with right upper limb pain and swelling that had persisted for 10 days. Two years prior to admission, the patient was diagnosed with hyperthyroidism and persistent atrial fibrillation (AF). At admission, the patient had not been taking her anticoagulation or anti-platelet aggregation therapy for more than a year. Physical examination revealed a blood pressure of 98/63 mmHg and fast AF with ventricular beating rates in excess of 100 beats/min. Cardiac auscultation revealed variable intensity of first heart sound and a grade 2/6 tricuspid systolic murmur. Upon physical examination, the right upper limb was cold, pale and swollen, with positive tenderness and no palpable radial and brachial pulses. Electrocardiography (ECG) showed AF, ST-segment depression and T-wave inversion on leads V5-V6 . Echocardiography revealed enlargement of right atrium (47 mm), left ventricular end-diastolic dilatation (60 mm), and diffuse left ventricular anterior wall hypokinesis with an ejection fraction (EF) of 28%. Significantly, a (mural or mobile) thrombus measuring 15 × 9.5 mm was present at the left ventricular apex. In addition, there was evidence of moderate mitral regurgitation, severe tricuspid regurgitation, and an elevated mean pulmonary arterial pressure (30 mmHg) . Right upper limb vascular ultrasound showed thrombi in the right innominate vein, subclavian vein, internal jugular vein, axillary vein, brachial vein, and the proximal segment of right brachial artery. The chest radiograph showed an enlarged heart without pulmonary congestion.
+Laboratory thyroid function test revealed thyroid-stimulating hormone level of 0.005 mIU/L, free T3 level of 9.71 pmol/L, and a free T4 level of 47.1 pmol/L, all of which are indicative of active hyperthyroidism. Liver and kidney function tests, routine blood coagulation assessment, and urine analysis were all normal.
+The patient had a history of hyperthyroidism in the absence of other risk factors for heart failure, so hyperthyroid-related cardiomyopathy could be diagnosed. Meanwhile atrial fibrillation aggravated heart failure. Upon admission, the patient was treated with intravenous urokinase infusion (200,000 units daily) for the first 7 days of admission. The right upper limb pain and swelling gradually improved, and the radial and brachial pulses returned.
+However, on May 20, 2013, a week after admission, the patient complained of a sudden onset of severe central chest pain, which was not relieved by sublingual or intravenous nitroglycerine. The patient collapsed suddenly within 5 min of pain onset and ECG monitoring indicated ventricular fibrillation (VF) and convex-upward ST-segment elevation, and merging T wave in leads I, aVL, and V1-V6, consistent with anterior acute ST-elevation myocardial infarction . Cardiopulmonary resuscitation (CPR) was immediately initiated and spontaneous circulation and respiration were restored. However, the patient remained unconscious and an emergency coronary angiography was performed. Left coronary angiography demonstrated abrupt ‘cut-off’ of the distal ends of both the left anterior descending (LAD) coronary artery and the first diagonal artery, consistent with embolization; the circumflex and right coronary arteries were normal . Thrombus aspiration was performed using a 6-French Export Aspiration catheter (Medtronic; crossing profile, 0.068 in.), initially in the LAD coronary artery followed by the first diagonal artery. No thrombi or debris were aspirated. Therefore, balloon angioplasty was next performed using a 2.0 × 20 mm Ryujin balloon in the LAD coronary artery and the first diagonal artery occlusion sites. The balloon angioplasty caused the thrombi to migrate more distally in both the LAD and diagonal arterial branches . The procedure was thus terminated and the patient was returned to the coronary care unit (CCU) with stable hemodynamics and persistent AF. Continuous intravenous infusion of tirofiban at 10 ml/h was initiated in the CCU. Subsequently, ECG showed resolution of ST segments elevation on leads V1-V6 . Troponin I and creatine phosphokinase MB isoenzyme levels were 0.04 ng/ml (normal range: 0–0.04 ng/mL) and 95 U/L (normal range 0–16 U/L), respectively, 1 h after the onset of tirofiban treatment. Additional maintenance medical treatment regimen included dopamine and metaraminol administration. However, 10 h after attempted coronary recanalization therapy, the patient suffered a second VF cardiac arrest from which she failed to be resuscitated.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1835_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1835_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e15e12456297f03ec61a5275040d57cca489052d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1835_en.txt
@@ -0,0 +1,5 @@
+On 3rd November 2009, the first MCGR was implanted in a 5-year-old girl with Ehlers-Danlos Syndrome (type VI). This patient was born with generalized hypotonia and a flail right upper limb. She had a curve of 58.5 degrees at T1–9 and 72.8 degrees at T9-L4 with a single MCGR anchored at T3–4 and L3–4 . An extra short rod was placed on the other side to facilitate any additional MCGR without changing the foundation. At postoperative 13 months, the MCGR failed to distract between lengthening episodes due to unrestricted turning of the internal magnet. The rod returned to the pre-distraction state at follow-up indicating a loss of distraction. The unrestricted turning was observed through internal testing by the developer. There was increasing truncal shift and shoulder elevation. An external magnet was placed outside the skin to prevent the magnet from turning back . The rod was redesigned with an internal keeper plate added to prevent further loss of distraction . The overall balance was suboptimal and after the rod was used up, she developed proximal junctional kyphosis (PJK) as well as a “crooked rod sign” .
+At 9-years-old, a set of dual MCGRs with the new design were inserted with extension proximally to C7-T1. Her spinal balance improved and distractions continued. She subsequently developed adding-on below . At 15-years-old, the rods failed to distract with frequent rotor stalling. A “crooked rod sign” was again observed on radiographs . No further distractions were possible. Autofusion was also observed in the lumbar spine. Final fusion surgery was performed from C7-L4 leaving a residual tilt below to avoid fusion to the pelvis as she was a candidate for the para-Olympics table tennis team and we wanted to maintain mobility. Gross metallosis observed around the actuator and extendable portion of the rod was debrided .
+The rods were extracted for visual inspection, X-ray examination and dissection . On the external appearance, from the anteroposterior (AP) view, the two MCGRs were aligned. However, from the lateral view, the piston rod in the left MCGR showed a “crooked rod sign” close to the barrel opening. Dissection of the left rod revealed that the “crooked rod” radiographic sign was caused by fracture of the stud close to the barrel opening . The rotor and stud could not drive the piston rod to extend due to this complete material failure. Part of the stud remained inside of the piston rod and the fracture site could have repetitive frictions caused by rod stalling during distraction sessions with magnet rotation. Corrosion could be seen at the stud fracture site and the barrel opening of the sleeve portion .
+Additionally, the debris from inside of the sleeve was collected on petri dishes and observed under light microscopy . Morphologically, wear particles were seen for the left rod with fracture , whereas for the right rod, the debris was larger and had the appearance of screw thread tracks . The concentrations of elements (mg/kg) in the sample were measured by inductively coupled plasma optical emission spectrometers (ICP-OES; Agilent 700 Series; Agilent Technologies, Inc.; US). The testing process followed the instructions from the manufacturer . The ICP-OES revealed the elements from the debris contained both metal wear particles (Titanium, Aluminum, Vanadium, Neodymium) and human tissues (Calcium, Phosphate, Potassium, Sulfur, Sodium) . For the left rod there was predominantly metal particles, whereas for the right rod, elements from human tissues were increased.
+The patient is now more than 2 years after the final fusion surgery with maintenance of the Cobb angle correction. The overall balance remains unchanged without any loosening of the implant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1845_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1845_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..059f9f9194818c62d3424fe0ef26cf63c3b64640
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1845_en.txt
@@ -0,0 +1,5 @@
+A 55-year-old male with AS was presented with neck pain after falling off from a table while incarcerated. The non-contrast cervical computed tomography (CT) revealed a transverse three column fracture of the C6 cervical vertebra with minimal displacement; there was a mild kyphotic deformity and attendant evidence of multilevel auto-fusion of the spine consistent with the diagnosis of AS . The patient's body habitus precluded performing an MR (e.g., severe kyphosis).
+Originally, the patient was intubated, and posterior fixation was attempted but aborted 2 days after admission (e.g., elevated peek pressures, inability to ventilate, and severe kyphosis). Somatosensory evoked potentials (SSEP) and motor evoked potentials (MEP) prior to and after positioning remained unchanged from baseline. The CT of the cervical spine following this aborted procedure revealed significant new malalignment and distraction of the fracture margin . Nevertheless, the progressive displacement mandated surgical fixation.
+Further, a cervicothoracic fusion from C2 to T2 was performed in the right lateral decubitus position using the Mayfield head holder, a beanbag, and spinal neuronavigation. Throughout surgery, the SSEP and MEP signals were stable (e.g., before, after positioning, and postoperatively).
+Reduction of the fracture was achieved predominately by positioning the patient in the Mayfield head rest. Segmental instrumentation with cervical lateral mass screws and thoracic pedicle screws was performed uneventfully. This was followed by posterolateral arthrodesis with allograft.
+Three weeks later, the patient remained neurologically intact and the wound healed. The postoperative CT confirmed adequate alignment, intact instrumentation, and a good reduction of the injury . A tracheostomy and percutaneous gastrostomy tube were placed owing to the patient's prolonged ventilator dependence and debility. He was transferred to an inpatient rehabilitation center by the 4th postoperative week.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1882_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1882_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9232b891a6fab331a11304cb94c038d60490f9ce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1882_en.txt
@@ -0,0 +1,13 @@
+An Asian boy from eastern Nepal, who is now 12-years old, was delivered in a local hospital in Jhapa (Eastern region in Nepal, Asia) and was discharged after 1 week of hospitalization for neonatal jaundice which appeared on the second day of life. His mother queried the baby’s apparently smaller phallus, the opening of urethra on undersurface of glans penis, and empty scrotum. The health care providers in the hospital reassured her that it was a normal variant and the testis will descend with time. However, his phallus did not increase in size as expected and his scrotum was still empty. This forced the parents to consult again when he was at the age of 24 months. They were again reassured. They did not know where to go for further advice and hoped that development would be normal with time. Then he did not have developmental milestones like other children. He began to walk at age of 2 years and spoke only words of one or two syllables. In addition, he had progressive hearing impairment on both sides from the age of 4 years. However, he has normal vision, gait, and intellect with good school performance. His mother noted that he had an increased black complexion all over since the age of 3. By the age of 5 years he was found to be taller than most of his peers and around the same time he developed deepening of voice and axillary and facial hair appeared. There is no history of blood transfusion or any prolonged medication. There is no history of maternal ingestion of androgens during pregnancy. He has one elder brother who is normal and healthy. There was no maternal history of hirsutism, genital abnormality, or menstrual irregularity. The family history is negative for infertility, ambiguous genitalia, or unexplained neonatal death.
+He is now 12-years old and is attending school. He prefers to wear a t-shirt and jeans; he feels more comfortable playing with boys, watching wrestling, and playing football.
+At the age of 8 years he developed abdominal pain. He was referred to a tertiary center for evaluation of his abdominal pain. On presentation, his weight was 39 kg, height was 136 cm with upper segment to lower segment ratio of 75:61 cm. His body mass index (BMI) was 21.08 (which falls between 3rd and 97th percentile). Pallor was present. His blood pressure (BP) was 150/100 mmHg with grade two hypertensive retinopathies. There was a masculine look with mustache; no hypertelorism was present.
+On genital examination, the child had ambiguous genitalia with 3-cm long protrusion and presence of hypospadias with Prader score IV. No testis was palpable in his scrotum, inguinal canal, thigh, or perineum and his anus was normal in position. Tanner stage IV male pattern pubic hair was seen .
+There was no gynecomastia .
+Laboratory investigations revealed normal serum urea and creatinine and normal serum electrolytes. He had low serum cortisol of 1.1 μg/dL at 8 a.m. (reference 4.46 to 22.7 μg/dL) but increased 17-hydroxyprogesterone of 4.13 ng/ml (reference 0.07 to 1.70) and adrenocorticotropic hormone (ACTH) level of 691.0 pg/ml (reference ≤46.0 pg/ml). A test for 11-deoxycorticosterone was not done due to financial constraints.
+There was mild concentric left ventricular hypertrophy on echocardiography suggesting hypertensive heart disease. There was presence of hemolytic anemia with iron deficiency, hemoglobin E (HbE) variant of thalassemia. There was also severe (76 db) sensorineural hearing loss of the right ear and profound (83 db) sensorineural hearing loss of the left ear.
+An X-ray of his left hand revealed premature closure of epiphysis .
+Ultrasonography of his abdomen/pelvis revealed a uterus and there was significant doubt about whether an inguinal mass was a testis or lymph node. Solitary cholelithiasis was also noted.
+Magnetic resonance imaging of his abdomen/pelvis revealed presence of Müllerian structures and no testis was seen . Karyotyping revealed 46,XX chromosome.
+Thus, he was diagnosed as having CAH with 11β-hydroxylase deficiency, ambiguous genitalia, hypertension with hypertensive heart disease, sensorineural hearing loss, and hemoglobinopathy (β thalassemia HbE variant).
+There was a treatment dilemma as anti-androgenic medicine might reveal female characteristics. The patient's parents were counselled about the disadvantages of sex change to genotypic sex, fertility issues, sexual functioning, and expensive surgeries. Possible features of gender dysphoria and phenotyping changes on not initiating treatment were also explained. Our patient’s legal guardian was unwilling for our patient to change gender and the patient himself is underage. As our patient is a minor, the condition was well explained to his parents. Our patient was put on cortisone tablet 5 mg at bedtime and spironolactone tablet 25 mg along with amlodipine 5 mg. He responded well to the treatment and his BP came down to 100/60 mmHg; he has been in follow-up for the past 2 years and presently is not having any side effects.
+He is now 12-years old. On examination thelarche was seen . His serum luteinizing hormone (LH) and follicle-stimulating hormone (FSH) have increased. His serum cortisol is still in lower range. So, he was prescribed with leuprolide, which is a gonadotropin-releasing hormone (GnRH) analogue, to decrease LH and FSH, letrozole (aromatase inhibitor) to decrease his estrogen level, and the dose of spironolactone was adjusted. His serum iron and ferritin were within normal range.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_188_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_188_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..58361180190326882aecfc8933da46e7efe36d0e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_188_en.txt
@@ -0,0 +1,3 @@
+A 62-year-old Caucasian woman presented with a two-month history of intermittent fever. Her past medical history included hypertension, dyslipidema, coronary artery disease and mild chronic kidney disease. She was found to have Enterococcus faecalis endocarditis of her native, bicuspid, aortic valve. She was treated with vancomycin, gentamicin and penicillin and subsequently underwent aortic valve replacement (AVR) with a Saint Jude valve in October of 2004. Her postoperative course was complicated by evacuation of a mediastinal hematoma, splenectomy and a partial colectomy with diverting colostomy for hemorrhagic colitis. The patient had been discharged and re-admitted multiple times and was ultimately transferred to the Oklahoma University Medical Center in May 2005.
+Upon transfer, the patient complained of dyspnea, orthopnea and lower-extremity swelling. She was afebrile and hemodynamically stable. Her physical examination revealed jugular venous distention, a III/VI systolic murmur in the right second intercostal space, and bilateral lower-extremity edema to the knees. No peripheral stigmata of endocarditis were identified.
+Nine blood cultures obtained over a five-day period were positive for Candida lusitaniae. Susceptibility testing was performed on the initial isolate only and revealed sensitivity to amphotericin B, caspofungin and fluconazole . Transesophageal echocardiography revealed multiple vegetations on a partially dehiscent mechanical aortic valve with severe aortic valvular regurgitation and a left ventricular ejection fraction of 50% . Therapy with caspofungin was initiated prior to obtaining results of susceptibility testing on the initial isolate and was continued based on the minimal inhibitory concentration (MIC). The patient eventually underwent repeat AVR with coronary artery bypass grafting. Vegetations were noted on her removed prosthetic valve . Her post-operative course was complicated by a chest hematoma which was evacuated. Despite eventual clearance of her fungemia, the patient died from multi-organ failure in June 2005.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1896_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1896_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51393e7bd87b483f15f54c07e67aa3d6f352023d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1896_en.txt
@@ -0,0 +1 @@
+A 30-year-old man with a history of car accident and diagnosis of anterior glottic stenosis on tracheostomy tube was admitted to the University of Malaya Medical Centre, Kuala Lumpur, Malaysia in January 2012. Endoscopic carbon dioxide (CO2) laser-assisted resection was done for this patient. A custom-made laryngeal keel, which was made from a silastic sheet, with 0.3 mm thickness, was placed endoscopically to cover the entire raw edge. Using a Lichtenberger endo-extralaryngeal needle carrier (Prolene 2.0), the silastic sheet was anchored to another silastic sheet on the skin. The patient was discharged with a prescription of oral omeprazole 20 mg, once a day, on the following day. He came back to the clinic two weeks after the operation with complaint of itchiness in his throat, abnormal sensation in his chest and blood stained phlegm. On cervical inspection, the area around the suture was inflamed. Flexible nasolaryngoscopy revealed that the silastic sheet was dislodged. Using flexible bronchoscopy through the fenestra of tracheostomy tube, the silastic sheet was seen in the right main bronchus . The patient was admitted and flexible bronchoscopy was performed through the fenestra of the tracheostomy tube and the keel was removed. Mitomycin-C was applied over the raw edges. A new custom-made silastic keel was inserted using a Lichtenberger endo-extralaryngeal needle-carrier and passing a 2.0 Prolene suture through the cricothyroid membrane inferiorly, keel and thyrohyoid membrane superiorly, to allow anchor to the skin. The patient was seen a week later at the clinic and as indicated by flexible nasolaryngoscopy, the keel was in situ. The subject was re-examined under general anesthetics three weeks post-operation and the silastic sheet was removed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1906_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1906_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e8000e12049f0b565737b53468909f34d135a3e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1906_en.txt
@@ -0,0 +1,2 @@
+A 51-year-old female, who is known to have hypertension, presented to our outpatient department with a complaint of left breast mass for 2 months duration. According to the patient, the mass was not associated with any pain, discharge from the nipple or skin changes. She is a mother of 7 children and had her first menarche at the age of 13. Her family history was unremarkable for any malignancies. She utilized oral contraceptive pills for 13 years. Her past surgical history was significant for subtotal thyroidectomy performed for goiter 15 years back, and was kept on replacement therapy since then. Menstrual history confirmed a regular and non-heavy menstruation. Upon examination, a mass was detected in the left breast, measuring around 4 x 3 cm, located at 2 o’clock, 7 cm away from the nipple, with no attachment to the skin or muscles. Examination of the right breast along with the axilla bilaterally was unremarkable.
+A diagnostic mammography was performed and illustrated the presence of an irregular mass with obscured margins measuring around 4.5 cm x 2 cm, occupying the upper lateral quadrant of the left breast, 5 cm away from the nipple, with fine pleomorphic suspicious calcifications, as shown in . No suspicious axillary lymph nodes were identified, and the right breast was demonstrated with no architectural distortion or suspicious masses. A core-needle biopsy was obtained and was consistent with grade three metaplastic carcinoma with squamous differentiation. The lesion was triple negative with a Ki-67 score of 90%. The decision was made to proceed with neoadjuvant chemotherapy to be followed by breast-conserving surgery, or total mastectomy, with sentinel lymph node biopsy based on the cells’ response to neoadjuvant agents.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1910_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1910_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a5740150ade8376b2102ad61d8804f94055f97f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1910_en.txt
@@ -0,0 +1,20 @@
+In January 2011, a 45-year-old Italian bisexual man, known to be HIV-infected since 1998, presented to the Infectious Diseases Unit with partial vision loss in both eyes.
+Since 2000, HIV infection had been treated with combination antiretroviral therapy (cART) including zidovudine, lamivudine and lopinavir/ritonavir. Nadir absolute CD4+ T-cell count was 320/mm3.
+The patient had been regularly attending different Day Hospital Services and was adhering well to cART. He had received two lines of cART, including ritonavir-boosted protease inhibitor regimens without experiencing virological failure.
+On admission, his absolute CD4+ T-cell count was 385/mm3, HIV viremia was undetectable and his cART consisted of tenofovir emtricitabine and boosted atazanavir.
+The patient's past treatment history revealed that he had received a single intramuscular injection of 2.4 million units of penicillin G benzathine for primary syphilis contracted in November 2000 after unprotected heterosexual exposure. At that time, he had a penile lesion with inguinal adenopathy, and he tested positive for syphilis as follows: serum Venereal Disease Research Laboratory (VDRL) test ++, Treponema pallidum haemoagglutination assay (TPHA) 1: 1280, positive FTA-Abs. Serological post-treatment follow-up showed that the VDRL test had reverted to non-reactivity within 12 months. His last known non-reactive VDRL test result was in June 2009.
+Two weeks before admission to the Infectious Diseases Unit, the patient had noticed an ulcer on his left upper eyelid and four days before admission he had begun to experience reduced visual acuity, with associated photophobia and mild headache which had subsequently improved. His general practitioner suspected a chalazion and the patient was referred to our Ophthalmology Section because of visual impairment.
+A small, painless, resolving ulceration with barely elevated edges was present above the external canthus of the LE . No other abnormalities were seen in the remainder of his eyelids, eyelashes, cornea, bulbar conjunctiva, the other eye or on the rest of his face. His left preauricular and submandibular nodes were slightly enlarged, non-tender and firm.
+Best corrected Snellen visual acuity was 20/32 in both eyes. Fine pigmented keratic precipitates, aqueous cells, flare and posterior synechiae were seen in the anterior chamber. Examination of the posterior chamber revealed vitreitis, retinal vasculitis with perivascular sheathing and hemorrhages, edematous retinal areas and disc swelling. Intravenous fluorescein angiogram showed masked retinal areas, optic disc hyperfluorescence and leakage from retinal venules .
+Structured face-to-face interviews were conducted with the patient to obtain information about his behavioral risk factors and symptoms. He had a history of multiple sexual partners in the previous year and unprotected oral sex intercourse with a sperm contamination of his eyes. His sexual contacts were traced and two immunocompetent young men tested positive for syphilis.
+Complete blood count was unremarkable. Hematologic values were within normal range and Polymerase Chain Reaction (PCR) for Toxoplasma gondii, Herpes viruses, Mycobacterium tuberculosis (MT), non-tuberculous mycobacteria (NTM) and other pathogens which are epidemiologically relevant in our geographic area (i.e. Rickettsia conorii, Brucella spp) gave negative results. Negative results were obtained for CMV DNA (using Real Time for amplification of the IE region) and CMV pp65 antigen in 200000 leukocytes. EBV-DNA (amplifying the Bam Hi W region) and HSV DNA (amplifying viral polymerases) were also negative. Serum VDRL titer was 1 : 16, and TPHA titer was 1 : 1280.
+Macroscopic and humoral studies of cerebrospinal fluid (CSF) performed at the time of admission were negative. CSF VDRL and CSF PCR test results for the above-mentioned microorganisms were also negative.
+The patient was treated with intravenous penicillin G (24 MU/day) for two weeks and received 1 intramuscular dose of penicillin G benzathine (2.4 MU) after completing the I.V. therapy [,].
+He was treated topically with dexamethasone qid and atropine 1% bid, and was prescribed 60 mg of oral prednisone daily, tapered over 4 weeks.
+At the two-week follow-up visit, papillitis had disappeared, and retinal vasculitis and uveitis had improved. Best corrected Snellen visual acuity remained unchanged. The topical therapy was tapered.
+After one month, aqueous cells and flare had further decreased but some retinal hemorrhages and perivascular sheathing were still observed.
+At 2-months follow-up, signs of uveitis had disappeared, posterior synechiae were sporadic and fundus examination showed a normal disc and peripheral hyalinized vessels with attached retina .
+One year after treatment, serological testing for syphilis was repeated, showing positive VDRL 1:2 and positive TPHA 1:80.
+At present, the patient is regularly attending our Day Care Unit where we can monitor his adherence to therapy.
+His last CD4+ T-cell count was 530cells/mm3 and viral load was undetectable.
+Ocular examination showed that both eyes were quiet.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1928_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1928_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..84e0664216f792a1a5dc601998836b0642ba7e32
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1928_en.txt
@@ -0,0 +1,9 @@
+A 30 year-old man was referred to our trauma center with impaired wound healing and infection after multiple surgeries for bilateral intra-articular calcaneal fractures. Six months ago, he had jumped from a fire protection staircase at a height of about 2.5 m on a concrete surface while doing parkour sports. Initial fracture treatment consisted of bilateral open reduction and interlocking plate fixation via extensile lateral approaches. In the subsequent course, a deep infection developed on both sides necessitating multiple revisions with complete hardware removal, serial debridements and lavage until 4 months postoperatively. As part of this procedure, resorbable bone cement had been implanted. Because wound drainage and infection persisted, the patient had been offered bilateral partial calcanectomy. He therefore presented to our Foot & Ankle Center for a second opinion.
+For initial examination at our center, 6 months after the initial injury, the patient appeared in a wheelchair. The scars of the extensive lateral approaches over both heels displayed a fistula formation of almost 2 cm in the wound angles on both sides . With continuous effusion that was more pronounced on the right side than on the left side. Bone could be probed from the fistula on both sides. The peripheral blood circulation was intact. A hypesthesia was noted on the lateral aspect of both feet distal to the scar area and interpreted as sural nerve affection. The total range of motion of both feet displayed 30 degrees of plantarflexion and no dorsiflexion in the sagittal plane. Hindfoot motion was severely restricted with no eversion and inversion of 15° bilaterally. The subtalar joint appeared stiff on both sides. Lab results upon presentation included a leukocyte count of 6.87 GPt/L s and a C reactive protein (CRP) level of 30 mg/L. CT scans on admission revealed a heled calcaneal fracture with minimal residual step-off in the subtalar joint on both sides and a central osseous defect in both calcanei. On the right side, amorphous hydroxyapatite bone cement was in place that seemed encapsulated by a fibrous membrane (see ).
+The patient was admitted to our hospital and after a detailed discussion of all possible treatment options.
+An extended reconstructive therapy after infected ORIF of calcaneus fractures was established: we decided for a radical irrigation and debridement of all necrotic and infected bone and soft tissues, removal of the bone cement and insertion of a polymethylmethacrylate (PMMA) cement spacer with gentamycin (Palacos-G, Heraeus Inc., Hanau, Germany) and with vacuum assisted closure (3 M™ V.A.C., Germany) dressing to eradicate infection. There were in total seven debridements accomplished. Intraoperative swabs revealed multibacterial infection with Staphylococcus epidermidis, Staphylococcus saprophyticus, Staphylococcus equorum, Enterococcus. avium and Enterococcus. faecalis. The wound debridement’s were repeated until negative swabs were obtained.
+Additionally, an intravenous antibiotic first with Vancomycin for 10 days and then, matching the antibiogram, Amoxicillin was administered for 6 weeks intravenously. Following complete resection of all necrotic tissue, a bone defect remained measuring 20 × 19 × 14 mm on the right side and 57 × 25 × 14 mm on the left side . Furthermore, a full thickness soft tissue defect in the lateral hindfoot region 140 × 50 mm on the left and 150 × 70 mm right resulted, necessitating flap coverage .
+Following negative cultures from multiple bone biopsies, reconstruction of the bone and soft tissue defect was performed 8 weeks following admission and first debridement. The osseous defects were filled with resorbable bone cement containing gentamicin sulfate (Cerament G, Bonesupport Inc., Lund, Sweden).
+An abductor digiti minimi flap was raised on both feet to cover the soft tissue defects. The incision was carried out from the distal insertion of the abductor digitus quintus muscle at proximal phalanx of the fifth toe to the lateral aspect of the calcaneus at the transition from the glabrous to the hairy skin of the heel. The abductor digiti minimi muscle and tendon were identified and gently separated from the flexor digiti minimi muscle, technique also described in Wie Mardini, Flaps and Reconstructive Surgery (2nd Edition, pg. 818–823, 2009). The tendon was detached from the proximal phalanx of the fifth toe and held with a PDS suture for atraumatic handling. Dissection from the fifth metatarsal bone was continued proximally until the first perforators were reached. The wound edges were mobilized towards the lateral calcaneal wall. After mobilizing the muscle flap, it was pivoted around the perforators into the defect zone on the lateral calcaneus . Finally, the abductor digiti minimi muscle flap was covered with meshed split thickness skin graft from the thigh and sealed with a V. A. C. dressing that was removed after 4 days.
+The patient was kept nonweight-bearing for 4 weeks and on partial weight-bearing for another 8 weeks in hindfoot-offloading Donjoy boots using two crutches. He returned to full weight-bearing after three months after prolonged clear drainage with particles of the bone substitute (“white washout”) for 10 weeks, the soft tissues healed on both sides.
+The patient was seen for a follow-up examination 9 months after defect filling and flap coverage. He was ambulating freely without crutches in sports shoes with insoles. He did not report pain when walking on even ground. The soft tissues had healed uneventfully without residual drainage on both feet . Range of motion was 45 degrees of dorsiflexion/plantarflexion in the sagittal plane and 20 degrees of eversion/inversion in the frontal plane. Except for the pre-existing hypesthesia, there were no neurovascular deficits. Standing radiographs including hindfoot alignment views revealed correct position of the hind foot and no signs of arthritis at the ankle, subtalar and calcaneocuboid joints. There was slight loss of heel height bilaterally. The bone cement was for the most part resorbed and replaced by cancellous bone.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1937_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1937_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..14a8f729bc2b6095a644398fcd8258bd7e1fcb71
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1937_en.txt
@@ -0,0 +1,2 @@
+A 39-year-old female came to our clinic complaining of gradual loss of visual in the left eye for 5 months. She had been diagnosed with acute retinal necrosis in the right eye, and wide-field photograph of the right eye showed patchy and diffusive retinal necrotic lesions . Pars plana vitrectomy was performed due to retinal detachment of the right eye 5 months earlier. The visual acuity in the left eye at the time of initial presentation was 20/20. In the meantime, she noticed floaters in her left eye. Superior retinal necrosis had been detected and it was recorded in her previous medical chart. The aqueous fluid from the left eye was positive for herpes zoster virus (VZV). She received repeated (nine rounds) intravitreal ganciclovir injection (3 mg/0.1 ml) into her left eye, one injection every 2 weeks, and systemic antiviral therapy for 5 months. The patient noticed a decrease in the visual acuity of the left eye and was referred to our clinic.
+When the patient came to our clinic, her best corrected visual acuity was 20/400 OS, 20/33 OS. The intraocular pressure was within the normal range in both eyes. There was no inflammation in the anterior chamber, and the lens was normal in the left eye. There was no posterior necrotizing involvement and no macular edema or exudation in the left eye. Indirect ophthalmoscope examination revealed pigmentary change in the superior peripheral retina of the left eye. Slight abnormality of the interdigitation zone in the fovea area of the left eye was detected on OCT. Angio-OCT revealed normal capillary density of superficial retinal capillary, deep retinal capillary, outer retina, and choriocapillaris layers in the left eye . The Humphrey visual field (central 24–2 threshold test) showed massive visual field damage in the left eye. The amplitude and implicit times of pattern visually evoked potential (VEP) and flash VEP were within the normal range in the left eye. The amplitudes of dark-adapted flash electroretinography (ERG) were slightly low in the left eye. Photopic single-flash response showed decreased amplitude of a-wave and b-wave in the left eye. The amplitudes of photopic 30-Hz flicker were decreased in the left eye. Trace arrays showed subnormal multifocal electroretinography (mERG) with decreased amplitudes for the left eye. The three-dimensional topography map showed a blunted foveal peak .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1946_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1946_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5923c9306fac22680d0af55f4bc3fe961e02324f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1946_en.txt
@@ -0,0 +1,4 @@
+A 55-year-old Taiwanese woman had a history of Hailey—Hailey disease with some stable erythematous macerated patches over bilateral axillary and submammary areas without regular treatment. She presented with four large (size ranged from 2 × 2 cm to 4 × 4 cm), itchy, tendered, erythematous, weeping, and infiltrated noduloplaques with a surface cobblestone appearance over the vertex and occipital scalp for 5 days (a,b). Skin biopsy was performed under the impression of atypical infection and oral minocycline and topical gentamicin ointment were administered. A histologic examination revealed surface erosions with serum crusts, papillomatosis, and acanthosis with finger-like downward projections of the epidermis. The dermal changes included prominent papillary dermal edema and heavy lymphohistiocyte infiltration extending from the upper dermis to the reticular dermis (c). Cytoplasmic vacuolation (koilocytic change) of the upper epidermis and intracytoplasmic eosinophilic inclusions in vacuolated epidermal cells (d) were also noted. No acantholysis change related to Hailey—Hailey disease was noted. Special stains, including Grocott-Gomori’s methenamines silver (GMS), periodic acid-Schiff (PAS), and acid-fast stain all revealed negative results. The tissue Gram stain and fungal and mycobacterial culture were also negative.
+One week later, her skin lesions improved partially with less swelling and oozing, but was still indurated with some yellowish crusts. On questioning, the patient reported that she was a farmworker that raised goats and sold goat milk. Many lambs had some skin lesions located at the muzzle area during that period. Since Orf infection was highly suspected based on the occupational history and consistent histologic findings, we further arranged a polymerase chain reaction (PCR) analysis of the formalin-fixed paraffin-embedded skin biopsy specimens.
+The genomic DNA was extracted from the skin tissue slides. The extracted genomic DNA was used for PCR amplification using primers forward 5′-CGGTGCAGCACGAGGTC-3′, and reverse 5′-CGGCGTATTCTTCTCGGACT-3′ according to Andreani et al. with some modification. These primers are specific for the B2L gene, which encodes the major membrane protein of parapoxvirus. The primers were added to more base pairs (bp) (33 bp on the forward primer and 34 bp on the reverse primer) to add an adaptor sequence for the subsequent next generation sequencing. The adaptor sequence was following the instruction of Illumina guidance (Illumina, San Diego, CA, USA). Next generation sequencing (NGS) was performed on the iSeq 100 Sequencing Machine (Illumina, San Diego, CA, USA). The DNA product was run on 2% agarose gel and revealed that the size of the DNA products was 147 bp (80 + 33 + 34 bp) (a). The DNA sequence specific for the B2L gene (80 bp) (b) was confirmed using next generation sequencing. Thus, orf infection was diagnosed.
+At a follow-up visit 2 weeks after initial presentation, all the noduloplaques on the scalp resolved with residual erythema and some crusts.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1949_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1949_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3da90aac9d84609f681854cd794d0c2f3415e4b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1949_en.txt
@@ -0,0 +1,7 @@
+A 49-year-old female patient complained of fever and headache for 32 day was hospitalized in the Department of Infectious Diseases of Guangzhou Panyu Central Hospital, Guangdong, China, on October 29th, 2020. She had lived for one and a half years in Los Angeles, USA and just returned to China 2 days before. While living in the United States, she traveled around Los Angeles and trimmed plants for several times in the garden.
+The symptoms included a sudden onset of fever (39 °C), severe headache, and rash on her face and back while she was in Los Angeles on September 27th. The patient went to local hospitals several times, but computed tomography (CT) showed no abnormities on her head. She received symptomatic treatments, but had not fully recovered.
+When admitted to our hospital, the patient was with headaches, fevers, vomiting, and maculopapular rashes (1.5 cm × 1.5 cm) on the face and back. Her white blood cell count (WBC), erythrocyte sedimentation rate (ESR), and C-reactive protein (CRP) were slightly higher than the normal range, but her electrolytes was slightly lower. CT examinations revealed small nodules in the posterior apex of her left upper lobe and lateral segment of middle lobe of right lung, but no abnormalities in head.
+The empiric combinatory therapy (ceftriaxone sodium 2 g daily and acyclovir 0.5 g q8h) for both viral and bacterial meningitis was given. A lumbar puncture was performed on day 34. The CSF opening pressure was greater than 400 mmH2O. CSF analysis demonstrated positive pandy test and negative cryptococcal antigen, gene Xpert MTB/RIF assay, and culture result . Drug dehydration and other symptomatic treatments were added. But there was no relief of the symptoms.
+A lumbar puncture was repeated on the 39th day . Autoimmune encephalitis spectrum results were positive of the anti-MOG-IgG antibodies for the serum and the CSF (1:32 and 1:3.2, respectively). To further identify the pathogen, PACEseq mNGS (Hugobiotech, Beijing, China) of CSF and blood was performed on a Nextseq 550 platform (Illumina, California, USA). A total of 308 unique sequence reads were finally aligned to the C. posadasii genome in CSF, which showed a dominant abundance of 2.32% in all microbial species after excluding the human reads from the total gene pool . The blood mNGS showed negative of the pathogen. A targeted PCR of C. posadasii and Sanger sequencing were subsequently applied, which finally confirmed the mNGS detection of CSF . In addition, the tissue biopsy of the patient’s back rash indicated HE Stain, PAS stain (+), and hexamine silver stain (+) , which were also in line with coccidioidomycosis. Considering the abnormal signals in the bilateral parieto-occipital lobes and the meninges by magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA), the patient was finally diagnosed with C. posadasii infected meningitis.
+The treatment was adjusted with fluconazole (800 mg intravenously daily) and ceftriaxone (4 g q24h). Other symptomatic treatments were also performed, such as mannitol (125 ml intravenously q8h) to reduce intracranial hypertension. The detailed treatments were shown in Fig. .
+The patient gradually recovered over the next 7 days. The body temperature returned to normal, and the headache and dizziness relieved. Repeated lumbar puncture revealed the pressure at 200 mmH2O . The patient's vital signs were stable. The patient was then transmitted to Third Affiliated Hospital of Sun Yat-Sen University for antifungal treatment with altericin B combined fluconazole. One month later, the patient’s symptoms improved and was finally discharged. She was required oral fluconazole. On February 2021, reexamine of the patient found high blood fat with intrajugular venous thrombosis and head sinus. The patient was given levarabban, oral anticoagulant therapy, fluvastatin, and oral calcium supplements. After 3-month follow-up, her headache aggravated with a increase intracranial pressure. The patient then received dehydration treatments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1964_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1964_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..19a6e13004763702233f7a67fbf92ca83c381d51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1964_en.txt
@@ -0,0 +1,4 @@
+A 75-year-old Japanese male was transferred from another hospital after presenting with hemorrhagic shock due to hematochezia. He had been transported by ambulance to the previous hospital after complaining of discomfort and bloody stool on the previous day. He had undergone distal pancreatectomy and right lower lobectomy for pancreatic cancer and lung cancer, respectively, 5 years prior and total pancreatectomy due to residual pancreatic cancer eight months prior. The reconstruction procedure consisted of hepaticojejunostomy, Braun’s anastomosis, and gastrojejunostomy. In addition, a stent had been inserted for stenosis of the hepaticojejunostomy 1 month prior. The patient’s medical history also included atrial fibrillation, and he was taking insulin and apixaban. On arrival, he appeared to be pale and his extremities were cold. His vital signs were as follows: respiratory rate, 20 breaths/min; pulse rate, 105 beats/min (bpm); blood pressure, 77/54 mmHg; temperature, 34.9 °C. Arterial blood gas analysis detected severe lactic acidosis (lactate concentration: 9.9 mmol/L) and anemia (hemoglobin level: 3.1 g/dL). The laboratory data showed a white blood cell count of 5850/μL, C-reactive protein level of 0.08 mg/dL, procalcitonin level of 0.097 ng/mL, and serum glucose level of 389 mg/dL. Contrast-enhanced computed tomography of the abdomen did not detect any active bleeding. His melena had already ceased. Fluid resuscitation and massive transfusions resolved his hemorrhagic shock. Crystalloids were administered 800 mL over an hour. Blood products were initiated 30 min after the patient’s arrival. The patient required 16 units of red blood cell concentrate, 14 units of fresh frozen plasma and 20 units of platelets within 12 h of his arrival for hemostatic resuscitation. A classification of hemorrhage of the patient was considered as class IV based on the American College of Surgeons. Urgent upper gastrointestinal endoscopy was a poor study because of food residue and failed to identify the source of the patient’s bleeding. Thus, he was admitted to the emergency intensive care unit for careful observation. The patient’s acute physiology and chronic health evaluation (APACHE II) score on the day of admission was 24, and the Charlson comorbidity index was three.
+Since fresh bleeding was detected in the terminal ileum during capsule endoscopy the next day, colonoscopy was performed without bowel cleaning. But the exam produced poor findings due to blood clot. Therefore, transanal double balloon enteroscopy was scheduled for further investigation 4 days after the patient’s admission. The patient took 5 h to ingest 2 L of PEG plus an additional liter of PEG for bowel preparation. This was the first time he had consumed PEG. 1 h after consuming the 3 L of PEG, he complained of a feverish chill and his heart rate and temperature increased to over 130 bpm and 39 °C, respectively. The transanal double balloon enteroscopy exam was performed uneventfully and did not reveal the source of the patient’s bleeding.
+After the examination, he appeared to be agitated and distressed and exhibited hypotension, high fever, and an elevated lactate level, which indicated septic shock. He did not have any other complaints. His abdomen was soft, flat, and non-tender. Empirical antibiotic therapy with meropenem was administered, and two sets of blood cultures were obtained at the same time. Fluid resuscitation and a noradrenaline infusion were initiated due to septic shock, followed by intubation and mechanical ventilation. Table shows the patient’s laboratory data at the time that he suffered septic shock. Repeated lab tests revealed a significantly elevated procalcitonin level. Liver function tests produced normal results during the course, so we excluded biliary stent infection. Figure shows the patient’s clinical course during the first 15 h after he ingested PEG, the hypotensive phase of his condition, and the resuscitation period. Ongoing intensive care led to a gradual improvement in the patient’s condition and he was successfully extubated on day 4 (the day when the PEG preparation was administered was defined as day 0, at which APACHE II score was 34). An examination of his blood cultures detected C. braakii and we replaced the meropenem with ceftazidime based on the results of sensitivity tests. Later, the identity of the pathogen was confirmed by biochemical analysis and partial sequencing of 16S rRNA. Urinalysis produced normal results. Cultures of the patient’s urine and sputum at the onset of septic shock were negative. The tip cultures of central venous catheter which had been placed in a femoral vein on admission were found to be negative. Stool culture was obtained 1 week after presenting septic shock, which was also negative. Antibiotics were administered for a total of 10 days. The patient was discharged from the emergency intensive care unit on day 8. Figure shows the patient’s clinical course over the 8 days after he first suffered septic shock.
+Melena occurred intermittently. Upper gastrointestinal endoscopy subsequently identified marginal ulceration of the gastrojejunal anastomosis, which was successfully treated with coagulation hemostasis. The patient was discharged on day 33.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1968_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1968_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c3951b46e0c5c724cb8bad9b2f53ca6da83320a9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1968_en.txt
@@ -0,0 +1,11 @@
+A 10-year-old boy referred to the pediatric cardiology clinic of Chamran Hospital, Isfahan University of Medical Sciences, Isfahan, Iran on 1-May-2012 with a chief complaint of recurrent chest pain from two weeks ago. He had an atypical chest pain in the 4th and 5th left intercostals areas without any radiation which lasted for several minutes. He had no other symptoms though.
+In physical examination, the pulses of left upper limb and left carotid artery were not detected; however, the other pulses were normal. He had no cyanosis or clubbing in his extremities. In heart auscultation, the S1 and S2 sounds were normal and a grade I-II/VI systolic ejection-type murmur was heard on the left sternal border. The other examinations were normal.
+No abnormal findings were revealed in electrocardiography.
+The cardiothoracic ratio was in upper normal range and the pulmonary vascular markings were normal in chest X-ray (CXR). The right sided aortic arch was observed in .
+The main abnormal findings in echocardiography included mild mitral valve prolapse (MVP) and tricuspid regurgitation (TR) with a pressure gradient of 25 mmHg. Besides, the right sided aortic arch was observed.
+In CT angiogram, the left carotid artery was significantly narrower than the right one which seemed to be dilated for enough cerebral circulation. Moreover, as a rare anomalous finding, the left subclavian artery aroused from this narrow carotid artery and the left vertebral artery originated from this subclavian artery (.A and .B).
+Thereafter, the patient underwent the left heart catheterization. The arterial catheter passed from the femoral artery into descending aorta (DAO), ascending aorta (AAO), and left ventricle (LV), respectively. It entered into the right and left coronary arteries (RCA and LCA) normally.
+Systemic sample was saturated. In addition, it entered into the right subclavian and right carotid arteries, but it could not enter into the left brachiocephalic artery.
+LV, coronary arteries and aortic root injections revealed no pathologic findings. The right sided aortic arch was observed again. Aortic arch injection in the right anterior oblique view showed normal right subclavian and right carotid arteries and also showed with no connection of the left subclavian artery to the aortic arch.
+Selective right carotid artery injection showed opacified left subclavian artery. The left subclavian and left vertebral arteries supplied from the circle of Willis (right vertebral artery). Selective right subclavian artery showed no anomaly (.A, .B, and .C).
+Following the whole procedures, the patient was discharged and was advised to refer periodically for clinical follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1990_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1990_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ee7f0f6f020bf28aa6ceee58f9cb1d52a16fb751
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1990_en.txt
@@ -0,0 +1,4 @@
+A 41-year-old Chinese man presented with palpable right breast lumps for 1 year. On physical examination, a large retroareolar hard nontender mass approximately 4.5 cm in size was palpated over the right breast. The mass was nonmobile and superficial but did not have any overlying skin findings. A smaller adjacent mobile and nontender lesion, approximately 3 cm, was palpated just medial to the first mass. Initial laboratory evaluation was normal for prolactin, estradiol, luteinizing and follicle-stimulating hormone levels. Furthermore, he had never previously been treated with radiation, according to his past medical history.
+Conventional mammography was performed on Flat III (Metaltronica Company, Rome, Italy). Mammography showed a subcutaneous oval mass with a smooth and sharp margin on his right breast, and another small oval mass with a less well-defined margin was seen adjacent to the main lesion .
+MR imaging was performed on a 1.5 T Signa Infinity TwinSpeed MR scanner (GE Company, Milwaukee, WI, USA). The examination comprised of routine T1- and T2-weighted fast spin echo (FSE) sequences in axial and sagittal planes; T1- and T2-weighted imaging fat-suppressed in axial and sagittal planes, respectively. On T1-weighted imaging, the lesions were predominantly hypointense to subcutaneous fat and mildly hyperintense to the pectoralis major muscle. On T2-weighted imaging, the lesions were of a higher signal than the subcutaneous fat. Furthermore, the larger lesion had a smooth contour and well defined borders on all sequences which, on T2-weighted images, had a lower signal central region. Along the border of the larger lesion, there was a distinct rim of decrease in signal between the lesion and fat interface , whereas, the small lesion had a less poorly defined border on conventional T2 weighted images. On the fat-suppressed sequences, both lesions had better depiction for the margins and borders and there was a mild mass effect of the dominant lesion on the underlying pectoralis major muscle .
+The gross pathology of the specimens after surgery showed a yellowish tanned smooth surface mass measuring 4.5 cm × 3.0 cm × 2.0 cm and a smaller lesion with similar features measuring 2.5 cm × 2.0 m × 1.0 cm. Histologic specimens showed high cellularity monomorphic slender spindle cells arrayed in a storiform pattern aligned at right angles to small vessels and collagen fibers intermixed with scattered adipose tissue. The nuclei of the spindle cells were well differentiated with only rare mitotic figures. The larger mass had a fibrous envelope and plentiful collagen fibers in the central region. The smaller mass lacked the fibrous envelope. There was positive immunohistologic staining for vimentin and cluster of differentiation (CD) 34, negative for b-cell leukemia-lymphoma (Bcl -2), S-100 protein, smooth muscle actin (SMA), desmin and epithelial membrane antigen (EMA).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2001_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2001_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b2d982ebd92691f10c980fdd8bfe9c6ed6d9eee5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2001_en.txt
@@ -0,0 +1,10 @@
+A 26-year-old Caucasian woman, gravida 2, para 1, with a spontaneous normal vaginal delivery 2 years ago was referred to our institution at 20.3 weeks of gestation after a sonographic finding of a sacrococcygeal mass of 26 × 24 mm in a male fetus.
+The patient had no family history of birth defects or genetic disorders. She did not have any medical or surgical history, and she had no alcohol or smoking habit. She had no relationship with the father of her fetus and received no drug therapy while pregnant.
+She had a normal gestational course with low risk of aneuploidies in the first-trimester screening and a normal first trimester scan at 13 weeks. Her sonographic examination revealed a single intrauterine pregnancy with an estimated gestational age of 20 weeks. The study revealed an exophytic, mixed echogenic mass arising from the sacrococcygeal region with high vascularization seen on Doppler flow . The examination showed adequate amniotic fluid, and no other abnormalities were detected.
+Magnetic resonance imaging was performed, which confirmed the diagnosis. There was no evidence of possible invasion of the fetal pelvis or abdomen. The spine appeared intact. The lower extremities, fetal kidneys, and bladder appeared normal. On the basis of these findings, a diagnosis of external variety, type I in the Altman classification, was confirmed .
+Amniocentesis guided by ultrasound scanning was done with normal karyotype and microarray results. The result of a fetal echocardiographic scan was normal.
+The patient was scheduled for follow-up by ultrasound weekly . These scans showed an increase in the size of the mass up to 190 × 150 mm with high Doppler flow and severe polyhydramnios (amniotic fluid index 37) . The patient developed gestational diabetes, which required insulin treatment.
+At 33.6 weeks of gestation, the patient was admitted to the obstetric ward for preterm labor. Her vital signs were normal (body temperature 36 °C, pulse rate 90 beats/minute, and blood pressure 135/82 mmHg), as was her physical examination. Treatment with a corticosteroid (12 mg intramuscularly, twice) and atosiban was started. The tocolysis was effective, and an elective cesarean section was scheduled at 35 weeks of gestation in conjunction with the neonatal service and the pediatric surgeon. However, 1 day before the scheduled cesarean section, the patient had premature rupture of membranes. Fetal heart rate monitoring revealed recurrent late decelerations at that moment, and an emergency lower segment cesarean section was performed.
+A male infant was born at 35.1 weeks with an SCT of 200 mm. The combined weight of the baby and teratoma was 4030 g . His Apgar score was 9-10-10.
+Excision of the teratoma was performed at 36 hours of life, after embolization of the middle sacral artery. Surgery was done without incident, with an operative time of 3 hours. The reconstruction was done without any excess skin . Pathological findings revealed an immature teratoma and no evidence of yolk sac tumor or other malignant elements. The postoperative alpha-fetoprotein (AFP) levels decreased quickly, being 150,000 before surgery and 64,500 afterward. The neonatal AFP values were followed during the first months with values of 14,915 at the 14th day after birth, 4136 at 6 months after birth, and 1.3 at 12 months of life. Other blood test parameters (including liver function, blood cell count, and hemostasis) were normal in both mother and infant samples.
+The baby was discharged at 25 days after birth with normal results of abdominal, cerebral, and kidney ultrasound scans. Neonatal follow-up was performed during the first 16 months, and no long-term neurological deficits have appeared.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2037_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2037_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..706ae577458051b01102551966e664ba0d0191c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2037_en.txt
@@ -0,0 +1,10 @@
+A 12-year-old boy was admitted to our hospital on September 10, 2018 with a chief complaint of calvarial mass for 2 mo and multiple masses around the whole body for more than 1 mo.
+At 2 mo before hospital admission, a mass with a diameter of 2 cm on the left parietal was found in the patient, without local swelling, heat, or pain. The mass was considered a “scalp cyst” by the local hospital and was surgically resected without a pathological diagnosis. The masses resurfaced on the scalp on day 7 after surgery and quickly involved the whole body within 4 wk. The masses were hard and in progressive enlargement. The patient suffered fever, low back pain, sensory and motor dysfunction in the lower limbs, left eyeball protrusion, poor appetite and weight loss of 4 kg (13.3%). Ceftizoxime (1.3 g, intravenous infusion every 12 h [Q12H]) for anti-infection and mannitol (100 mL, intravenous infusion Q8H) for decreasing intracranial pressure were not effective.
+According to the past medical history, the patient was in good health.
+He had no family history of hematological diseases or tumors.
+Physical examination on admission was as follows: clear mind, weak reaction, appearance of malnutrition, painful expression, and passive position. The superficial lymph nodes around the whole body appeared a multiple, enlarged, and qualitative hard, with a diameter of 1.5-5 cm. Multiple subcutaneous nodules and masses were observed throughout the body, with sizes of 1-3 cm in diameter and tough/hard in texture. The left maxillofacial area was swollen with exophthalmos of the left eyeball. Cardiopulmonary and abdominal examinations showed no abnormalities. Muscle tension in both lower limbs was reduced with a muscle strength grade of 0. Abdominal reflexes and cremasteric reflexes still exist, but bilateral patellar tendon and Achilles tendon reflex are absent. Tests results were positive for Kernig sign, bilateral Babinski sign and Chaddock sign; and negative for Brudzinski’s sign.
+There were normal peripheral white blood cell counts and hemoglobin levels, elevated platelet 822 × 109/L (normal reference range 100-300 × 109/L), significantly elevated lactic dehydrogenase 1345 U/L (normal reference range 110-295 U/L), normal blood coagulation, and test results for hepatitis B, hepatitis C, hepatitis E, Epstein-Barr virus, cytomegalovirus, human immunodeficiency virus were negative. The cerebrospinal fluid was pale yellow and transparent with normal white blood cells, glucose, chloride, and protein levels, and no tumor cells were found. Bone marrow smears indicated 7%-47.5% of tumor cells, with large cell bodies, large amount of gray-blue cytoplasm, and fine nuclear chromatin . Flow cytometry analysis of bone marrow demonstrated that 4.48% of the cells expressed CD4dim but not CD45, CD56, CD8, CD3, CD2, CD7, CD30, cCK, GD2, CD15, cCD3, CD20, cCD79, Ki67, and so on, malignant hematopoietic system cells should be considered.
+Positron emission tomography/computed tomography revealed multiple enlarged lymph nodes in the neck, mediastinum, abdomen, pelvis, and inguinal region; and nodular lesions with increased level of 18-fluorodeoxyglucose metabolism in the encephalon, left posterior pharyngeal wall, left external rectus muscle, left lateral femur muscles and left kidney .
+Bone marrow biopsy revealed the absence of hematopoietic cells, infiltration of diffuse tumor cells, large volume of tumor cells, few lightly stained cytoplasm, some of which were vacuolar, presenting immunoblast-like appearance; round or irregular cell nuclei, light staining, prominent nucleoli; mononuclear and multinuclear tumor cells. Immunohistochemistry performed using lymphohematopoietic system markers indicated as follows: positive for CD45, weakly positive for CD10 and CD163; T-cell markers: negative for CD3 and CD5; B-cell markers: negative for CD20, CD79a, and paired box 5 (PAX5); immature cell markers: negative for CD34, CD117, TDT, CD123 and CD43; other markers: negative for CD56 and CD30. Lymphohematopoietic tumor should be considered, if it was unable to classify, myeloid sarcoma should be considered.
+To obtain a definite diagnosis, a neck lymph node biopsy was performed. Microscopic analysis showed the structure of the lymph node was destroyed, and it consisted of single large immunoblast-like cells, with round and light nuclei, large nucleoli and abundant cytoplasm; plasmoblast differentiation appeared; atypical multinucleated tumor giant cells were observed occasionally; presented as intrasinusoidal growth patterns. Immunohistochemistry analysis indicated as follows: T/natural killer cell markers: negative for CD2, CD3, CD43, CD4, CD8, TIA-1, and CD56; B/plasmocyte markers: positive for OCT2, BOB1, CD38 (focal weak), and MUM1; and negative for CD20, CD79a, PAX5, CD138; other immunomarkers: positive for LCA (leukocyte common antigen), ALK (cytoplasm, granular), immunoglobulin A, Ki-67 (> 90%), EMA, CD31, and FLI-1 ; negative for CD30, CD163, S-100, CD34, and TDT.
+Fluorescence in situ hybridization (FISH) study with ALK break apart probe (Wuhan HealthCare Biotechnology Co., Ltd., Wuhan, China) showed ALK gene disruption in the cervical lymph node. B-cell clonality assays revealed monoclonal IGH rearrangement. Next-generation sequencing (NGS) high-throughput RNA sequencing was performed for genetic testing of tumor cells in bone marrow, and in combination with Sanger first-generation sequencing, the CLTC-ALK fusion gene in the bone marrow of the patient was observed positive , in addition to the PGS1-CLTC fusion gene.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2046_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2046_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..489b789917a659b5215893e6ef5d3324e145905b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2046_en.txt
@@ -0,0 +1,3 @@
+A 65 years old right-handed woman, came to neurosurgery for consultation due to progressive bilateral visual loss in her temporal fields. This had occurred over 10 months, and 2 weeks prior to her admission she reported sudden loss of consciousness, prompting her admission to the hospital. On examination, she was alert and oriented x 3, she had a normal cranial nerve examination except for decrease visual acuity (20/200 in her left eye, 20/80 in her right eye), bitemporal hemianopia and mild atrophy of the optic disk in the left eye. Gait, motor and sensory examination was normal.
+Laboratory studies showed a LH at 0.22 IU/L (reference value in Postmenopausal females 15.0–62.0 mIU/mL)and prolactin at 53 ng/mL (reference value in non-pregnant females 2–29 ng/mL)0.7. A contrast enhanced brain MRI was obtained and revealed a sellar lesion which was hypointense in T1 but hyperintense in T2 sequences with enhancement of the periphery. The lesion extended into the sphenoid sinus and parasellar space without encasement of the carotids and into the suprasellar cistern abutting the optic chiasm. The patient underwent endoscopic endonasal transsphenoidal surgery for resection of the sellar lesion . Intraoperatively, the lesion appeared reddish in color and it was of soft consistency. Moderately bleeding was encountered during resection and a sample was taken for pathology. At the end of the tumor removal, the scaffold was implanted to close the bone defect in the sphenoid sinus . Due to the fact that the graft could be molded into shape, it was easily set and allowed to cover the entire size of the defect. A standard fat graft was then placed in the sphenoid sinus covering the outer membrane of the chitosan graft. Finally, fibrin sealant was used, and a nasal packing was inserted in both nostrils.
+The patient had an unremarkable postoperative period and after a few days the patient was discharged without evidence of CSF leak or complications. After one month the patient showed complete recovery of her visual acuity and visual fields. At follow up, the patient underwent a postoperative brain MRI illustrating gross total resection and good closure of the sellar floor. There were no signs of rejection or inflammation in the area where the chitosan scaffold was implanted.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2068_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2068_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd36e910c00f3e41937e6ea5e1b9adc9b7379406
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2068_en.txt
@@ -0,0 +1 @@
+A 60-year-old Kashmiri female presented to our department after having sustained a fracture of femur in the supracondylar region. After initial management, the fracture was fixed with a dynamic condylar screw assembly. After an uneventful postoperative period, the patient was discharged with advice to undergo supervised physiotherapy. 3 months into the postoperative period, the patient reported to our emergency department with pain in the thigh. X rays revealed a fracture above the dynamic condylar screw at the plate bone interface. The patient was admitted and revision surgery with a longer barrel plate performed. The patient followed up for a period of 4 months and was bearing weight when she again had pain in the peri implant area. Radiographs revealed a fracture of the femur at the new peri implant region. The patient's femoral neck radiograph revealed an osteoporosis grading of 3 according to Singh's classification . Keeping in view the potential morbidity associated with the repeat plating we planned a method that would be less invasive and less destructive to the local fracture environment. The proposed surgery was explained to the patient and her attendants. The ethical board permission was sought and obtained. The patient was taken to the operating room and placed on a fracture table. The screws in the plate were removed percutaneously under image intensifier control to ensure the patency of intramedullary canal leaving the plate insitu to avoid reexposure of the bone surface. The fracture was reduced and fixed with a reamed antegrade intramedullary nail. Anticipating the difficulties in distal locking with an insitu plate an external locking device comprising of a distal full ring and a proximal Italian arch connected by two threaded rods were used. No blood transfusion, bone grafting were used and the mean operating time was 40 minutes. The patient was ambulated on the first post operative day and discharged from the hospital on the same day after advising range of motion exercises of the knee. The patient was advised to compress the fracture at a rate of 1 mm per day in divided increments. The follow up was done at two week intervals. At a mean follow up of 8 weeks when the signs of healing were seen on the radiographs the external ilizarov fixator was removed. The fracture united at 14 weeks with a mean range of motion of the ipsilateral Knee being 0 to 120 degrees. There were no complications associated with the procedure.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2075_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2075_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a1bf79196e638cadf8f70cc298b5923198f8567f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2075_en.txt
@@ -0,0 +1,2 @@
+A 7 year-old Caucasian female was admitted to our hospital because of chest pain, cough, and fever. We learned from her medical history that, a ventriculoperitoneal shunt was placed with the diagnosis of hydrocephalus when she was 6 months old, and that the proximal part of the shunt was removed due to dysfunction two months ago but the part in the abdomen was left in its place and a new shunt was placed. During the physical examination, only crepitant rales were detected by chest auscultation. The chest roentgenogram showed an old shunt adjacent to diaphragm in left upper abdomen and a new shunt extending from in the right side . Computed tomography of thorax revealed a cavitary lesion with a diameter of 2 cm at the lower lobe of left lung, bronchiectasic areas, partial pleural thickening and a catheter end in left hemithorax .
+We performed a left thoracotomy from 6th intercostal space and encountered a 1 cm defect in the middle of left diaphragm and the 4 cm end part of the catheter entering from this defect into thorax cavity. The borders of the defect in diaphragm were widened and the shunt was removed by eliminating the adhesions in the abdomen, and then the diaphragm was closed primarily . After 5 days of postoperative period, patient was discharged from the hospital without any clinical problem. She was remained asymptomatic for 6 months follow-up after operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2082_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2082_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7dc79f82562a15c8b8149966391ab43c6c3b06e1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2082_en.txt
@@ -0,0 +1,5 @@
+The patient was a 49-year-old man from Shanxi province who was born to non-consanguineous parents. He presented with a history of progressive shortness of breath and edema of both lower limbs for 7 days. One week before admission, the patient developed shortness of breath in a supine position at night, which improved after 3-5 minutes of rest in the sitting position. The shortness of breath recurred 3–4 times per night, accompanied by progressive edema of both lower extremities. The patient denied any history of hypertension, diabetes, or smoking. Starting from the age of 8 years, the patient showed signs of bilateral upper and lower limb weakness during exercise and his sports tests never met the standard. At the age of 35 years, he started to complain of difficulty in swallowing solid food. Mild bilateral ptosis was noticed from the age of 45 years. He had a family history of MM. His eldest sister was diagnosed with MM based on histochemical analysis of skeletal muscle biopsy. However, no records of the exact site of mutation in the eldest sister were available. She developed respiratory failure at the age of 52 years and died of respiratory failure several years ago. The second sister showed progressive ptosis and bilateral limb weakness; however, she has not yet undergone skeletal muscle biopsy. The parents and the little sister of the patient appear in good health at present. The pedigree map of three generations of the family is shown in Fig. . The patient in our report is the family member, II-3.
+The patient had acute symptoms, but had normal sensorium at the time of hospitalization. He looked very thin and his height was 1.83 meters and weight was 49 kg. His vital signs were: body temperature, 36.6°C; pulse rate, 89 beats/min; respiratory rate, 25 beats/min; blood pressure, 124/85 mmHg. There was ptosis and facial weakness. Chest percussion showed dullness on the right chest wall and no significant enlargement of the heart; no cardiac murmur was heard on auscultation. Neurological examination showed no cranial nerve deficit. His cognitive abilities were normal. Ptosis was mild on the right and moderate on the left side. At rest, muscle strength and tone were normal in all 4 limbs. Serum creatine kinase (CK) level was 2280 IU/L (normal value < 200) while liver enzyme levels were slightly increased, including aspartate aminotransferase (AST) (120 IU/L; normal value <40 IU/L) and alanine aminotransferase (ALT) (57 IU/L; normal value <40 IU/L). Serum antinuclear autoantibodies/extractable nuclear antigens (ANA/ENA) levels were normal. Electrocardiogram and D-dimer level were normal. The B-type natriuretic peptide (BNP) level was 606 pg/mL and the level of soluble growth stimulating gene protein (sST2) was 97.64 ng/mL (normal value <35 ng/ml). Findings of arterial blood gas (ABG) analysis were: pH 7.286; PaCO2 73.6 mmHg; PaO2 62.7 mmHg; lactate 2.82 mmol/L (normal value <2.2 mmol/L); hemoglobin 177g/L. Although the PaO2 level was within the normal range on low-flow oxygen inhalation, the diagnosis of type II respiratory failure was considered because of hypercapnia. Pulmonary function test suggested severe restrictive ventilatory impairment. Chest high resolution CT showed bilateral pleural effusion (more on the right side) and increased thickness of pulmonary artery trunk and branches. The patient showed none of emboli, mosaic perfusion, disparity in segmental vessel size, parenchymal densities and thickening of bilateral pulmonary arteries in Computed tomographic pulmonary angiography (CTPA). Echocardiography revealed right heart overload characterized by dilated right ventricle (RV diastolic dimension: 44 mm) and right atrium (RA dimension: 45 mm) . Color Doppler ultrasound revealed mild tricuspid regurgitation and mild to moderate pulmonary hypertension; the systolic pulmonary arterial pressure was 56 mmHg. The tricuspid annular plane systolic excursion (TAPSE) level was 22 mm. Echocardiography showed normal left ventricular chamber volume with normal systolic function (estimated ejection fraction 71%) and normal filling pressures. Left ventricle short-axial view showed symmetric slight thickening of the left ventricle (LV) and the LV mass indexed for BSA was 118.07g/m2. At the end diastolic phase of the left ventricle, the thickness of both the ventricular septum and the posterior left ventricular wall is 13 mm.
+Needle electromyography (EMG) examination showed rapid recruitment of short-duration, low-amplitude motor unit potentials (MUPs) in bilateral deltoid muscles. He underwent muscle biopsy of left lateral thigh, which revealed variable size and shape of muscle fibers, with coexistence of oblong or small round fibers, occasional necrosis or regeneration of muscle fibers, hypertrophic fibers and split fibers in addition to typical features of mitochondrial dysfunction, including 8% ragged red fibers (RRF) and 42% COX-negative fibers.
+Gene sequencing analysis conducted by BGI Clinical Laboratory Center (Shenzhen, China) revealed a novel TK2 mutation at c.584T>C. The predicted amino acid change was p. Leu195 Pro. Whole exon gene results of the proband and family members showed that the mother had wild-type and the father, sister, and the patient had heterozygote TK2 variant (NM_001172644: c.584T>C, p.Leu195Pro). In-depth analysis revealed a heterozygous variant in an intron of TK2 (NM_004614.4:c.156+958G>A; rs1965661603) in the mother of the proband, the sister, and the proband. Based on the findings of muscle biopsy and DNA sequencing, the patient was diagnosed as a case of MM .
+He was administered intravenous diuretic and recombinant human brain natriuretic peptide. Round-the-clock non-invasive ventilation was provided during the first 10 days of hospitalization; subsequently, artificial ventilation was provided only at night. The shortness of breath was significantly alleviated with complete resolution of bilateral lower limb edema. ABG analysis results prior to discharge were: pH 7.388; PaCO2 52.7 mmHg; PaO2 123.5 mmHg; and hemoglobin 155 g/L. The patient was prescribed with the nocturnal non-invasive ventilation and coenzyme Q10 (CoQ10) at discharge. CoQ10 can promote oxidative phosphorylation and protect the integrity of biological cell membrane, it increases adenosine triphosphate (ATP) generation and cellular energy by mediating electron transfer in the electron transport chain. CoQ10 can be used as an adjunctive therapy for mitochondrial myopathy or heart failure. Echocardiography performed after one month showed no obvious abnormalities in cardiac structure or function. Echocardiography findings also showed improvement after treatment . No abnormalities were observed in BNP and sST2 levels. CK was reduced to 1250 IU/L and liver enzyme levels were restored to normal. ABG parameters were within the normal range (pH 7.411; PaCO2 42.9 mmHg; PaO2 86.5 mmHg; lactate 2.0 mmol/L; hemoglobin 151 g/L). A one-year follow-up, the patient was found to have well tolerated non-invasive ventilation support. He was able to perform his routine activities with no restrictions. Echocardiography showed normal cardiac structure and function. Currently, nocturnal bilevel positive airway pressure (BiPAP) therapy via a basal mask had been well-tolerated and ABG analysis was performed every 1 month, the ventilation pattern had not been changed after discharge. The patient is regularly receiving CoQ10.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_20_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_20_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2759fe54e2c81988a20309a77f5db8290bfe76b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_20_en.txt
@@ -0,0 +1,5 @@
+A 31-year old man was admitted with symptoms of acute joint pain of three weeks' duration in both hips. The patient had no specific past history of disease and his laboratory findings were normal. Plain radiographs and MR examination revealed Ficat II osteonecrosis of both femoral heads. The left femoral head was treated by allograft immediately after core decompression, while the right side was treated by injection of autologous cultured osteoblasts for four weeks after the core decompression .
+Follow-up CT obtained one year following treatment, demonstrated that the right femoral head had bone reformation in multiple necrotic areas, that the femoral head was still in optimal condition, and that the left head showed absorption of the grafted bone as well as disease progression.
+Radiographs obtained five years following surgery showed evidence of remodeling as well as maintenance of the right femoral head, but the left femoral head showed slight irregularity, sclerotic changes, and osteophyte formation . On both the MRI and the CT images obtained five years following surgery, the right femoral head showed nearly complete healing of the necrotic lesions, while the necrotic lesions and subchondral bone breakage were still demonstrated in the left femoral head. At the time of five-year follow-up, the patient did not complain of right hip joint pain and had considerable restoration of a full range of joint motion, however, he still complained of intermittent pain and slight limitation of motion in the left hip.
+Approximately 3 ml of bone marrow aspirated from the patient's posterior iliac crest, were added to a container filled with 30 ml of 10% FBS -α MEM (Sigma Chemical Company, St. Louis, MO, USA) and 350 units of heparin; the mixture was then taken to a laboratory. The mixture was centrifuged at 4°C, 472 g for 10 minutes after which the supernatant was discarded and 20 ml of culture medium was added to the remaining pellets. The mixture was filtered (Falcon, Franklin Lakes, NJ, USA), 10 ml of the medium were added per T-75 culture flask (Corning Science Products, Corning, NY, USA) and culture was initiated. The incubator (Automatic CO2 Incubator, Forma Scientific Inc, Marietta, OH, USA) was maintained at 37°C with 5% CO2. The next day, 50 μg L-ascorbic acid (Sigma)/10 ml and dexamethasone 10-7M were added to facilitate cell differentiation into osteoblasts. The cell culture condition was evaluated by a light microscope, and the culture medium was changed on the fifth day of culture, after which the culture medium was changed every three days with the subsequent addition of L-ascorbic acid. On the fourteenth day of culture, NBT-BCIP (nitro blue tetrazolium chloride – 5-bromo-4-chloro-3-indolyl phosphate) staining was performed to confirm activation of the alkaline phosphatase. Twenty-four days after beginning the culture, Alizarin red staining was performed to detect newly produced calcium, and it was thus confirmed that most of the cultured cells were osteoblasts. Approximately four weeks after beginning the culture, the medium was removed and the cells were washed with 5 ml 0.02% trypsin-ETDA (Gibco BRL, Gettysburg, PA, USA). 3 ml of 0.02% trypsin-ETDA was again added and the cells were incubated for five minutes. The trypsin-ETDA activity was stopped by adding 3 ml of culture medium, and all contents were collected in a conical tube and were centrifuged at 4°C, 265 g, for 6 minutes. The supernatant was removed, and the precipitate was collected. After adjusting the cell count to 1.2 × 107/ml, the cells were used in the transplant.
+Under local anesthesia, the patient was placed on a fracture table in a lateral position with the affected hip upside. A 19-G spinal needle was attached to a 2-ml-syringe which contained the cultured osteoblasts which were then inserted into the deepest portion of the core decompression site with the guidance of a C-arm fluoroscopic image intensifier. Two ml of cell mixture were slowly injected with progressive withdrawal of the spinal needle into the junction of the femoral head and neck. After completing the injection, a slight compression force was applied to the injection site for hemostasis and the lateral position was maintained for 10 minutes. After core decompression surgery, the patient did not put weight on both hips for six weeks, after which he gradually advanced during the next eight weeks to full weight-bearing.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2106_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2106_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..97e16dd646eb38338c5ed47f5bac86d424859773
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2106_en.txt
@@ -0,0 +1 @@
+A 54-year-old man attended the emergency department of the hospital with a painful locking of the right knee. He was trying to attain a kneeling position on the bed when his knee struck on the edge of the bed. Clinical examination revealed no palpable gap in the patellar tendon. The superior pole of the patella was projecting anteriorly and there was a prominent dimple below the patella. The patient was not able to perform straight leg raising. Plain radiographs confirmed a superior dislocation of the patella, which was manipulated by passing fingers under the prominent surface of patella, lower pole of patella was pushed posteriorly, and upper pole was pushed distally, gently flexing and then extending the knee which provided immediate pain relief. This procedure was done under the effect of intramuscular analgesia. The knee was then immobilized in a posterior long knee brace for three weeks. After three weeks, patient was active with pain-free range of movements and a stable right knee.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2108_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2108_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10d78b2a82c58ef5becab00cb0c47c668fba9832
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2108_en.txt
@@ -0,0 +1 @@
+A 65-year-old male with ischemic cardiomyopathy, permanent AF (diagnosed for five years), and a single-chamber DF-1 ICD for primary prevention was brought to the emergency department for multiple internal electrical shocks. He had his first device implanted 12 years ago and subsequently underwent two box changes, with the last being two years prior to the current presentation. His presenting ECG showed atypical atrial flutter/AF with a fast ventricular rate of 180 bpm . Device interrogation revealed a total of 51 shock therapies, all for rapid AF, which were mislabeled as ventricular fibrillation . No clinical signs or symptoms of decompensated heart failure were obvious on physical examination. The laboratory findings were unremarkable, including normal blood count and thyroid function. The echocardiography showed an enlarged left ventricle with a severely depressed ejection fraction (30%), mild valvular regurgitations, and a dilated left atrium with a diameter of 50 mm and a volume of 105 ml. The ICD had a ventricular tachycardia detection zone programmed at 170 bpm and a ventricular fibrillation detection zone programmed at 200 bpm with an initial detection duration of 3 s. Since most of the shocks were delivered for rates well above 200 bpm, we considered that reprogramming the device would be futile. So, because the patient was on optimal heart failure therapy (including an angiotensin receptor/neprilysin inhibitor, mineralocorticoid antagonist, and sodium-glucose co-transporter-2) and maximum AVN blocking agents (10 mg of Bisoprolol and 0.25 mg of Digoxin five days per week), a decision was made to control the heart rate with a physiological pace and ablate strategy. Successful LBBAP was first performed using a Medtronic C315 His catheter (Medtronic, Minneapolis, MN, USA) and a Medtronic SelectSecure 3830 lead (Medtronic, Minneapolis, MN, USA), with the identification of a large proximal left bundle branch potential and non-selective capture resulting in a paced QRS complex of 110 ms duration . The capture threshold for the left bundle branch was 0.7 V at 0.4 ms and the sensing values were above 12 mV. The lead was connected to the existing defibrillator`s IS-1 sense-pace port and the defibrillator coils to the corresponding high-energy ports. During the same procedure, successful ablation of the AVN was performed . The device was programmed with a single ventricular fibrillation detection zone at 200 bpm with an initial detection duration of 5 s. The patient was discharged the next day. The 6-month follow-up showed constant pacing and sensing thresholds, no inappropriate shocks, and an improvement in ejection fraction to 40%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2119_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2119_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4f2353fd29f20640495ba949f093b0d81ce25b3f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2119_en.txt
@@ -0,0 +1,7 @@
+A 4-year-old boy with history of an accidental ingestion of a metallic nail presented to the emergency department few hours after the ingestion and the examination was normal at that time, the plain abdominal X-ray confirmed the presence nail in the abdomen. The parents were reassured about the possibility of the spontaneous passage of the nail with the stool and they have been advised to visit the hospital if the child develops any kind of symptom. One week later he presented with right iliac fossa pain and one attack of vomiting.
+During abdominal examination, the abdomen was not distended and soft, there was tenderness and rebound tenderness at the right iliac fossa, the bowel sounds were normal and no palpable mass detected.
+Plain abdominal X-ray of the abdomen showed the metallic nail in the region of the right iliac fossa, with no other abnormal finding, . Ultrasound examination of the abdomen showed no fluid collection and there was tenderness on putting the probe on the region of the right lilac fossa.
+The white blood cell count was elevated (14,000 cells per microliter).
+Before surgery we suspected impaction at the ileocecal junction and if surgery is delayed it may lead to bowel perforation. During surgery surprisingly the nail was impacted the lumen of the vermiform appendix causing inflammation , .
+Appendicectomy done and the patient admitted for two days with no postoperative complications.
+The patient discharged on the third day in a good general condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2122_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2122_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ea54b984575f06cadfb69156e0e0781faf2f95b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2122_en.txt
@@ -0,0 +1,7 @@
+A 73-year-old man in need of nursing care visited our dental clinic in 2020 with severe gingival pain and intraoral bleeding. His medical history included cerebral infarction, hypertension, atrial fibrillation, and type 2 diabetes mellitus. The patient was treated with apixaban (10 mg/day), nifedipine (30 mg/day), olmesartan medoxomil (20 mg/day), metformin hydrochloride (75 mg/day), sitagliptin phosphate hydrate (15 mg/day), lansoprazole (10 mg/day), flunitrazepam (1 mg immediately before sleep), zolpidem tartrate (5 mg immediately before sleep), and sennosides (12 mg immediately before sleep). The patient’s family medical history was unremarkable.
+At the first examination, the patient’s gingiva showed generalized redness and bleeding with spontaneous pain . Prominent bleeding and discharge of suppuration were observed in the gingiva. The interdental papillae exhibited crater-shaped ulcerations. Severe oral halitosis was present. Physical examination findings were as follows: body temperature, 36.7 °C; blood pressure, 142/60 mmHg; and heart rate, 84 beats/min. The initial blood test indicated the following: white blood cell count, 6500/μL; platelet count, 22.8 × 104/μL, total protein (TP); 6.9 g/dL, C-reactive protein (CRP); 0.14 mg/dL, prothrombin time (PT), INR, 1.2; activated partial thromboplastin time (APTT), 40 s; and HbA1c, 6.0%.
+Although there were no suspicious symptoms or signs suggesting the possibility of human immunodeficiency virus (HIV) infection or leukemia, we ruled out these diseases through blood examination. Because the patient presented with gingival necrosis, spontaneous bleeding, severe pain, and halitosis, he was temporarily diagnosed with NPD. Periodontal examination and scaling were not performed during the first visit to avoid exacerbating gingival pain. Instead, we carefully removed the accumulated dental plaque from the tooth surfaces using gauze and applied 2% minocycline hydrochloride ointment to the gingival mucosa and periodontal pocket throughout the oral cavity.
+The acute symptoms resolved on day 7 (A). We conducted a periodontal examination, including an assessment of probing pocket depth (PPD) and bleeding on probing (BOP). Because our patient had difficulty undergoing extensive examinations, we evaluated the one-point PPD instead of the six-point PPD (B). Panoramic radiography was also performed (C). During the periodontal examination, the entire circumference of each tooth was explored using the walking probe technique, and the value of the deepest pocket was recorded as representative of that tooth. In 11 teeth, PPD ≥ 4 mm with bleeding was detected. Of these, seven had deep pockets of >6 mm (B). Panoramic radiography revealed a horizontal absorption of the entire alveolar bone (C). On the basis of these comprehensive findings, NP was confirmed as the final diagnosis. Our patient also met the transiently and moderately compromised status criteria in the 2018 classification of NPD.
+To improve daily oral hygiene, a team of periodontists, dentists, and dental hygienists educated care workers and other staff at the nursing home on appropriate oral cleansing, including brushing three times a day using the Bass technique. Basic periodontal therapy, including whole-mouth scaling and debridement of the root surfaces using hand and ultrasonic instruments, was also performed.
+On day 14, the patient’s periodontal condition was seen to have improved following treatment, and the gingival necrosis, redness, and pain resolved . The halitosis had also reduced. After periodontal treatment, six teeth had a poor prognosis (#4, #9, #26, #30, #31, and #32). These teeth had severe mobility and dental caries. We discussed the issues with the patient, and extraction of these problematic teeth was planned considering the patient’s overall well-being and situation, including the general condition, previous and present medical history, medication, paralysis, nursing care system, and the patient’s needs.
+On day 21, we extracted three teeth (#4, #9, and #32). One week later, on day 28, we extracted three more teeth (#26, #30, and #31). Seven days before the first extraction appointment, apixaban, a direct oral anticoagulant (DOAC), was changed to clopidogrel sulfate (75 mg/day), an antiplatelet agent. We thoroughly stopped the bleeding from the extraction fossa using sutures and cellulose oxide. No severe bleeding occurred after tooth extraction. The sutures were removed seven days after each extraction appointment. Seven days after the second extraction appointment, apixaban was restarted, and clopidogrel sulfate was ceased. On day 77, BOP and PPD ≥ 4 mm were no longer observed . Currently, dentists visit the patient fortnightly to manage his oral hygiene. To date, good oral health has been maintained.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_213_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_213_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..97910596f0c314f5e93261b86e1c45d7e67aa2cc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_213_en.txt
@@ -0,0 +1,10 @@
+A 53-year-old man with a long-lasting history of objective vertigo and neck pain accessed to emergency care because of a severe headache, disabling vertiginous crisis with falls, increasing neck pain also in lateral head movements and decline in health-related quality of life. Clinical examination showed hyperreflexia in lower limbs, diffuse burning paresthesia of the four limbs, bilateral Babinski sign, and downbeat nystagmus. Magnetic resonance imaging (MRI) and computed tomography (CT) scans showed a complex CVJ malformation with the basilar impression and radiological signs of myelopathy at the C2 level . Furthermore, a dynamic cervical spine X-ray proved that there was no instability in flexion and extension movements of the CVJ .
+The patient underwent a transnasal image-guided fully 3D endoscopic approach . Intraoperative neurophysiological monitoring was used: Somatosensory evoked potentials of the four limbs and motor evoked potentials. The technique to reach the CVJ has been described elsewhere.
+The lowest part of the clivus and the upper-medial portion of the C1 anterior arch were removed. After subperiosteal preparation of the C1 anterior arch, every effort was made to preserve the anterior arch integrity, drilling only its anterior–superior portion in the midline but keeping its continuity. At this stage, the partial drilling of the uppermost part of the odontoid peg was safely performed. After image guidance confirmation of the odontoid, a 3 mm coarse diamond burr was used to enter its anterior cortex. An ultrasonic bone curette was used to remove the tip of the odontoid, the base and the interface between the posterior cortex of the dens and the soft tissues covering the spinal dura. The decompression of the medulla and spinal cord was performed by using the neuronavigation system.
+Furthermore, pulsatility of the dura during surgery confirmed the achievement of sufficient decompression.
+After the procedure, the reverse U mucosal nasopharingeal flap harvested at the beginning of surgery was reapproximated and fixed with fibrin glue. A Foley catheter was held in place for 2 days to compress the mucosal flap. No tracheostomy was needed, and the patient received food orally the day after surgery
+Immediately after surgery, a dynamic X-ray scan was performed: The anterior atlas-dens interval (AADI), posterior atlas-dens interval (PADI), and C1–C2 total lateral overhang were measured as morphological criteria to determine the upper cervical spine stability. AADI and PADI remained stable after surgery, and the total C1–C2 overhang was no more than 7 mm, thus demonstrating no difference in CVJ motility compared with the preoperative radiographic pictures . Therefore, we did not proceed to posterior cervical stabilization, postponing the eventual decision in light of the clinical status in the follow-up.
+The postoperative course was uneventful, and the patient was discharged showing a significant improvement in paresthesia and the disappearance of nystagmus.
+Postoperative dynamic CT and MRI confirmed complete CVJ decompression, and the patient underwent a nasal endoscopic follow-up 1 month after surgery and another one 6 months after surgery .
+After an 18-month follow-up, the patient reported neither other vertiginous episodes, nor neck pain. Clinical examination showed normoreflexia in lower limbs, the absence of paresthesia of the four limbs, normal motor functions, bilateral negative cutaneous plantar reflex, and mild downbeat nystagmus.
+At the 18-month re-evaluation, a new dynamic X-ray scan showed no difference in CVJ motility in comparison with the preoperative and immediately postoperative ones .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2154_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2154_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a6e45a221c3c8f31f6150bb5c5610658e8c2adc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2154_en.txt
@@ -0,0 +1,19 @@
+In April 2018, a 37-year-old Syrian female came to the surgical outclinic of our institute in Aleppo-Syria, complaining of a palpable mass in her left breast, with retraction and ulceration of the skin, pain and redness. The mass grew gradually over the period of four months .
+The patient is an illiterate housewife that lives in a rural area. She has one child that she has breastfed him.
+The patient reported hypothyroidism. She was on l-thyroxin 50 μg/day but stopped the medicine two months ago without medical consultation. Otherwise, her past medical, surgical and medicinal history is clear, including pulmonary diseases.
+Review and examination of other systems was not significant. There was no history of weight loss, loss of appetite, night sweats or fever.
+The patient performed an ultrasonography (US) a month earlier. It showed a (4 × 6) cm poorly identified structure, which infiltrates in the glandular tissue and distorted the normal structure of glandular lobes, but without observing an isolated mass. No dilation in the mammary ducts was observed. The US also revealed an enlarged left axillary lymph node, 2 cm in diameter. The right breast and the right axillary region showed no abnormalities. At that time, two biopsies from the mass were performed by an interventional radiologist to investigate the mass. Histopathologic examination revealed no malignancy with acute non-specific mastitis and foci of fat necrosis.
+We performed another US and mammography for the two breasts. The mammography showed two dense and disproportionate breasts, and a (4 × 3.5) cm irregular mass located in the lateral upper quadrant of the left breast . For ultrasonography, the breasts were studied with a 7.5 MHz probe. We found a small, irregular, hypoechoic mass (4.5 × 3.6) cm located at 1 o’clock in the left breast, and an axillary lymph node in the left side was observed. We suspected malignancy.
+Chest X-ray was normal.
+The patient was admitted to our surgical department to be prepared for excisional biopsy of the mass.
+Laboratory values were as follows: Hb: 10.8 mg/dl– WBC: 10800/mm3 - TSH: 31.4 μIU/mL- CRP : 31 mg/L - ESR : 1st h 46.
+Hypothyroidism was corrected before surgery by l-thyroxin.
+Echography of the thyroid gland was within normal limits with some degree of atrophy. Once the patient reached euthyroidism (TSH: 2.1 μIU/mL), we performed lumpectomy under general anesthesia .
+The resected mass was tan and rubbery, measuring 13 cm. The cut section revealed irregular surface admixed with fat, and many dilated ducts with cystic formations and large areas of necrosis.
+Microscopic examination revealed granulomatous caseating tuberculous mastitis in the left breast. .
+Then the patient was put on (Rifampicinb150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg, Ethamputol 275 mg) and after one month of treatment by ATT drugs:
+HB: 14.5 mg/dl - WBC : 7500/mm3 -ESR : 34 1st hour - CRP : 6.8 mg/L - Iron : 70 mcg/dL.
+The patient did not adhere to treatment because she lives in a remote village, with limited accessibility to TB treatment facilities due to war. She came after three months with 3 masses in her left breast, The patient was sent to a radiologist and the echography revealed the presence of three masses: the first mass was (2 × 1.5) cm above the middle of the surgical incision by (2) cm with irregular borders, the second was (2 × 0.6) cm with irregular borders below the end of the lateral line of surgical incision by (2) cm, and the third was (3) mm lateral to the latter described mass.
+Near the place of pervious surgical incision, there was a hypoechoic tissue (2 × 2) cm and the Doppler showed a relative increase in blood supply. The rest of glandular tissue looked normal. Three axillary lymph nodes were seen (17–13–12) mm with a normal adipose hilum.
+We performed another lumpectomy. Biopsies were sent to the pathology laboratory and the result was caseating tuberculosis mastitis with abscess and fibrosis of left breast with no malignancy.
+The patient was successfully treated after the excision of the three masses and returning to the ATT drugs (Rifampicin150 mg, Isoniazid 75 mg, Pyrazinamide 400 mg, Ethamputol 275 mg) for 9 months with thorough follow-up. Another echography was performed after a year and was normal and the patient recovered.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2182_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2182_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a274c83bba531a77fcaed00753eb8d34de55adc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2182_en.txt
@@ -0,0 +1,4 @@
+A 31-year-old patient, gravida 1, para 0, of Romanian origin, with no medical or surgical history, was followed in the Obstetrical Department at Montpellier University Hospital (France). She was not related to her husband. After discontinuing an oral contraceptive, she rapidly became pregnant with a singleton pregnancy with a normal first-trimester ultrasound scan and a low risk for Down syndrome prenatal screening (1/10,000) with a PAPP-A at 1.42 MoM, freeB-HCG at 1.07 MoM. She was referred to the prenatal diagnosis unit because of an unusual imaging of the fetal profile during second-trimester ultrasound imaging. A specialized ultrasound scan, performed at 25 weeks, confirmed the presence of a eutrophic male fetus with a single medial incisor and a narrow superior maxilla possibly ogival, without posterior palatal cleft . Fetal brain was normal with no sign of holoprosencephaly. Additionally, a flattened nasal sulcus and a flat profile were also mentioned (D). The nose aspect and medial central incisor were suggestive of nasal pyriform aperture stenosis.
+A fetal magnetic resonance imaging (MRI) was then performed at 30 weeks’ gestation, confirming upper jaw dysmorphism of triangular appearance, with a single median incisor and nasal pyriform aperture stenosis . The morphological assessment of the median line of the brain did not reveal any malformation, especially no holoprosencephaly, no hypertelorism, no choanal atresia, no cerebral lobes agenesis, and no microcephaly. After genetic counseling, an amniocentesis was performed retrieving a normal fetal karyotype (46XY) and a normal CGH array. In the absence of cerebral abnormality, the couple was informed not only of the good prognosis of the malformation but also for the need for a specialized consultation with a pediatric otolaryngologist/pediatric plastic surgeon. Depending on the size of the nasal pyriform aperture stenosis, the newborn could experience rapidly after birth or within a few weeks a respiratory distress syndrome, or, he could also tolerate very well the overall hypoplasia. The delivery was therefore organized in a type III maternity for postnatal close survey of the child.
+The women delivered vaginally, at 39 weeks’ gestation of a baby boy weighing 3085 g (−0.8DS) measuring 46 cm (−1.7DS) with a head circumference of 33 cm (−1DS). He initially adapted very well in the delivery room with an Apgar score of 10 at 5 minutes, venous pH at 7.26, and arterial pH at 7.17. He did not experience immediate transient respiratory distress, and a routine neonatal intensive care unit survey for respiratory disorders was established. The newborn remained in spontaneous ventilation with an air humidifier and no desaturation below 90% was observed despite obstructive dyspnea associated with nasal pyriform aperture stenosis and mid-nasal stenosis confirmed by nasofibroscopy. Neurological clinical examination, child behavior, and paraclinic examinations were noted as normal, especially transfontanellar ultrasound, cerebral MRI screening on day 4, auditory screening, and funduscopic examination. The hormonal balance of the hypothalamic-pituitary axis was also normal.
+At 5 days of life, a facial computed tomography (CT) scan confirmed a nasal pyriform aperture stenosis measured at a maximum transverse diameter of 5.4 mm, associated with an overall hypoplastic aspect of the anterior half of the nasal fossae, which had a triangular morphology. The nasal septum, although medial, had a thickened aspect (measured at 4.5 mm). Choanal atresia was not associated and the single median incisor diagnosed prenatally was confirmed . Due to good respiratory tolerance, the baby boy was discharged at home at 12 days of life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2191_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2191_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..14a70a34e83ee6070befe24234e2ba46cfea4e72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2191_en.txt
@@ -0,0 +1,2 @@
+A 17-year-old male with progressive visual loss and photopsia was admitted to our ophthalmology clinic. He had a history of blunt trauma with a basketball to his right eye 6 months ago and had begun to suffer from visual disturbances since then. His visual acuity (VA) was 20/400 in his right eye. Dilated fundus exam of his right eye revealed a giant tear in the superotemporal retina with a shallow retinal detachment involving the macula . His visual acuity was 20/20 and anterior and posterior segments were normal in the left eye. He underwent a three-port pars plana vitrectomy for the giant tear without crystalline lens extraction. Perfluorodecaline was used intraoperatively. Three weeks postoperatively, perfluorodecaline was observed in the anterior chamber in contact with the corneal endothelium . No tilt or dislocation of the crystalline lens was detected on slit lamp biomicroscopy. We referred our patient to another eye clinic for ultrasound biomicroscopic (UBM) or endoscopic examination in order to determine zonular dialysis, but could not obtain these results as the patient refused (4)
+After our attempt to remove the perfluorodecaline in the anterior chamber with a 27G needle failed, an anterior chamber wash was performed with balanced salt solution via two wide paracentesis. Two months after vitreoretinal surgery, his best-corrected visual acuity (BCVA) was 40/200 in the right eye. The vision and retina remained stable in his follow-up .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2194_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2194_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..adbc57d5d92c2847890a4a8e81bada7a105aff23
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2194_en.txt
@@ -0,0 +1,4 @@
+A 55-year-old male patient had presented to us in the outpatient department with a gradually progressive swelling over ankle anteriorly, noticeable for the past 15 years. The swelling was globular, bony hard to feel and non-fluctuant in nature. It measured 100 × 70 × 50 mm clinically . The overlying skin was non-adherent to the underlying swelling, with no local signs of inflammation. Examination revealed dorsiflexion of the ankle beyond neutral to be restricted; however, plantar flexion was preserved. The subtalar movements were unaffected. There was no evidence of compression symptoms of the neurovascular structures in the vicinity.
+On radiographic evaluation, there was a huge anteromedial bony swelling originating from the neck of the talus and abutting the distal tibia . Computed tomography scan suggested a benign bony mass originating from the talar neck, likely to be osteochondroma . In view of the long-standing nature and benign radiographic appearance, the patient was planned for excisional biopsy of the swelling.
+The patient was operated in supine position, and a single anteromedial incision was given . The lesion was well-encapsulated and well-marginated from the surrounding soft tissues. It was excised en-mass, following osteotomy from the base and sent for histopathological examination (HPE) . The HPE showed the lesion to be an osteochondroma . The skin was closed primarily, and the redundant skin was left intact. A well-padded compressive dressing was done for a period of 02 weeks. Post-operative radiographs revealed complete removal of the lesion with a congruent mortise.
+The patient was full weight-bearing ambulant from post-operative day 1. The dorsiflexion of the ankle improved to 30°. The patient essentially had an uneventful recovery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2197_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2197_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..15bd3373fd56d3c1e3621b5fb2982187ce04de8d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2197_en.txt
@@ -0,0 +1,5 @@
+We report a case of a 54-year-old woman who presented with a new mass on the abdominal wall scar that had grown in the past 3 months. She had a cesarean sections 31 years ago. In 2017, she underwent laparoscopic right adnexectomy for a chocolate cyst of the right ovary.
+An increased abdominal mass was reported in our hospital, and physical examination revealed a subcutaneous solid tumor with a diameter of 3 cm around the scar of laparoscopic surgery on the right lower abdomen. Transabdominal ultrasound showed a cystic tumor in the subcutaneous adipose layer of the right lower abdomen . Trans-vaginal ultrasonography showed normal findings.Routine laboratory findings and tumor markers (AFP, CA125, HE4 and CEA) were normal, but serums CA-199 were elevated at 41.48U/m U/mL. The patient was excised under general anesthesia. During the intraoperative exploration of the fat layer, a 3 × 2 cm mass with hard texture could be reached. After the fat was cut open, a cystic mass could be seen, in which coffee-colored fluid flowed out a poorly differentiated endometrioid carcinoma . PAX-8, ER, KI-67 and CD10 were positive, while STATB2, GATA3, CDX-2 and PR were negative. Combined with the patient's history of laparoscopic surgery, ultrasound and pathological findings, it was highly suspected that the tumor was a malignant transformation of laparoscopic trocar endometriosis.
+Whole-body positron emission tomography and computed tomography (18-FDG PET-CT) were performed at disease stage 14 days after surgery and showed slight hypermetabolism in the incision area. Multiple swollen lymph nodes in retrodiaphragmatic, retroperitoneal, bilateral iliac vessels and right inguinal area, abnormal metabolism.
+Our patient then underwent surgical staging, laparoscopy through the peritoneum. The abdominal and renal pelvis were carefully examined, intraoperative adhesions between the greater omentum, the abdominal wall and the fundus of the uterus were observed. Tumor nodules were observed on the surface of the sigmoid colon and rectum. Right total iliac, external iliac, internal iliac, obturator lymph nodes and para-aortic lymph nodes were enlarged and fused into masses. Final pathology revealed a metastatic poorly differentiated adenocarcinoma arising from a foci of endometriosis.Tumor metastasis was observed in right pelvic lymph node and right inguinal lymph node.The remainder of the specimens were negative for malignancy.
+Serum CA-125 and CA-199 increased to 36 one month after operation, 48 U/mL and 77.67U/mL, respectively. Serum CA-125 and CA-199 decreased to normal 4 months after surgery. After the operation, patients received systemic chemotherapy (6 cycles of tri-weekly liposomal doxorubicin 30 mg/m2 and carboplatin AUC = 5), which is similar to adjuvant chemotherapy for epithelial ovarian cancer. CT scans showed no evidence of recurrence after 6 cycles of chemotherapy. Three months after 6 times of chemotherapy, she underwent repeat 18-FDG PET-CT examination, which revealed most of the original enlarged lymph nodes disappeared, with only a few small lymph nodes behind the peritoneum and low metabolism.Our patients showed no signs of recurrence 16 months after initial diagnosis,CA199, AFP, CA125, HE4 and CEA were all normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2201_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2201_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c694c584a6a341ac0150d2815f9cced76aabeba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2201_en.txt
@@ -0,0 +1,2 @@
+The patient is a 24-year-old right-hand dominant Hispanic female that initially presented to an urgent care office in October 2021 with a right small finger mass on the ulnar aspect of the proximal interphalangeal joint that had been present for several months prior to presentation. She had no pertinent medical or surgical history and a family history positive for renal cell carcinoma and diabetes on her maternal side of the family. She reported the mass would grow and reduce in size, especially during her pregnancy, when at times, she states it would grow to the size of an olive. Her pain worsened after pregnancy, with her newborn child grasping the finger frequently. The urgent care provider attempted aspiration of the mass, which was unsuccessful, and it was diagnosed as a likely ganglion cyst. The patient saw another local hand surgeon sometime after her urgent care visit, with apparent plans to remove the mass that was never executed. In March 2022, the patient presented to the treating hand surgeon with complaints of increasing pain and an open wound with bleeding from the original site of the mass starting one month prior. Plain radiographs demonstrated a soft tissue mass on the ulnar aspect of the small finger near the PIP joint, with some possible small punctate calcifications seen within. The patient underwent a surgical excisional biopsy of the mass on 3/15/22. The surgical pathology was reviewed by two independent pathologists, which was consistent with low-grade leiomyosarcoma of the finger. The immunohistochemical staining and histological slides are seen in . The patient underwent a PET/CT scan in early April 2022 , demonstrating a suspicious lymph node in the right axilla. However, the treating oncologist thought it was benign and likely reactive. This is a clinical and pathologic assessment consistent with AJCC stage 1 A disease. The right small finger mass was also appreciated on the PET/CT scan. A general surgeon was also consulted for a second opinion and felt the lymph node to be benign and reactive.
+Given the above clinical and imaging findings, in early May 2022, the patient was discussed at the tumor board of the treating hospital, and it was agreed that she would likely get the most benefit from a ray amputation. Routine laboratory studies around this time were unremarkable for any infectious or inflammatory workup. The same day, the patient presented to the treating surgeon's office with a new complaint of another mass, which was more distal on the small finger than the original mass. The exam and radiographs seemed consistent with what was likely another focus of leiomyosarcoma. On 6/15/22, the patient underwent successful right-hand minor finger ray amputation for her primary leiomyosarcoma. The small finger ray was amputated to the level of the mid-metacarpal shaft. The small finger digital nerves also underwent targeted muscle reinnervation. The wound was closed with primary wound closure . The surgical margins assessed by a pathologist were clear for any tumor, with the biopsy results again consistent with low-grade leiomyosarcoma. The patient was followed by her medical oncologist and the hand surgery team as an outpatient over the next several months. Her disease was stable, with the right axillary node showing no sign of change on repeat chest CT scans. The patient's right hand showed no evidence of recurrence or residual tumor clinically or on an MRI of the right hand obtained on 10/11/22. The patient continues progressing well postoperatively and initiated hand therapy approximately three weeks postoperatively. Most recent occupational therapy clinic notes indicated the full function of the right-hand digits 1–4, flexion 0.5 cm from the distal palmar crease, and comparable grip strength to the contralateral hand. She has no pain or other masses. Postoperatively she commented on a prominent and ropy scar, for which she also underwent aggressive therapy and massage . Continued oncologic surveillance and repeat MRI of the right hand showed no local or systemic disease recurrence at nine months postoperatively .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2209_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2209_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..edba0ca77b6a0386108cd260444e5582daa5287d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2209_en.txt
@@ -0,0 +1,30 @@
+We present the case of a female patient, 60 years old, which was admitted in May 2019, in the Dermatological Clinic of Emergency Hospital of Craiova after the onset of a new episode, consisting in the appearance of violaceous erythematous-oedematous infiltrated plaques, located on the face, neck, upper limbs , trunk and knees .
+The onset of the cutaneous manifestations had occurred 2 months prior this presentation, accompanied by pain, chills, flares of fever and arthralgia.
+A written informed consent of the patient was obtained, agreeing with publishing these data.
+Personal medical history: Umbilical hernia, treated by surgery 2 months prior.
+Relevant behavior: does not smoke, does not drink alcohol.
+Analysis of the case history revealed that the patient was first diagnosed with Sweet syndrome in 2014, during the hospitalization in another clinic. Based on the case history available from the patient, the results of the histopathological examination of the skin lesions at the time of initial diagnosis described:
+-polymorphous inflammatory infiltrate, relatively dense, located at the level of the superficial and middle reticular dermis, comprised of neutrophils and neutrophilic nuclear dust, intricated with mononuclear cells with immature appearance, lymphocytes, and some eosinophils;
+-inflammatory infiltrate with lymphocytes and some eosinophils with superficial perivascular location;
+-important oedema at the level of the papillary dermis.
+At that moment, in 2014, immunohistochemistry was also performed on the surgical specimen, resulting data showing: CD3-positive frequent small lymphocytes, CD20-positive rare small lymphocytes, CD30-negative infiltrate, CD-68 positive histiocytes and mononuclear histiocytoid cells, MPO-positive segmented granulocytes and mononuclear histiocytoid cells (immature granulocytes), and CD33-positive segmented and immature granulocytes.
+Based on the clinical, histopathological, and immunohistochemical profile, the diagnosis of histiocytoid Sweet syndrome was made.
+She followed a treatment with 32mg/day methylprednisolone, with positive response, but had many relapses after the discontinuation of the treatment.
+In 2017, due to a new episode, the histopathological examination was repeated and revealed the following features: tegument fragment showing minimal surface parakeratosis, marked inflammatory lymphoplasmacytic infiltrate with a large number of perivascular neutrophils and areas of leukocytoclasis with periadnexal and interstitial location in the reticular and deep dermis, dilated blood vessels lined by endothelial cells with intraluminal bulging.
+She received treatment with Disulone (which she did not tolerate) and Colchicine. She had not been administered any treatment throughout the previous year.
+The onset of the current episode (2019) occurred following the treatment she received for umbilical hernia.
+At clinical examination, we noticed a phototype II, normal weight female patient, having pains and crackling in the joints of knees and fingers on both hands.
+Laboratory blood tests showed: leukocytes 12.5x1000/microL, neutrophils 72,5%, ESR (erythrocyte sedimentation rate) 32mm/1h, HBsAg negative, Anti-HCV antibodies-negativ, anti-Ro and anti-La antibodies-normal; complements C3 1.55g/L normal and C4 57mg/dl (10-40) elevated, anti-DNA antibody 5.4UI/ml (<25), CIC (circulating immune complexes) <2U/ml (2-20), glycaemia 111mg/dL (65-110), GOT 12UI/l, GPT 17UI/L, GGT 34UI/L (7-32), CK (creatin kinase) 38U/L (<145U/L), FR (rheumatoid factor) 8.2IU/ml (<14IU/ml).
+Urinalysis findings: relatively frequent flat epithelial cells, relatively frequent leukocytes.
+Faecal parasitology findings: normal.
+Chest X-ray: heart within limits, without progressing pleural-pulmonary lesions.
+Ultrasound examination of the abdomen and pelvis regions revealed liver with steatosis, left lobe measuring 71mm, right lobe 152mm.
+Gallbladder reduces in size, two hyperechogenic images measuring 9 and 6mm respectively, suggesting the presence of stones, VP 7mm, main biliary duct 3mm, pancreas with infiltrate. Homogenous spleen, measuring 100mm along the long axis. Kidneys with normal size, without dilatations. Urinary bladder with soft walls. Uterus measuring approximately 46/38mm, homogenous structure, without fluid in the peritoneal cavity.
+Under local anesthesia induces by 1% Lidocaine biopsies were performed from representative lesions located on the forearm and right arm.
+The surgical specimen was fixed in 10% buffered formalin, processed for routinely paraffin embedding, sectioning and Hematoxylin-Eosin (HE) staining) in the Pathology Department of the same hospital.
+The histopathological examination showed:
+-abundant lymphoid cells, rare eosinophils and PMN with leukocytoclasis ,
+-inflammatory infiltrate in the dermis around the capillaries with turgescent endothelial cells .
+-tegument with orthokeratosis and inflammatory infiltrate in the dermis .
+Based on the case history, on the objective clinical examination, and on the histopathological and immunohistochemical findings the diagnosis of was supported.
+We initiated the treatment with 32mg methylprednisolone 1 tablet/day in the morning, topical Clobetasol ointment, 10mg Rupatadine-1 tablet/morning, 1mg Ketotifen-1 tablet/evening, with positive response.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_221_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_221_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..659fb4bfde77597785d481283da5f16acbce320b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_221_en.txt
@@ -0,0 +1,8 @@
+A 65-year-old Moroccan man with a history of diabetes and cigarette smoking had no relevant exposure to chemical industrial products in the past, and no notable surgical or family history.
+The patient presented 3 months before his medical consult with macroscopic hematuria, pollakiuria, and painful urination, without acute urine retention or digestive disorders, evolving in a context of conservation of the general state. Physical examination did not reveal any abnormalities. No mass was palpable on clinical examination of the abdomen.
+Pelvic ultrasound showed an echogenic irregular mass on the left lateral wall of the bladder associated with soft dilatation of the upper urinary tract . The baseline blood workup, including NSF and Glomerular Filtration Rate, did not reveal any abnormality.
+Cystoscopy revealed a non-papillary massive mass on the left lateral wall of the bladder, and a transurethral resection of the bladder tumor (TURBT) was performed at the same time. Pelvic MRI was not done due to lack of means.
+Histopathological analysis of the resected tissues showed a biphasic epithelial and mesenchymal proliferation, with invasion of the lamina propria and muscularis, compatible with the diagnosis of bladder carcinosarcoma, stage pT2. The transurethral resection was complete.
+Staging including pelvic CT scan revealed a heterogeneous mass of the dome and the left wall of the bladder, measuring 10 × 6 cm, invading the bladder wall until serosa . There were no iliac lymph nodes, the ipsilateral ureteral orifice was intact, and there weren't any signs of upper urinary tract obstruction. Thoraco-abdominal CT, as well as bone scan, were free of metastasis. The patient was classified as T3N0M0.
+After urology tumor board meeting, the patient underwent radical cystoprostatectomy with ileal conduit urinary diversion (Bricker), and an extended pelvic lymph node dissection. There were no post-operative complications. Histopathological examination of the specimen revealed a high-grade carcinosarcoma invading the bladder wall until the serosa and the trigone, with the prostate and the urethra free from tumor extension. Two of eight pelvic lymph nodes were positive for metastatic carcinosarcoma without extra-nodal extension. All surgical margins were negative for tumor. Immunohistochemistry showed positivity of Pan-cytokeratin, GATA3, and vimentin, and negativity for CK7, myogenin, desmin, and PSA .
+After discussion with the multidisciplinary board, an adjuvant chemotherapy based on gemcitabine-cisplatin was indicated, and a total of six cycles were received with no significant toxicity. The patient was scheduled for trimestrial clinical visits, Cystoscopy · months after finishing treatment, UroTDM performed each semester. Twelve months after treatment, the patient is still under follow-up with no locoregional or metastatic disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2224_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2224_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..20a65b48e6e8292fea5356d7516d266564b490f4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2224_en.txt
@@ -0,0 +1,4 @@
+A 12-year-old girl brought by her mother complaining of abdominal pain and dyspepsia for the last 6 months; the pain was located around the umbilicus and left hypochondrium irradiating inferiorly associated with dysuria. The patient also suffered from fatigue, lethargy, and high fever (38–39.5°C) due to a urinary tract infection which was treated with antibiotics; her drug and surgical history were clean. Clinical examination was normal except for a solid mobile palpitated mass in the left pelvic associated with mild tenderness toward the left hypochondrium.
+The ultrasound (US) showed a mass consisting of solid and cystic parts; the cystic compound occupied 85% of the mass and showed multiple fluid-filled microcysts . The cystic compound was only 1.7 cm away from the abdominal aortic branching and extended inferiorly adjacent to the right main iliac vessels and completely surrounded the left iliac vessels, the left psoas, and prevertebral muscles and extended behind the upper part of the bladder. The computed tomography (CT) showed a large cystic formation that extended from the spleen’s hilum inferiorly and medially, infiltrating the pancreatic tail and reaching the upper surface of the bladder; the fluid’s signal indicated blood or high-protein fluid. The imaging features were consistent with CL amongst different possible diagnoses, such as diploid cyst and mesenteric cyst. Therefore, the doctors decided to surgically remove the mass.
+The patient underwent open surgery to remove the mass, and A.S. and S.A. (authors of this article) carried out the surgery. The cystic compound and infiltrated spleen and pancreas’s tail were removed as a single mass . Histopathological findings revealed benign CL. A follow-up using US was done one year after the surgery, and it showed normal abdominal structures with no residual components or signs of recurrence .
+This work has been reported according to SCARE (Surgical CAse REport) criteria.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2286_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2286_en.txt
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index 0000000000000000000000000000000000000000..3c1f0561e08684bb9f017af560da0b8fc5884948
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2286_en.txt
@@ -0,0 +1,3 @@
+A 28-year-old woman was admitted to Jordan University Hospital in Amman, Jordan, February 22, 2009, complaining of severe muscle spasm. The history of the present illness dated back to three months earlier when she started to complain of painful muscle spasms in her arms, hands and legs. This had been associated with mouth deviation, teeth clenching and involuntary eye twitches with left-sided predominance. The episodes were associated with loss of consciousness and on one occasion associated with tongue bite, but were never preceded with an aura. The attacks were only relieved by taking diazepam and were followed by dizziness and generalized weakness lasting for a few hours. Laboratory studies showed hypokalemia (K = 0.69 mmol/L), hypocalcemia (Ca = 1.47 mmol/L), hypomagnesemia (Mg = 0.58 mmol/L) and pure metabolic alkalosis. Five years ago, she had gone on many kinds of diets in order to lose weight, and decided that the suitable one for her comprised the eating of one small bag of chips and a large quantity of water daily, and she started to vomit several times a day after eating any kind of food. The only food she could tolerate was salt, lemon, citric acid, tomatoes and cucumbers. As a result she developed some sort of addiction to salty food; claiming to consume 3 to 4 tablespoons of table salt (NaCl), 4 tablespoons of citric acid, and 10 lemons a day. Over the past 18 months, she had had difficulty urinating without the use of diuretics (Lasix® Furosemide 40 mg 12 tablets per day) and had become physically dependent on it. On occasions she also experienced legs swelling associated with high blood pressure self managed by increasing her diuretic dose. Afterward, she suffered from severe constipation due to her lack of appetite and reduced food intake caused by depression, the patient relied mainly on salty chips and lemon only as her sole food and was not well-fed as normal healthy people; consequently, the gastrointestinal motility was negatively affected which led to constipation. The patient was unable to pass stool except by the help of a laxative (Dulcolax® bisacodyl 5 mg 12 tablets per day) which she had become dependent on.
+The patient lives with her 3-year-old daughter and her sister in-law. She claimed to have poor sleeping habits and usually slept during the day. She sometimes spent 2 to 3 days without sleeping at all. She claimed to use amphetamine and have attempted suicide several times. The most recent was attempting to jump off the balcony, which was prevented by her mother. She has been a heavy smoker (3 packs/day for the past 15 years) and drunk one pint (one pint is equal to 473 mL) of beer every 3 days. The patient didn’t have any seizure.
+Upon hospitalization, and correction of serum K, Ca and Mg her symptoms were relieved. Known organic causes of salt craving such as Addison’s disease were excluded by appropriate investigations. A psychiatric consultation revealed a disturbed social history with masked depression. The patient was started and discharged on mirtazapine 30 mg 1×1, risperidone 1 mg 1×3 and citalopram 10 mg 1×2, CaCO3 tablets, K-gluconate syrup, Mg-sulfate sachets and vitamin D supplements for 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2301_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2301_en.txt
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index 0000000000000000000000000000000000000000..0a10051006f38503bdd3c9784aa39e9c7ff951b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2301_en.txt
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+A 33-year-old gravida 1 para 1 with a past medical history of seasonal rhinitis and severe AD dating back to early childhood, presented in the setting of worsening AD refractory to high potency topical corticosteroids, systemic corticosteroids, antibiotics for staphylococcal superinfection, methotrexate, cyclosporine as well as ultraviolet phototherapy. Her initial diagnosis and care were directed by a different healthcare provider 4 years prior to examination at our institution. Her examination at that time revealed periorbital hyperpigmentation, erythematous lichenification of the anterior chest, arms, and neck. The back was spared. She was subsequently started on hydroxyzine, clarithromycin and triamcinolone cream which resulted in mild improvement, but on discontinuation her AD flared. Three years after multiple therapies she sought treatment in the United States. Her Investigator Global Assessment for Atopic Dermatitis score of 4 was indicative of severe disease with greater than 10% total body surface area involvement. She was subsequently initiated on dupilumab 300 mg every 2 weeks with significant improvement in her skin disease and quality of life. She became pregnant 12 months later. Discussions about continuing dupilumab during pregnancy were held with both her allergist and dermatologist reviewing the risks and benefits of therapy during pregnancy as well as concerns regarding maternal antibodies crossing the placenta. She decided to remain on dupilumab 300 mg every 2 weeks. During her pregnancy, the patient had routine monitoring including regular bloodwork and guideline-based ultrasounds which were normal during the first 2 trimesters. The patient continued use of lubricating eye drops and thus, did not develop ocular symptoms during her pregnancy. At 27 weeks gestation, the patient self-discontinued dupilumab. Unfortunately, she experienced a self-reported severe flare of AD only 2 weeks after discontinuation that was refractory to topical treatments and the patient self reinitiated dupilumab at 29 weeks gestation. The patient was not assessed in clinic at this time and therefore there are no severity scores available for this flare. The patient remained on dupilumab until 36 weeks of gestation. At 38 weeks gestational age, ultrasound imaging revealed concerns for intrauterine growth restriction as well as breech position. The patient underwent urgent Caesarean Section with delivery of a healthy female infant (Weight 2480 g). Surgical pathology revealed normal umbilical cord vasculature, normal villous maturation compatible with a third trimester placenta with no evidence of villitis or infarct, and no chorioamnionitis. There were no issues postpartum. The patient was reassessed 6 weeks postpartum and had opted to breastfeed. The patient did not develop any further flares of AD despite self discontinuation of dupilumab. To date post-partum, the infant continues to meet age appropriate milestones.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2307_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2307_en.txt
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index 0000000000000000000000000000000000000000..ff8c16bfc732e2deee699a3ce98d21306b1c5a7a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2307_en.txt
@@ -0,0 +1,3 @@
+The patient was a man in his 60s who visited the Department of Gastroenterology for the treatment of autoimmune pancreatitis and had been diagnosed with pancreatic cancer with liver metastasis (T2N0M1, stage IV) two years previously. Subsequently, he consulted the Department of Medical Oncology and started chemotherapy, which included four courses of FOLFIRINOX, 10 courses of GEM + nab-PTX, and two courses of nal-IRI + 5-FU/LV. As his case was judged to be a progressive disease one year prior, the hospital focused on palliative care. At that time, he was referred to the Department of Supportive Medicine and Care for Cancer because of severe abdominal pain, which was considered cancer-related, and administration of 10 mg/day of oxycodone was started. Thereafter, he continued outpatient visits, and the oxycodone dose was adjusted according to the pain level. However, three months prior, he was admitted to the Department of Neurosurgery because he developed a brain abscess associated with infection after surgery for a cerebral aneurysm. After subcutaneous irrigation and drainage, his symptoms improved, and he was discharged from hospital. He continued to receive LVFX 500 mg/day to prevent recurrence of brain abscess. Subsequently, the dose of oxycodone was increased to 50 mg/day for worsening abdominal pain by the outpatient clinic, but it was still difficult to control the pain; therefore, he was admitted to the Department of Supportive Medicine and Care for Cancer for pain control. At the time of admission, his height was 169.0 cm and body weight was 63.5 kg; he was ambulatory and capable of all self-care but unable to perform any work activities (performance status 2; denoting the day of admission as day 1).
+Upon admission, hepatic dysfunction and exacerbation of inflammation were observed. In addition, CT examination indicated exacerbation of the primary tumor, enlargement of the liver metastases, and appearance of multiple lung metastases; therefore, the primary disease was judged to have aggravated rapidly. At the time of admission, he complained of severe pain with a numerical rating scale (NRS) score of 7/10 . Therefore, he was switched to an injection of oxycodone 40 mg/day, and the dose had to be adjusted to 100 mg/day by day 10. However, the pain persisted, with an NRS score of 5/10, and ketamine 30 mg/day was initiated because of the poor response to increasing opioid doses. Several hours after the start of the ketamine treatment, the patient complained of nausea. Therefore, the oxycodone dose was reduced to 70 mg/day and the nausea improved. The day after the start of the ketamine treatment, an improvement to NRS = 3–4/10 and a decrease in the number of rescue doses was observed; methadone was introduced because the patient and his family wanted him to be discharged. Methadone treatment (15 mg/day) was initiated on day 14. The doses of oxycodone and ketamine were tapered and terminated . In addition, we considered that LVFX, which carries a risk of QT interval prolongation, has to be discontinued or changed; however, the neurosurgeon recommended the continuation of LVFX because it showed no evidence of the recurrence of brain abscess. Additionally, bacterial culture showed that the causative bacteria of the brain abscess were very sensitive to LVFX. Therefore, the patient’s QTc was carefully monitored, along with his respiratory rate .
+Oxycodone was reduced to 50 mg/day and ketamine was reduced to 15 mg/day when methadone was started on day 14. Ketamine was discontinued on day 15 because he did not feel worsening pain. The oxycodone dose was subsequently reduced to 40 mg/day on day 16. On the same day, although it did not meet the diagnostic criteria for long QT syndrome, an increase in QTc of approximately 10% compared to baseline was observed. Therefore, we asked the neurosurgeon to change LVFX to sulfamethoxazole/trimethoprim (ST). On day 17, QTc improved, and the pain subsided (NRS = 2–4/10); therefore, the oxycodone dose was reduced to 20 mg/day. On day 18, oxycodone dose was further reduced to 15 mg/day; on day 19, it was again reduced to 7 mg/day and ended on day 21. Further, no recurrence of the brain abscess was observed by continuing with ST. As he did not experience pain exacerbation (NRS = 1–3/10) on day 22, he was discharged with a dose of methadone of 15 mg/day. Figure shows the changes in the NRS and the number of rescue doses during hospitalization. In addition, Table shows the changes in laboratory values after methadone treatment was initiated, and Table shows a list of the drugs used during hospitalization.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2315_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2315_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..41e25bd21732c7cacdfac8e706dfc38d529c97ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2315_en.txt
@@ -0,0 +1,6 @@
+A 29-year-old woman with systemic lupus erythematosus (SLE) diagnosed at age 12 years with severe idiopathic thrombocytopaenic purpura (ITP), presented acutely while visiting her baby in the Neonatal Intensive Care Unit with sudden onset chest pain and shortness of breath. Her SLE was complicated by spontaneous deep vein thrombosis, triple positive antiphospholipid syndrome (APLS), and Class IV lupus nephritis. This triggered an emergency call to the neonatal ward, with examination notable for tachycardia, but normotensive and normal oxygen saturation initially. Her chest was clear with dual heart sounds and no oedema. Her medications at presentation were enoxaparin 100 mg and aspirin 100 mg daily, transition to warfarin was planned at 2 weeks’ postpartum. Her immunosuppression regime was hydroxychloroquine 400 mg daily, azathioprine 150 mg daily, and prednisone 5 mg daily, other medications included calcitriol 0.25 μg daily and calcium carbonate 1.25 g daily.
+Electrocardiogram (ECG) showed sinus tachycardia with no ischaemic changes. Initial blood results shown in . Chest X-ray showed cardiomegaly with increased interstitial markings . She deteriorated rapidly over the next hour with climbing oxygen requirements and hypotension and was investigated for pulmonary embolism (PE) and treated with morphine and enoxaparin. She was escorted to radiology from the neonatal ward for the CT pulmonary angiography (CTPA) which showed pulmonary oedema and no PE and was admitted to cardiovascular intensive care (CVICU). On arrival, she was intubated for respiratory distress and, as no transthoracic echocardiogram had been performed, she had a transoesophageal echocardiogram. This demonstrated the posterolateral papillary muscle rupture and flail anterior leaflet with torrential MR and preserved left ventricular (LV) function (see ).
+She proceeded to emergency mitral valve (MV) replacement, on transfer to the operating table she had a pulseless electrical activity (PEA) arrest, resuscitated with adrenaline and CPR before return of circulation and the start of operative intervention. The posterolateral papillary muscle was pale and sheared directly off the ventricular wall. The MV was replaced by a 29-mm St Jude’s Mechanical valve. At the end of the procedure, VA ECMO was instituted due to persistent severe pulmonary oedema and biventricular failure despite maximal ionotropic support.
+The histology of the valve revealed preserved architecture with scattered fibrinous deposits and a focal larger fibrinous vegetation with occasional inflammatory cells, with no organisms, consistent with chronic Libman -Sacks endocarditis . The papillary muscle showed extensive central necrosis with a surrounding rim of acute inflammation consistent with infarction several days old, thrombi were seen within the intramyocardial arteries . The endocardial surface had mixed inflammatory infiltrates and focally fibrinous material with granuloma-like appearance, in keeping with Libman–Sacks.
+ECMO was required for 2 days, on decannulation and desedation, she had some abnormal movements so magnetic resonance imaging (MRI) brain was performed which showed widespread hypoxic injury. She had paroxysmal atrial fibrillation and mild LV impairment so was commenced on metoprolol CR 166.25mg and cilazapril 1 mg daily and transitioned from heparin back to warfarin and aspirin 100 mg daily. She underwent inpatient rehabilitation after 4 weeks in CVICU before discharge. At this point, her neurological function was normal.
+She continued the same immunosuppression regime from admission on discharge as well as the medications mentioned above. She was planned to continue both aspirin and warfarin given the recurrent thrombosis previously.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2344_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2344_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eacab8923cd92509de0cee9903e82fd904c22f51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2344_en.txt
@@ -0,0 +1,4 @@
+A 71-year-old female patient with the right knee tri compartmental osteoarthritis underwent a right TKA using a posterior stabilized (PS) fixed bearing cobalt chrome implant (PFC Sigma DePuy, Synthes). The surgery was performed through a medial para patellar approach. A combination of measured and gap resection method was used for ligament and flexion/extension balancing. The implant component used was size two femur, size two tibia, 8 mm polyethylene insert and a size 32 patella. The post-operative period was uneventful and post-operative radiographs demonstrated well aligned components . She was started on a standard TKA rehabilitation protocol with elbow crutch assisted full weight-bearing ambulation from post-operative day 1 for a month. A range of motion (ROM) of 0–125° was achieved by 3 months by which time she was comfortable walking unassisted.
+Twelve months after the index surgery, she presented with the operated knee locked in flexion. She described attempting to stand from a squatting position and falling forwards. Examination revealed moderately swollen knee in 60° of fixed flexion with further flexion to 120°. Neurologic examination was found to be normal. Standard radiographs revealed PKD .
+The patient was taken to theatre for an examination under anesthesia with a plan for revision if needed. Under general anesthesia, the knee was flexed to maximum to bring the polyethylene post below and parallel to the inferior aspect of the cam and tibia was pulled anteriorly to reduce the knee. After reduction, we attempted to re-dislocate the knee in full flexion with a posteriorly directed force on the proximal tibia . We found the joint to be stable through the entire range of movement in both sagittal and coronal plane and could not be dislocated even on applying a posterior force in full flexion.
+Her range of movement was restored to 0–125° and was mobilized full weight bearing. She had an uneventful recovery at 3 years follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_234_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_234_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c8578993c64dc897ba630ea0c3cb45bb49a295c8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_234_en.txt
@@ -0,0 +1,10 @@
+A 53-year-old female patient presented to the First Affiliated Hospital of Beilun Branch of Zhejiang University China on September 2015 complaining of pain on the right side of her abdomen associated with abdominal distension and multiple episodes of vomiting for 1-week duration. She denied changes in bowel habits, blood in stools, and past abdominal operations. Her family history was insignificant for neurofibromatosis type 1. On abdominal examination, she exhibited abdominal guarding, but no palpable mass was found. Abdominal CECT demonstrated intussusception in the ascending colon with a smooth enhancing 3.5 cm mass suspicious for neoplasm . Colonoscopy was deferred due to significant exacerbation of pain and worsening peritonitis. The patient subsequently underwent emergent exploratory laparotomy. Due to difficulty reducing the ileocolic , right hemicolectomy with ileocolic anastamosis was performed . Exploration of the abdomen revealed no carcinomatosis. The intraoperative frozen section displayed spindle cell tumor of the small bowel. Although there seemed to be no apparent lymphadenopathy in the mesentery, we resected the mesentery to include the potential lymph node metastases. The resected specimen revealed a 4.0 × 3.5 × 2.3 cm submucosal mass of the distal ileum . Macroscopic examination demonstrated a gray-white appearance of the tumor cross section, without hemorrhage and necrosis. Histologically, the tumor was composed of bundles and palisading arrangement of malignant spindle cells that extended into the muscularis mucosa . The tumor had dense cellularity with significant mitotic activity of approximately 10 mitoses per 10 high-power fields. The surgical margins were negative for the tumor. On immunohistochemical staining, the tumor was positive for S-100 and CD34, but negative for CD117, DOG-1, SMA, AE1/AE3, HMB45, and PNL-2. The Ki67 labeling index was approximately 15–20% . On the basis of these pathological findings, the tumor was identified as a low-grade malignant peripheral nerve sheath tumor (MPNST).
+The patient declined to undergo further genetic analysis and chemotherapy. She had a good postoperative course and was discharged 2 weeks after surgery. She presented with diarrhea, fever, and moderate anemia at 3 and 7 months post-operation. Abdominal CECT demonstrated no sign of tumor recurrence and metastatic disease. She underwent symptomatic treatment and was discharged home. In June 2016, she died due to complications of her disease.
+According to the WHO, MPNSTs are defined as any tumor originating from a peripheral nerve or exhibiting nerve sheath differentiation. MPNST is the sixth most common type of soft tissue sarcoma [, ]. Approximately 50% of all MPNST cases arise sporadically, whereas the other cases are observed in patients with neurofibromatosis type 1 (NF1) [, ], who carry an estimated 8 to 13% lifetime risk of developing MPNST . An estimated 3 to 10% of all MPNST patients have a clinical history of prior radiation exposure after a latent period of more than 15 years . MPNST is typically characterized in adults with most tumors occurring in patients between 20 and 50 years of age with a median age of 35 .
+Most MPNSTs are located along major nerve trunks, commonly arising on the body trunk, extremities, head, neck, and paravertebral regions . MPNSTs arising from nerves of the small intestinal wall are extremely rare, with only fewer than 10 cases reported worldwide [–].
+There seems to be no characteristic clinical symptoms of MPNST of the intestine. Most patients experience fatigue, weight loss, emesis, abdominal pain, and intestinal bleed . Our patient presented with intestinal obstruction due to intussusception. The diagnosis is often delayed because these symptoms are usually non-specific and vague, thereby increasing the difficulty of a preoperative diagnosis of MPNST of the small intestine.
+The quantitative FDG-PET imaging is used to distinguish between benign PNST and MPNST based on a tumor’s metabolic activity [, ]. Due to the disability to effectively confirm malignant transformation of lesions, CT and MRI are limited to define the anatomic tumor size and local invasiveness of PNST [, ]. The quantitative FDG-PET imaging combined with CT or MRI may be the best way to distinguish MPNST from benign PNST. However, radiographic imaging of MPNST has not supplanted histopathologic examination as the gold standard for the diagnosis of MPNST . In our case, the CECT of the abdomen revealed an intussusception in the ascending colon with a smooth enhancing 3.5 cm mass suspicious for neoplasm, but could not confirm its definite lesion.
+It is important to recognize that there is still a lack of widely accepted diagnostic criteria for MPNST . These tumors have well-described morphological heterogeneity, and staining reveals highly cellular spindle cell tumor in fascicles . S-100 protein has been the classic and most widely used antigen for documenting nerve sheath differentiation. CD34 is expressed in some MPNSTs and is likely a reflection of perineurial differentiation. Many studies suggest that elevated Ki67 expression is associated with decreased survival in MPNST [, ]. The reactivity of S-100 protein and high levels of p53 and Ki67 can be useful in making the final diagnosis . In our case, the diffuse expression of S-100 protein and the level of Ki67 were in favor of MPNST.
+Forty to 65% of MPNST patients experience local recurrence, and 30 to 60% develop metastases within 12 months of initial surgery . Factors that predict recurrence include anatomic site, tumor size (≥10 cm), and adequacy of margins. Factors that predict metastases include tumor size (≥10 cm) or tumors that are American Joint Committee on Cancer stage III . Over two thirds of metastases develop in the lung, whereas the other sites include the liver, brain, bone, and adrenal gland . To date, there is little knowledge on MPNST of the small bowel, which is thought to have a far worse prognosis than other soft tissue sarcomas.
+Because of its rarity, the optimal treatment of the small bowel MPNST is not well established . Current recommendations and treatment may be based only on what is known of this tumor in other locations of the body. Complete surgical resection with wide negative margins is the current standard of care for localized MPNST and is a strong predictor of survival . Adjuvant radiation therapy can been used to locally control MPNST . However, small bowel MPNST may not benefit from the radiotherapy due to the location in the abdominal cavity . Although chemotherapy has been carried out on gastrointestinal MPNST after surgical treatment, there are no further trials evaluating the role of chemotherapy in unresectable and metastatic tumors . Recent advances in therapy have focused on targeting the molecular pathways in MPNST, but the outcomes of recently clinical trials demonstrate that further studies are needed [, ]. The multidisciplinary approach should be adopted to cope with these tumors.
+According to the clinical and pathological characteristics, this patient was diagnosed the MPNST of the small bowel. Unfortunately, further genetic analysis was not obtained, due to patient preference as this could have been helpful for creating further treatment plans. Here, we report a rare case of MPNST of the distal ileum, which, to the best of our knowledge, was also the first Chinese case of this disease. Although MPNST arising from the small bowel is extremely rare, a surgeon should also be aware of the possibility of MPNST when dealing with intestinal obstruction or intussusception. Since patients with MPNST have very poor prognosis, it is necessary to perform a quick frozen section in the operation for a clear diagnosis. We suggest an extended radical operation in case of the fast frozen section displaying spindle cell tumors of the small bowel.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2353_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2353_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..27247f3e2b8ba9179ed42e144f240c223bb6b2de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2353_en.txt
@@ -0,0 +1 @@
+A 70-year-old male patient with no remarkable medical history presented to our emergency department with chest pain of 10 days’ duration. His initial vital signs showed sinus tachycardia (100 to 110 b.p.m.), a blood pressure of 134/85 mmHg, and a body temperature of 36.7°C. No heart murmur, no crackle and no rub detected by physical examination during first day of admission. An electrocardiogram (ECG) showed a sinus rhythm with ST-segment elevation and PR-segment depression on multiple leads . A transthoracic echocardiogram (TTE) showed normal left ventricular function and pericardial effusion without vegetations. The amount of pericardial effusion was large (>500 mL). Nevertheless, no compression of the right side of the heart due to pericardial effusion was observed . Laboratory data showed elevated inflammation markers [white blood cell count 13 600/μL; neutrophils 87% (upper limit of normal ≤9000/μL); C-reactive protein, 16.1 mg/dL (normal range ≤0.3 mg/dL)], and normal cardiac enzyme levels [creatine kinase 40 U/L (upper limit of normal ≤150 U/L); high-sensitivity troponin T 0.007 ng/mL (normal range ≤0.014 ng/mL)]. Chest X-ray showed mild cardiomegaly. The patient’s symptoms and the TTE and ECG findings led to a diagnosis of viral acute pericarditis, and colchicine and loxoprofen were initiated. His fever worsened on Day 7, and a blood culture was performed. Pericardiocentesis was performed on Day 8, draining 800 cc of bloody fluid, which on analysis showed 15 000 white blood cells (62% polymorphonuclear cells, 38% mononuclear cells), total protein 6.1 g/dL, lactate dehydrogenase 998 U/L, and glucose 20 mg/dL. Cytology, histology (cell block), and a mycobacterial culture showed no evidence of malignant pericardial effusion and tuberculous pericarditis. On Day 11, the blood and pericardial fluid cultures were positive for P. micra, and purulent pericarditis was diagnosed. A dental examination revealed decayed teeth, and intravenous antibiotic therapy (ampicillin-sulbactam 3 g every 6 h) and dental treatment were initiated. Although pericardial drainage was performed, the spiking fever persisted. Chest computed tomography (CT) performed on Day 14 showed an abscess cavity in the pericardial space around the right atrium (RA) and a trabecular shadow suggesting vegetation in the RA . Transoesophageal echocardiography (TOE) on the following day revealed vegetation with severe mobility (19.2 mm × 9.2 mm) in the RA near the abscess cavity ( and Videos and ). No vegetations were observed at the tricuspid valve or in the left side of the heart. Emergency surgery was performed via a median sternotomy. The surgical findings demonstrated frank pus in the abscess cavity and on the RA surface. After a pericardiotomy was performed and the abscess cavity communicating with the RA was removed, minor bleeding from the RA was observed. The surface of the RA was dented, very fragile, and easily penetrated. A cardiopulmonary bypass was therefore established, and large vegetation was observed in the RA . The vegetation, infected RA wall, and trabeculae carneae were removed, and the tricuspid valve and right ventricle were inspected carefully but showed no vegetations. The culture of the pus in the abscess cavity detected P. micra. Post-operatively, the patient improved clinically and was given intravenous ampicillin-sulbactam 3 g every 6 h for 4 weeks. Coronary CT angiography performed due to transient changes in ST-segment on the ECG monitor during the surgery showed no stenotic lesions. During follow-up, chest CT and TTE showed no recurrence of the abscess cavity or vegetations at 4 months post-operatively (Video ), and the patient experienced no recurrence of infection or signs of constrictive pericarditis at 6 months post-operatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2372_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2372_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7e72c80bce10b054f05f102fbef99cbdc01cfc7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2372_en.txt
@@ -0,0 +1,5 @@
+A 53-year-old male farmer who bred geese, fowls, dogs, and cats, and had frequent contact with their carcasses presented at our institution with intermittent fever for the previous week in July of 2013. He reported taking anti-histamines for his urticaria in recent years. His symptoms included general malaise, icteric sclera, yellowish skin, bilateral plantar skin rash, and a headache in the temporal and frontal areas. He denied any history of travel, unprotected sex, insect bites, transfusion, or toxin exposure.
+On admission, his body temperature was 39.1°C, pulse rate was 110 beats per minute, and blood pressure was 121/82 mmHg. He was oriented but had mild agitation. He had icteric sclera but no Kayser-Fleischer ring; his abdomen was not tender, and he had yellowish skin with several linear and erythematous lesions over bilateral plantar areas, but no eschar-like lesions. The results of a neurologic examination were unremarkable. A hemogram indicated a leukocyte count of 11,770/μL with 13% monocytes, and a platelet count of 85,000/μL. The prothrombin time was 19.1 s (reference range: 8-12 s) and the activated partial thromboplastin time was 36.2 s (reference range: 23.9-35.5 s). Biochemical analysis indicated elevated aspartate aminotransferase (2561 IU/L), alanine aminotransferase (2263 IU/L), alkaline phosphatase (274 IU/L), gamma glutamyltransferase (824 IU/L), total bilirubin (7.2 mg/dL), direct bilirubin (6.2 mg/dL), urea nitrogen (30 mg/dL), creatinine (2.6 mg/dL), and C-reactive protein (4.23 mg/dL). Analysis of arterial blood gas indicated a pH of 7.439 (reference range: 7.38-7.42) and HCO3- of 19.5 mEq/L (reference range: 22-28 mEq/L). A chest X-ray was unremarkable but an abdominal computed tomography indicated generally decreased liver parenchymal attenuation and mild ascites, compatible with a diagnosis of hepatitis .
+He was treated empirically with parenteral penicillin G (3 MU every 8 h) and parenteral levofloxacin (500 mg every 24 h) under impression of Leptospirosis and gram-negative bacterial infection. However, his fever persisted and he became drowsy with asterixis on day 6. At this time, there were also increases in the total bilirubin (18.2 mg/dL), direct bilirubin (14.2 mg/dL), and serum creatinine (5.9 mg/dL). Levofloxacin was discontinued and parenteral ceftazidine (2 g every 24 h) and vancomycin (1 g every 72 h) were administered. However, his condition continued to deteriorate. On day 8, there were generalized dark-red, painless, non-blanching macules over his trunk and four limbs and his serum total bilirubin had increased to 26.5 mg/dL. Penicillin G was replaced by oral doxycycline (100 mg every 12 h). There was no bacteria growth in blood cultures, and the serum anti-HAV IgM, HBsAg, anti-HCV Ab, anti-EB-VCA IgM, anti-HIV antibody, anti-HSV IgM and IgG were negative. Ceruloplasmin, anti-smooth muscle antibody, and anti-nuclear Ab were within the normal ranges. The serum collected for Q fever and Leptospira on day 2 was negative. Polymerase chain reaction (PCR) for C. burnetii also showed negative. On day 10, the serum anti-CMV IgM test was positive and he was given parenteral gancyclovir, after which his consciousness, liver, and renal function improved.
+On day 12, the phase II IgG for Q fever by immunofluorescent assay (IFA) was 1:320, and phase II IgM for Q fever was negative (performed at Taiwan Centers for Disease Control). According to the diagnostic criteria , the patient’s course was compatible with acute Q fever. Microscopic agglutination tests using serum antibodies against Leptospira santarosai serovar shermani, L. borgpetersenii serovar poi, and L. tarassovi (performed at Taiwan Centers for Disease Control) were negative. Parenteral levofloxacin (500 mg every 24 h) was reinitiated on day 21.
+On day 27, there were decreases in the serum total bilirubin (9.9 mg/dL) and creatinine (1.65 mg/dL) and the patient was discharged. After completion of a 24-week course of oral levofloxacin (500 mg every 24 h), there was normalization of the serum total bilirubin (0.8 mg/dL) and serum creatinine (1.04 mg/dL). A follow-up abdominal CT at 4 months indicated normal liver parenchymal attenuation without ascites. During the subsequent follow-up, he had not recurrent episodes or other discomfort. Figure summarizes the clinical, laboratory and drug treatments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2403_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2403_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9cf18fd5f08cf4489727879c44a2275eed0e3c42
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2403_en.txt
@@ -0,0 +1,3 @@
+A 61-year-old White man, non-smoker, with a diagnosis of long-standing arterial hypertension of difficult control, severe heart failure with a left ventricular ejection fraction of 30% receiving pharmacological treatment with carvedilol, ivabradine and losartan, and history of stage IIIB chronic renal failure without dialysis therapy. A year before the current admission, he consulted for urinary symptoms that rapidly evolved to systemic compromise with fever, diaphoresis, low back pain, hypotension, dyspnea, and increased acute phase reactants. He required hospitalization in the intensive care unit for multidisciplinary treatment with a diagnosis of sepsis of urinary origin. Alterations in calcium behavior were detected, which were associated to the underlying renal disease and to a severe hyperparathyroidism secondary to a functional adenoma in the lower left parathyroid treated with surgery, achieving control of symptoms and levels of calcium and phosphorus. Chest x-ray showed 2 lesions of tumor aspect with internal lytic areas in the fourth right and eighth left costal arches. The first lesion measured 25 × 21 mm with involvement of fourth right costal arch and the second measured 77 × 54 mm in eighth left costal arch showing growth toward the left pleural cavity . Both lesions were suggestive of a tumor of chondral origin, enchondroma, and as it was not possible to rule out malignancy with the images, he was admitted in our institution for excisional biopsy. The physical examination revealed a thin patient with chronic disease and a deformity in the neck with anterior flexion pronounced by severe dorsal kyphoscoliosis and secondary asymmetry of the right ribcage, which was retracted with decreased intercostal spaces. He referred increased dyspnea with the activities of daily life, with NYHA (New York Heart Association) functional class III. Blood pressure 120/70 mm Hg, heart rate 100 beats per minute, breathing frequency 16 breaths per minute, no cyanosis, with jugular engorgement at 90°, no neck masses, tachycardic rhythmic heart with no murmurs or gallop, decreased breath sounds at both lung bases, abdomen without ascites or masses, and extremities with edema grade II. No identifiable lesions in the chest wall other than deformity by kyphoscoliosis were found.
+Blood work was unremarkable, except for mild anemia of normal volumes (see ), spirometry showed a moderate restrictive ventilatory pattern and no significant post-bronchodilator changes and diffusing capacity of carbon monoxide, in normal limits (diffusing capacity of the lungs for carbon monoxide [DLCO]: 109%). The chronic kidney disease was stable. Thoracic computed tomography (CT) scan showed a heterogeneous rounded lytic lesion with sclerotic edges and growth toward the pulmonary cavity, of expansive type, causing displacement of pulmonary parenchyma, and measuring approximately 77 × 54 mm and depending on the eighth left costal arch . Given the size and characteristics of the mass, it was very difficult to determine if the lung was surrounding the lesion or if the mass was in fact infiltrating the parenchyma. In addition, in the fourth right costal arch, an image of similar characteristics, but smaller in size, is found, measuring 25 × 21 mm. In addition, a severe dorsal kyphoscoliosis was identified. No further studies were implemented; the decision was made to perform a surgical resection of the mass with the possibility of having to do a lobectomy.
+The patient was hospitalized in the intensive care unit for pre-surgical conditioning where a left ventricular ejection fraction of 30% was evidenced and a cycle of intravenous levosimendan was initiated. He received red blood cell transfusion and underwent resection of the left costal mass by thoracoscopy. During the surgical procedure, only 1 hard lesion was found that involved the eighth rib and soft tissues of the seventh to ninth left ribs, without infiltration into the lung tissue or pleural cavity. Therefore, only partial resection of these 3 ribs was necessary, without pulmonary lobectomy, the right side was not intervened. In the immediate postsurgical period, the patient presented a difficult evolution, with hemodynamic instability, required vasoactive support with norepinephrine, prolonged mechanical ventilation, and a need for a tracheostomy to assist a long-standing recovery process. Subsequently, it was possible to remove the vasoactive drugs, the invasive ventilatory support, and the tracheostomy with complete physical and respiratory rehabilitation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2407_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2407_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7423e87343efff73bc1d5b28fc35fd1e6e2a42d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2407_en.txt
@@ -0,0 +1,7 @@
+A 57-year-old Chinese man presented to our hospital for further management of a laterally spreading tumor (LST)-like lesion in the proximal rectum accidently discovered on colonoscopy over 1 mo prior.
+The biopsy results indicated an inflammatory hyperplastic polyp. The patient had no obvious symptoms and received screening endoscopy as part of a routine health examination. Gastroscopy showed chronic atrophic gastritis and inflammation of the cardia.
+The patient had a history of diabetes mellitus for more than 6 mo and was administered metformin and other drugs to control his blood sugar. He also had a history of hypertension for more than 1 mo without medication.
+He had a long smoking history of over 30 years, with an average of 20 cigarettes per day. He also had a drinking history for more than 30 years, with half a catty of liquor per day.
+Physical examination upon admission showed that the patient was 1.82 m in height and 94 kg in weight. He had a blood pressure of 139/84 mmHg with a heart rate of 68 beat/min. He had clear lungs and normal heart sounds with no murmurs or gallops on auscultation. There were no obvious pathognomonic signs during physical examination of the abdomen.
+No significant abnormal laboratory results were recorded in this patient.
+Colonoscopy in our hospital also revealed a 25 mm × 20 mm, LST-like slightly elevated lesion in the proximal rectum with a red color . To observe the microstructure and capillaries of the lesion, magnifying endoscopy with narrow-band imaging (NBI) was carried out. It showed enlarged and dilated branch-like vessels on the surface of the tumor similar to those of gastric MALT lymphoma . The margin of the lesion became clearer, and a type II pit pattern was observed on magnifying endoscopy after indigo carmine staining . Gastroscopy revealed atrophic gastritis and cardia mucosa erosion with irregular microstructure and capillaries on magnifying endoscopy. The biopsy pathology indicated cardia inflammation with mild glandular atypia in the absence of H. pylori. Therefore, there were no endoscopic and pathological findings indicating gastric MALT lymphoma. Abdominal computed tomography showed no obvious abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2408_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2408_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06d1d8d49b9330ae2b680a10cc616a8215ddc1a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2408_en.txt
@@ -0,0 +1,9 @@
+A 69-year-old woman was seen in follow-up at an outpatient orthopaedic clinic approximately 10 weeks after completing a 3-month course of antibiotic therapy for a right knee PJI due to Brucella suis, as reported previously . She completely recovered following treatment of her B. suis PJI, but noted onset of acutely worsening right knee pain, warmth, and overlying redness 1 day prior to her scheduled follow-up. She was afebrile and systemically well.
+An original total arthroplasty of the right knee was performed 12 years prior and she was diagnosed with a B. suis PJI after multiple synovial fluid aspirates grew the organism in 2015. She underwent irrigation and debridement with removal of all prosthetic components and implantation of a gentamicin, vancomycin, and ceftazidime impregnated static cement spacer. She completed 10 days of intravenous aminoglycoside therapy (initially tobramycin and then gentamicin) combined with oral doxycycline and rifampin. Oral antibiotics were continued for a total of 12 weeks. On initial follow-up, she had improved knee pain, no fever, normalization of inflammatory markers and a healed surgical wound.
+The patient’s past medical history was otherwise significant for obesity, hypertension, gastroesophageal reflux disease and osteoarthritis with chronic back pain. Her medications were hydrochlorothiazide, ramipril, and pantoprazole. She had no known allergies. The patient lives on a remote island in the Canadian Arctic and works as an artist. She would regularly butcher wild meat (including caribou, muskox, seal and fish) and often consumed the meat and fish raw.
+On physical examination, she was non-toxic and afebrile. Her right knee was swollen and erythematous. She had a static cement spacer at the time of this assessment and was not able to perform range of motion. There was no apparent drainage or visible sinus tracts on the right knee. The remainder of her physical examination was unremarkable.
+Radiographs of the right knee revealed that the position of the intramedullary pins and large spacer was unchanged with no skeletal changes, however diffuse soft tissue swelling was evident. Erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) had risen from normal levels 3 months earlier to 49 mm/h and 171.4 mg/L respectively. Complete blood count did not show leukocytosis or neutrophilia. Serum creatinine was 66 μmol/L. A repeat Brucella IgG plus IgM standard agglutination assay performed in the previous month was negative with a titre of < 1:40. Given the clinical suspicion for recurrent PJI, a right knee arthrocentesis was performed in the orthopaedic outpatient clinic, which revealed a synovial fluid white blood cell count of 25,330 × 106/L comprised of 87% polymorphonuclear cells. No organisms were seen on direct gram stain of the fluid.
+A gram-positive bacillus was reported to be growing from liquid media culture 2 days after collection. The patient was taken back to the operating room the following day where she had irrigation and debridement of the right knee with removal of the previous prosthetic components and reinsertion of a static cement spacer with 3.6 g of tobramycin per bag of polymethylmethacrylate bone cement. Three bags of cement were used. No preoperative antibiotics were given. Once intra-operative tissue specimens had been collected, 2 g of cefazolin IV were given.
+The organism recovered from the pre-operative knee aspirate was confirmed as E. rhusiopathiae by 16S rRNA sequencing at the Provincial Laboratory for Public Health in Edmonton, Canada. This organism was also seen on direct gram stain and eventually isolated from all 5 intraoperative tissue specimens. Whole genome sequencing was performed on two of these isolates using the Illumina MiSeq platform. The 250 bp paired-end reads were assembled de novo using SPAdes (v3.10.1), and the assemblies compared to sequence data from previously isolated E. rhusiopathiae from various mammal carcasses from the Canadian Arctic, isolates from domestic swine and poultry as well as wild birds, mammals, and fish originating from various locations in North America and Europe . This was done by generating a core genome alignment and phylogenetic tree using parsnp (Harvest Tools v1.2) .
+The isolate tested susceptible in vitro by E-test methods to ampicillin (minimum inhibitory concentration (MIC) 0.094 μg/mL), ciprofloxacin (MIC 0.047 μg/mL), and erythromycin (MIC 0.032 μg/mL) (interpreted according to the current M45 Clinical and Laboratory Standards Institute clinical breakpoints) and was reported resistant to vancomycin as this is an intrinsic characteristic. Four blood cultures, which were collected on the same day of this visit to the orthopedic outpatient clinic and prior to the administration of antibiotics, remained negative after 5 days of incubation. An echocardiogram was not performed as it was felt that the patient was unlikely to have endocarditis. She was initially treated with intravenous ceftriaxone 1 g daily but was switched to intravenous penicillin G once susceptibility results were available. She completed 6 weeks of intravenous antibiotic therapy and subsequently completed an additional 6 weeks of oral amoxicillin 1 g three times daily.
+On the last day of her oral antibiotic therapy she was reviewed as an outpatient and was clinically well with no fever and resolution of knee pain. Her surgical wound had healed well with no evidence of recurrent infection on physical examination. Her CRP and ESR had normalized to 1.4 mg/L and 13 mm/h respectively. She was again seen in follow-up 4 months later (approximately 8 months after her last surgery) and remained well with no clinical evidence of relapse and CRP and ESR remaining within normal limits at 0.9 mg/L and 15 mm/h respectively. The patient declined a second stage revision procedure and remained clinically well 1 year after her last surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2410_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2410_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1d99451ac2f265d05a0842f001998476737ece79
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2410_en.txt
@@ -0,0 +1,7 @@
+A 49-year-old male was referred to our emergency department complaining of progressive aggravated abdominal pain for 3 d.
+The initial pain was in the hypogastric region and worsened to diffuse abdominal pain 1 d prior, along with nausea, abdominal distension, and vomiting.
+The patient had suffered from hypertension for 10 years, which was well controlled medically by nifedipine and metoprolol. His past surgical history of renal transplantation had been 4 years due to chronic kidney disease. The immunosuppression therapy included prednisolone, mycophenolate mofetil, and tacrolimus.
+The patient had a free personal and family history.
+Clinical examination revealed tenderness on palpation of his full abdomen with rebound tenderness and muscle guarding.
+Laboratory evaluation showed that the leucocytes count was elevated at 31 × 109/mL, hemoglobin was 13 g/dL, and C-reactive protein was 33.86 mg/dL. The hepatitis serology and cytomegalovirus results did not suggest clinical virus infection.
+The abdominal contrast-enhanced computed tomography (CT) scan exhibited an extensive filling defect within the portal vein and right branch, extending to the superior mesenteric vein as well as splenic vein .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2417_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2417_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..24961740701c9e06cde8cf53e20c2a0ca1f7a8c6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2417_en.txt
@@ -0,0 +1 @@
+A 77-year-old Korean woman, gravida 5, para 5, was admitted through the emergency room because of lower abdominal pain, poor oral intake, and a recent increase in abdominal size for 4 days. The symptoms had gradually increased in severity. She had no history of acute pain or previous operation. Abdominal examination revealed tenderness and rebound tenderness of the lower abdomen with a palpable mass in the left lower quadrant. Ultrasound examination showed an enlarged left ovarian cyst measuring 14.3 × 14 × 8.6 cm with diffuse internal echoes, including a 6.1 × 6.0 cm hypoechogenic component without significant vascularity. The right ovary was not seen and the uterus was normal and atrophied. Contrast-enhanced computed tomography (CT) revealed an approximately 12-cm well-circumscribed mass (of fat and soft tissue density) in the pelvic cavity and a 9-cm well-circumscribed mass (of fat and soft tissue density) with calcification in the right subhepatic space . The suggested preoperative diagnosis was benign teratoma of the left ovary and right subhepatic space. With regard to preoperative examination, the laboratory tests, biochemical tests, complete blood counts, blood coagulation profile, and urinalysis were all normal. The C-reactive protein (CRP) level was elevated at 6.87 (normal range 0–0.3 mg/dL), CA-125 was elevated at 50.76 (normal range 0–35 U/mL), and CA 19-9 was normal at 22.06 (normal range 0–37 U/mL). We decided to proceed with laparoscopy. Laparoendoscopic single-site surgery (LESS) was performed through a 20-mm intraumbilical incision using a Glove port (NELIS, Bucheon, South Korea). During laparoscopy, torsion of the left adnexa due to an approximately 12 × 10 cm left ovarian cyst was visualized, with an atrophied normal uterus. The left adnexa was rotated 1440° clockwise with multifocal purple discoloration and severe adhesion to the sigmoid colon . The right ovary and tube could not be identified in the proper anatomical location . A second cystic mass of about 10 × 7 cm was noted in the right subhepatic space. It was surrounded by thin filmy adhesions to the omentum, bowel, and appendix . Left adnexectomy, intra-abdominal mass excision, and appendectomy were performed by LESS. The abdominal mass was carefully dissected from the surrounding omentum and bowel using a monopolar hook dissector and harmonic scalpel (Ethicon, Somerville, NJ, USA). There was no pedicle that needed to be clamped and no identifiable blood supply. The mass was removed intact. The entire specimen was removed through the umbilical incision without leakage of content using an EndoBag (LapBag, Sejong Medical, Paju City, South Korea). The patient recovered uneventfully and was discharged 4 days after surgery. The histopathological examination confirmed MCTs in the left ovary and right subhepatic space. The abdominal mass included ovarian tissue. These findings could also be interpreted as an autoamputation of the adnexa due to torsion of a previous ovarian cyst arising from the right ovary.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2419_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2419_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a29cc72044e733633859c278291063c4e039027
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2419_en.txt
@@ -0,0 +1,2 @@
+A 8-year-old Asian Indian male presented with complaints of pain, swelling and eruptions on right upper and lower lids for the last 7 days. No significant past medical/surgical/ family/social history was elicited. No rhinitis/pharyngitis/fever was present. No preauricular lymphadenopathy was present. Vision was 6/6 in both eyes. Vesicular eruptions were present on right side of face near the periorbital region, and right upper and lower lids showed swelling and vesicular eruption. Corneal sensations were diminished in the right eye.
+Slit lamp examination of the right eye with fluorescein staining showed well defined area of fluorescein staining in the lower bulbar conjunctiva resembling a geographic ulcer with irregular, angulated margins. Anterior segment and posterior segment examination were unremarkable. Patient was started on Acyclovir (3%) ointment 5 times/day local application on eye and skin and oral Acyclovir 200 mg 5 times/day. He was reviewed after 3 days and then after 12 days. Patient recovered completely after 12 days and medications were terminated.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2432_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2432_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e177498dbbcfe46ee9d5e484fe73bc56775c9ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2432_en.txt
@@ -0,0 +1,7 @@
+A 29-year-old woman with a history of out of hospital cardiac arrest with underlying ventricular fibrillation 4 months after delivery of her first child was referred to our centre to evaluate the risk of a second pregnancy. After her first pregnancy, the differential diagnosis of dilated cardiomyopathy vs. peripartum cardiomyopathy or primary electrical disease was made and an implantable cardioverter-defibrillator (ICD) was implanted as secondary prevention. Extensive investigations, including echocardiography and cardiac magnetic resonance imaging (MRI) revealed no abnormalities apart from mild mitral prolapse and mild left ventricular dysfunction.
+When she presented in our centre for counselling, she happened to be already 2 weeks pregnant. She had no complaints, no recent history of (pre)syncope’s. Clinical examination showed a lean woman (height 169 cm, weight 59 kg), with normal blood pressure 112/76 mmHg and an oxygen saturation of 98%. On auscultation, an apical mild systolic murmur was present with no signs of heart failure. The 12-lead electrocardiogram (ECG) demonstrated sinus rhythm with right bundle-branch block and ventricular extra systoles (PVC) . Exercise-ECG illustrated regular PVCs, no ST-segment changes, and moderate exercise capacity (81% of predicted maximal workload). Echocardiography showed a myxomatous mitral valve with some prolapse and mild to moderate regurgitation with normal left and right ventricular dimensions and function.
+Intensive follow-up both at the Department of Gynecology and Cardiology was arranged and the case was repeatedly discussed at the multidisciplinary pregnancy heart team in the presence of cardiologists, gynaecologists, and anaesthesiologists. The maternal risk for cardiac events was categorized as WHO class III and planned delivery with assisted vaginal delivery at our expert centre for pregnancy and cardiac disease was recommended. Medical treatment with metoprolol 100 mg/day was initiated. Prenatal foetal evaluation, genetic screening, and intensive follow-up of foetal growth under treatment with beta-blockers were provided. Pregnancy and delivery were uneventful. A healthy boy, birth weight 3040 g, was born after induction of labour at 39 weeks of pregnancy. She remained in the hospital for rhythm observation for 3 days. No cardiac events occurred in the peripartum period and on transthoracic echo her ventricular function remained good.
+However, 4 weeks later, she experienced a sudden syncope at home, while taking a shower. ICD interrogation revealed primary ventricular fibrillation, induced by a premature ventricular beat, terminated with a successful ICD shock. The morphology of the inducing beat could not be determined, since the recording of the intracardiac EGM starts after detection . A reversible cause like deterioration of left ventricular function or electrolyte imbalance was not found. Echocardiography revealed no new abnormalities. Medical treatment with metoprolol 100 mg/day was continued.
+She mentioned having PVCs as an adolescent. Reviewing her ECGs showed the presence of regular right bundle-branch block ventricular extra systoles and a right superior axis, i.e. with an origin in the inferolateral basal left ventricle (i.e. close to the posterior mitral annulus) . A frame-by-frame echocardiographic analysis allowed the diagnosis of a MAD with detachment of the root of the annulus from the posterolateral ventricular myocardium during systole .
+Re-evaluation of the cardiac MRI made after her first cardiac arrest confirmed the presence of MAD inferolateral in late systole and detected no signs of fibrosis.
+demonstrates an xPlane segmental analysis of the mitral valve and its annulus performed from the parasternal long-axis window with a lateral sweep at mitral annular level, orthogonal short-axis views are recorded on the secondary image. The xPlane image analysis of the mitral annulus illustrated clearly the presence of MAD at the posterior annulus and a normal anterior mitral annulus, explaining why the diagnosis of MAD can be missed when the cutting plane is incorrect .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2434_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2434_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0e308204897f7b45a3a1a3935aa10ab61f895941
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2434_en.txt
@@ -0,0 +1,18 @@
+A 70-year-old man presented to Aleppo University Hospital in order to have a routine check-up for benign prostatic hyperplasia (BPH) that was diagnosed when he was 31 years old.
+Through investigations, we performed an echography of the abdomen and detected a tubular-shaped, moving, echogenic structure with anechoic central line located in the gallbladder; the thickness of gallbladder wall was 4 mm. We did not detect any calculi . These findings suggest gallbladder ascariasis.
+As a history, he had controlled hypertension, a repaired hiatal hernia, gastroesophageal reflux disease (GERD), hemorrhoids, and BPH. However, his general condition was good.
+He was asymptomatic, but mentioned that two weeks ago he had experienced nausea, vomiting, hyperthermia, chills, and abdominal pain which started in the right hypochondrial region, radiated to the umbilical region, and lasted for 5 days. The patient did not report jaundice or a change in bowel habit. He dealt with these symptoms himself and took over-the-counter ciprofloxacin, metronidazole, augmentine, and paracetamol.
+Multi-slice computerized tomography (MSCT) have not shown any worm or calculi .
+His laboratory findings were all normal including aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma glutamyl transferase (γGT), bilirubin, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), amylase, and complete blood count (CBC). No eosinophilia existed. Ova and parasite (O&P) test was negative.
+As the patient is an elderly and hypertensive and was so afraid from operation, conservative treatment was applied with albendazole 400 mg (single dose) and wide spectrum antibiotics, with observation on echography.
+After one week, ecography revealed that the worm is still moving and so still alive; therefore, the patient was given a second dose of albendazole.
+After 2 weeks, the worm has not appeared on echography, but we noticed an echogenic debris in the gallbladder .
+So, the patient was advised to operate a cholecystectomy to avoid obstruction of bile or pancreatic ducts by the worm's debris, but he disapproved.
+The patient returned back to hospital after 10 days; we checked his gallbladder with echography again. It was clear and we did not notice any debris, which means aspiration of the remains of the worm.
+After 10 days, he presented to hospital complaining of nausea, vomiting, fever, jaundice, and right hypochondrial pain.
+On echography, the common bile duct was not distended and no obstructing structure was noticed.
+Laboratory tests revealed leuckocytosis (13800/mm3), with a left shift, as the neutrophils count was 12200/mm3. Eosinophils count was normal. We also found significant increase in CRP (20mg/l), mild elevation in ALT (115 U/L) and AST (90 U/L), and bilirubin was 4mg/dl.
+A diagnosis of acute cholecystitis was made, and we perfomed cholecyctectomy for the patient.
+There were many adhesions around the gallbladder.
+Pathology report confirmed acute cholecystitis. We detected no macroscopic or microscopic remains of the worm in the gallbladder. Under microscope, we noticed a marked number of eosinophils in the bile of the gallbladder.
+After three months, our patient is in a good health and has no complications.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2435_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2435_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cea6d5b2f0dafeb7002f658b80b642dfd2ce6af7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2435_en.txt
@@ -0,0 +1 @@
+A 58-year-old diabetic female presented to our Outpatient department with a severe painful shoulder on the left side with the inability to lift her arm for 15 days. The pain was disturbing her sleep. There was a history of pre-existing shoulder pain on the same side due to adhesive capsulitis with a stiff shoulder for 6 months. For the same problem, her shoulder was manipulated overzealously by a local bonesetter to improve her shoulder movements following a possible steroid injection. Ever since the manipulation, the patient complained of severe pain in the shoulder, affecting all the movements at the shoulder, her daily activities and sleep. On examination, there were no active movements possible at the shoulder with active-assisted forward flexion of 80° and active-assisted abduction of 50° with pseudoparalysis of the shoulder . There was no obvious wasting of the deltoid, supraspinatus and infraspinatus. The lift-off test and Belly-press test for subscapularis integrity were positive. Constant shoulder score was 12. On radiography, there was inferior subluxation of the shoulder . On magnetic resonance imaging, there was increased capsular hyperintensity, suggesting joint effusion and capsulosynovitis, subscapularis muscle tear and medial biceps tendon subluxation with edema around the tendon . The diagnosis of acute traumatic capsulosynovitis of the shoulder with the upper subscapularis muscle tear with biceps tendon subluxation with shoulder subluxation was made. The patient was posted for shoulder arthroscopic surgery. Intra-operatively, we found a severe amount of capsulosynovitis all around the shoulder joint more at the rotator interval . A thorough capsular synovectomy was done. Biceps tendon subluxation was noted, and a tenotomy was done. The upper third subscapularis muscle tear was noted at the humeral insertion site. Repair of subscapularis muscle was done with two fiber wires and one knotless PEEK anchor arthroscopically . Postoperatively, the patient was immobilized with an arm pouch for 6 weeks. Rehabilitation was started on day 10 postoperatively. The post-operative radiograph showed a concentric reduction of the shoulder . The patient was followed up regularly at 3 weeks, 6 weeks, 12 weeks, 6 months and 1 year. At the 2-year follow-up patient had completely pain-free movements at the shoulder and was regularly involved in household activities. Constant shoulder score had improved significantly to 82.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2443_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2443_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..33aca67f078cff90d9033bcba06db467735693f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2443_en.txt
@@ -0,0 +1 @@
+A 52-year-old female patient with recurrent urinary tract infections underwent abdominal ultrasound examination. The right kidney ultrasound showed a sharply restricted, hypoechoic solid renal mass of 2.5 cm diameter without posterior acoustic shadowing closely located to the renal sinus. The kidney was not congested. Atypical sinus lipomatosis, lipomas or a transitional cell carcinoma was suspected and subsequently a computer tomography scan was performed showing a homogenous mass that met the criteria for a classic angiomyolipoma . A computed tomography scan repeated 2 years later demonstrated a possible tumor growth to 3 cm in diameters. Another 2 years later, an ultrasound examination revealed two different areas of the solid mass: a hyperechoic outer rim (echogenicity tumor to normal kidney cortex ratio (TQ) of 2.27) and inner hypoechoic portion (TQ of 0.47.) as displayed in Fig. . Echogenicity was measured according to prior reported method [–]. A contrast enhanced ultrasound was performed displaying a distinct different perfusion pattern of these two areas. In the hyperechoic peripheral area, we noticed a strong perfusion that started nearly simultaneously with the renal cortex and a marked slower contrast material flooding with a relatively rapid wash out in the hypoechoic portion of the tumor . The finding of the contrast enhanced ultrasound of the hyperechoic part of the tumor was in line with a classic angiomyolipoma whereas the dignity of the hypoechoic part remained unclear. A target biopsy of both parts was performed. The histological examination showed a classic angiomyolipoma in the biopsy specimen of the outer rim and an epithelioid angiomyolipoma in the biopsy specimen of the center part . Immunohistochemistry showed strong positivity for melanocytic markers and smooth muscle markers, confirming the diagnosis of epithelioid angiomyolipoma. A subsequent nephrectomy was performed confirming the diagnosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2461_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2461_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d8ea5a5f50b934a426a659d64e5edd56e01fc95
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2461_en.txt
@@ -0,0 +1,6 @@
+We report a case of a 58-year-old male with peripheral artery disease. Although he had a 10-year history of intermittent claudication, he had not visited a hospital for consultation previously. When he experienced a stroke and was admitted to our hospital, an MRI revealed left carotid stenosis, and stenting was performed. During admission, arteriosclerosis obliterans (ASO) was detected. The ankle brachial pressure index (ABI) was 0.61 in his right limb and 0.76 in his left limb. He also had a history of depression, alcoholism, Chronic obstructive pulmonary disease (FEV1.0 was 45.7%, FEV1.0 predicted was 54.8%), hypertension, and chronic renal failure.
+After treatment for the stroke, he was referred to our heart and vascular team because of the ASO. An angiography through the left radial artery showed total occlusion of the right common iliac artery, 50% stenosis of the left common iliac artery, and 90% stenosis of the left extra iliac artery. Coronary angiography (CAG) was simultaneously performed because he had shortness of breath during exertion. The CAG showed three-vessel disease (#1, 100%; #5, 50%; #6, 90%; #11, 100%). The circumflex artery was perfused by the collaterals, but quite small, and right coronary artery, which was filled with collaterals, supplied the posterolateral area . Bilateral ITA demonstrated a good collateral pathway to both external iliac arteries.
+Echocardiogram revealed that Left ventricular ejection fraction was 45% by modified Simpson method, the wall motion in the base and mid potion from the inferior to posterior lesion, and there was no significant valvular disease. Preoperative evaluation according to Euro score 2 and STS score were 1.226% and 2.09% respectively.
+Our heart and vascular team concluded that CABG was recommended with bilateral ITA after a percutaneous transluminal angioplasty (PTA) because it was thought that keeping the access route for Intra-Aortic Balloon Pumping (IABP) was important and ITAs serve as good collaterals to both femoral arteries. In case of PTA failure of the right iliac artery occlusion, a concomitant procedure such as a femoro-femoral crossover bypass was planned for the CABG.
+Although the PTA to the left common iliac artery and the left extra iliac artery with stenting was successfully performed, the PTA to the occlusive lesion of the right iliac artery was not successful. Therefore, CABG with a femoro-femoral crossover bypass was performed. The left ITA was harvested, followed by the right ITA, both with a skeletonized technique. The patient underwent off-pump CABG with the left ITA, which was anastomosed to the left anterior descending artery, and the right ITA, which was anastomosed to the proximal part of the posterior descending branch. Then, the femoro-femoral crossover bypass was performed with an 8-mm ringed polytetrafluoroethylene graft. Anastomosis to the left common femoral artery in endo-to-side fashion was followed by anastomosis to the right common femoral artery in endo-to-side fashion. During the operation, the blood pressure was stable with norepinephrine (range: 0–0.06 µg/kg/min) and monitoring of the cardiac output revealed a flow of 3.3–4.3 L/min (cardiac index was 1.6–2.1 L/min/m2). The interval between the clamping of the right ITA and starting perfusion to the right femoral artery was 3 h and 47 min.
+After the operation, the patient’s condition was stable. Two hours after the operation, he was extubated in the intensive care unit, and no significant findings in his legs were noted. He underwent a routine postoperative blood test and showed an elevated creatine kinase level (2669 U/L), which peaked out at 7177 U/Lon postoperative day 1. Subsequently, it decreased gradually to the normal range for 10 days. Postoperative angiography showed that all ITA grafts and the femoro-femoral crossover bypass were patent. The intermittent claudication symptoms improved, and the ABI was 0.95 in the right side and 0.88 in the left side. He is followed as outpatients without symptom of angina 6 months after surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2470_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2470_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbdeb22b6f1762b00d7419a00b7df77cd0f9f20a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2470_en.txt
@@ -0,0 +1,7 @@
+Due to aggravated cough and expectoration with fever, chest tightness and shortness of breath, a 64-year-old female was admitted to our hospital four days ago. She had been diagnosed with xerostomia and xerophthalmia over 20 years.
+Emission Computed Tomography (ECT) examination revealed decreased functions of bilateral parotid and submandibular glands. A chest CT three years ago showed scattered, various-sized and roundish radiolucencies, striped or hazy opacities in both lungs and multiple small nodules in the right lung . Another chest CT one year later revealed new patchy opacities in the right lung and lingual lobe, scattered various-sized and roundish radiolucencies, multiple small nodules in the right lung which were similar to those in the previous CT image; the striped or hazy opacities seen previously were still visible in both lungs .
+The patient was admitted to our hospital one year and 4 months later due to recurrent cough, expectoration and low fever. The chest CT revealed multiple cysts with multiple patchy and nodular opacities in both lungs . Results of antinuclear antibody profiles and vasculitis series were: SSA (RO-52) positive (+), SSA antibody positive (+), ESR 87 mm/hr, immunoglobulins: IgA 4.29 g/L, IgG 20.3 g/L and IgM 0.68 g/L. Blood gas analysis: pH 7.39, pCO2 39.5 mmHg, pO2 68.4 mmHg and SaO2 93.1%. Pathological report on (right lung biopsy): Chronic inflammation of lung tissue with diffuse distribution of lymphocytes in focal areas . Diagnosis: lymphoma could not be excluded. Preliminary clinical diagnosis: (1) Sjogren's syndrome, lymphocytic interstitial pneumonia first consideration; (2) malignant lymphoma to be excluded; (3) pulmonary infection. The patient received anti-inflammatory treatment and was discharged after symptoms were improved.
+After discharge, the patient continued to experience constant cough, expectoration and fever even after repeated anti-inflammatory treatments. A left lung biopsy was performed 4 months later during her inpatient treatment in another hospital. The pathological report indicated chronic suppurative inflammation with massive necrosis and cellulitis.
+The patient’s chest enhancement CT after this admission displayed obviously more patchy and nodular foci in both lungs compared to previous CT images. Some of the lesions were surrounded with ground glass shadows . The diagnosis was: malignant tumor to be excluded. Auxiliary routine blood examinations showed white blood cell count 21.8 × 109/L and absolute neutrophil count 21.14 × 109/L.
+Pathological results from our hospital (right lung biopsy) and another hospital showed small areas of proliferating inflammatory fibrous tissue and small numbers of heterotypic cells within the necrotic tissue. Malignancy could not be excluded.
+Immunohistochemistry showed: CD20 (+) , Ki-67 (high-value-added activity), BCL-6 (+), CD21 (+). Based on history and pathological results, the final diagnosis was Sjogren's syndrome, malignant transformation of LIP into diffuse large B-cell lymphoma. Subsequently, chemotherapy with a reduced-dose regimen of rituximab and Chop (R-miniCHOP) was administered eight times. Following treatment, PET/CT showed complete remission of lymphoma, but the patient was at high risk of recurrence and is under active follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2473_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2473_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..54b5c745df7d33f6524db7b76ad3c001f403ffc0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2473_en.txt
@@ -0,0 +1,2 @@
+A 58-year-old female presented to our clinic with a one-year history of blurry vision in her left eye. Her ocular history was unremarkable, except for the intolerance to contact lenses and amblyopia in her right eye. Her best-corrected distance visual acuity (CDVA) was 0.20 with -9.00/-1.50 x 25◦ in the right eye and 0.80 with +4.00 sphere correction in the left eye. Distance visual acuity was measured using a standard Snellen acuity chart at 6m and presented in decimals. Her best corrected near visual acuity (CNVA) was J9 with +2.50 and J1 with +2.50. The Jaeger eye chart was used in testing near vision acuity. On this card, on which paragraphs of text are printed, text sizes increase from 0.37 mm to 2.5 mm.
+Slit-lamp examination revealed incipient cataracts in both eyes, otherwise normal anterior segment findings. A dilated fundus examination revealed vitreous liquefaction and myopic macula in the right eye, otherwise normal findings of a posterior segment in both eyes. Intraocular pressure (IOP), measured with iCare (Tiolat Oy, Helsinki, Finland), was average at 18/19 mmHg (including correction factor of the corneal thickness). The axial length of the eye measured by the IOL master (IOLMaster 700; Carl Zeiss Meditec) of the right eye was 27.96 mm and 22.44 mm of the left. As a solution to the patient’s problem, due to intolerance to contact lenses, we had two possibilities: to implicate implantable collamer lens (ICL) or cataract surgery with intraocular lens (IOL) implantation. ICL implantation was no option due to the incipient cataract that already existed and the possibility of its progress in the future. So we decided on the second option. We wanted to choose an intraocular lens with which she would get the maximum. Considering the anisometropic amblyopia, we decided to implant the Eyhance lens. This type of lens has been designed to improve visual acuity contrast sensitivity and reduce the effects of glare in patients who have undergone cataract surgery. The procedure involved removing the patient’s natural lens and replacing it with the Eyhance lens. After a month, the patient’s visual acuity significantly improved in both eyes, with her best CDVA of the right eye now at 0.35 and her left eye at 0.95. Near visual acuity also improved, with the patient now able to read at J4 and J1 for her right and left eye, respectively, with +1.50 sphere correction. These improvements in vision have likely improved the patient’s quality of life and ability to perform daily activities. It’s important to note that cataract surgery carries potential risks and complications that the doctor should discuss with the patient beforehand. For this reason, it’s crucial that patients are well-informed about the procedure and its possible outcomes to make an informed decision about their treatment options.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2482_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2482_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dbf72d5b726863dc24279c60021938ed67187194
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2482_en.txt
@@ -0,0 +1 @@
+A 31-year-old male patient presented to our clinic with symptoms of neck pain, back pain (pain in the lower cervical and upper thoracic region), and numbness in both arms for the last 3 months. His physical examination revealed hypoesthesia at the C4 and C5 dermatomes in both arms with no loss of strength. Cervical computed tomography (CT) showed a destructive and compressive lesion in the C4 vertebra corpus . The retropulsion caused by compression had narrowed the canal. The lesion was also seen to be completely wrapped around the vertebral foramen at the right C4 level and to extend to the lateral mass posteriorly in the axial sections on CT . Weinstein, Boriani, Biagini (WBB) classification was used for the classification of the tumor . In this case, the tumor was located at the regions 5, 6, 7, 8, and 9 and invaded all the layers except the dura mater. Corpectomy was performed to the C4 vertebra with an anterior approach together with discectomy to the upper and lower disc spaces during surgery. The lesion was seen to extend to the right C4 vertebral foramen in the surgical observation after corpectomy, and the tumor was carefully dissected 360° around the vertebral artery at this level. Once the vertebral artery was revealed, we entered between the mass extending posteriorly to the lateral mass, the spinal cord, and the vertebral artery and performed meticulous intracavitary curettage. In order to ensure stability after tumor excision, the upper and lower corpus endplates were decorticated with the curette. A corpectomy cage was placed into the C4 space, and the system was fixed by placing a plate screw on the upper and lower vertebra from the anterior . There was no additional neurological deficit postoperatively. The patient’s neurological complaints improved during the postoperative period. There was no residual or remaining tumor after resection. The pathological microscopical evaluation revealed a tumor rich in osteoclastic multinuclear giant cells interspersed in a stroma composed of cells with oval-fusiform nuclei. The pathological diagnosis was giant cell tumor of the bone . No recurrence was seen during 3 years of follow-up .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2505_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2505_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a186351fbdeb9427e06801c2fd43cfa04cb52929
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2505_en.txt
@@ -0,0 +1,7 @@
+A 6-year-old child was admitted to the Eye Department of the Second Affiliated Hospital of Anhui Medical University (on June 3, 2017) with a complaint of ocular proptosis and no light perception after his tricycle had come to a sudden stop.
+He was admitted to our department 4 h after the left eyeball was dislocated without any other facial injury after his tricycle had come to a sudden stop. He had pain in his left eye and experienced no light perception; moreover, his extraocular motility was limited.
+The child and his grandfather denied any other medical conditions.
+The child and his grandfather denied any family history of related diseases.
+Upon clinical examination, the patient presented with intact left globe luxation, exophthalmos (L/R = 5 mm), no visual acuity, no perception of light and a complete limitation of extraocular motility in all directions. The eyelid was intact, the conjunctiva showed hyperaemia, the cornea was dry and completely exposed and the pupil was mid-dilated, with no reaction to light . Furthermore, he could not keep his right eye open.
+No laboratory tests.
+Computed tomography and magnetic resonance imaging showed proptosis of the left globe and gas accumulation in the superior intraconal space and stretching of the EOM . Magnetic resonance angiography excluded carotid cavernous fistula .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2546_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2546_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5060ec0696a187d9c84258a7847ad95c5ec1e029
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2546_en.txt
@@ -0,0 +1,4 @@
+A 73-year-old woman with pancreatic head adenocarcinoma underwent pancreatoduodenectomy (PD) at the Division of Hepato-Biliary-Pancreatic Surgery, Shizuoka Cancer Center Hospital, Shizuoka, Japan, in July 2005. The patient’s height, body weight, and body mass index were 154 cm, 56 kg, and 23.6 kg/m2, respectively. The patient was discharged 40 days postoperatively; however, approximately 1 month after discharge, she visited the hospital’s Division of Dentistry and Oral Surgery with a chief complaint of tongue pain with dysgeusia. The first examination revealed glossitis characterized by complete atrophy of the lingual papillae, which became erythematous; this is a symptom of glossitis . Furthermore, remarkable taste disorder (hypogeusia) and oral pain were reported. The angle of the mouth had stomatitis with erosive changes. The extremities showed acrodermatitis enteropathica-like eruption and abnormal keratinization . Blood test results showed hypoproteinemia and hypoalbuminemia (total protein (TP) 5.1 g/dL, albumin (ALB) 2.4 g/dL) . Examination of trace elements showed remarkably lower serum zinc and copper levels (30 μg/dL and 40 μg/dL, respectively) . We diagnosed malnutrition, dysgeusia, glossitis, angular cheilitis, and acrodermatitis enteropathica due to zinc deficiency. However, she had no obvious frequent diarrhea or steatorrhea.
+Initially, we orally administered 150 mg of Promac® granules 15% (polaprezinc, ZERIA Pharmaceutical Co., Ltd, Japan) per day (total zinc dose, 34 mg/day) to treat the zinc deficiency. However, due to the insufficient effectiveness of the replacement therapy, we additionally administered multi-trace elements (MTEs) for high-calorie infusions. Elemenmic® (Ajinomoto Co Inc, Japan) was administered intravenously, one ampule of which contained elemental iron (Fe) 35 μmol, manganese (Mn) 1 μmol, zinc (Zn) 60 μmol (= 4 mg), copper (Cu) 5 μmol, and iodine (I) 1 μmol; this was administered twice a week for 2 weeks as an outpatient treatment. However, the intravenous replacement therapy was similarly inadequate at this dosing interval and did not provide sufficient improvement in the serum copper and zinc values. The blood test results 4 months after PD were as follows: TP, 4.4 g/dL; ALB, 2.0 g/dL; Zn, 34 μg/dL; and Cu, 28 μg/dL; the patient required nutritional management during hospitalization with total parenteral nutrition (TPN) . An improvement was observed in the zinc level (99 μg/dL) and copper level (204 μg/dL) after 20 days of administering one ampule of Elemenmic® per day. Concurrently, her tongue pain and dysgeusia gradually improved. Because of a similar improvement in her nutritional status, she completed TPN (TP 5.1 g/dL, ALB 2.5 g/dL, Zn 99 μg/dL, Cu 204 μg/dL). A central venous catheter (CVC) inserted after admission was removed, and she was discharged 20 days after the second admission. On this occasion, intravenous zinc replacement therapy was discontinued.
+One month after discharge, the serum zinc level decreased sharply, her oral pain increased again, and she had reduced food intake (Zn 35 μg/dL, Cu 44 μg/dL) . The patient was readmitted at the end of December 2005. To improve malnutrition, a CVC was re-inserted through the external jugular vein and injected with the MTE formulation and high-calorie infusions on consecutive days for 4 weeks (TP 5.9 g/dL, ALB 3.4 g/dL, Zn 75 μg/dL, Cu 47 μg/dL). In January 2006, since her oral pain and diet had improved, she was discharged from the hospital after receiving an implant of a central venous port, and she continued home self-injection of MTEs to maintain zinc levels. In February 2006, her taste function tended to improve, and in April 2006, the taste almost improved. When MTEs were self-injected daily, the serum zinc level gradually exceeded the normal range and reached 167 μg/dL in August 2006 ; therefore, the administration was switched to every other day. Subsequently, we had to confirm the blood test data repeatedly to monitor serum zinc levels to ensure that they were within the normal range . Despite continuing intravenous zinc replacement therapy, serum zinc levels decreased when additional oral zinc was discontinued in May 2007. After resuming the oral administration of Promac® due to the recurrence of dysgeusia, both the serum zinc level and dysgeusia improved. Since 2008, Pancreatin® (pancreatic enzyme, Mylan Co Inc, USA) 3 g/day had been administered alongside conventional zinc administration for this patient .
+As of January 2012, she continued using MTEs intermittently while her serum zinc values were monitored; however, slight angular cheilitis was observed, and she exhibited no signs of glossitis and dysgeusia . Moreover, recurrence and metastasis of the primary tumor were not observed. She subsequently died of lung cancer in May 2020.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2552_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2552_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5f0fd974f50341482f102e34abf7a482b9f8295b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2552_en.txt
@@ -0,0 +1,4 @@
+This is the case of a 54-year-old male patient who received a kidney transplant from a living donor, his wife, in December 2014. His underlying nephropathy was a focal and segmental glomerulosclerosis, presumed secondary to a genetic mutation since he had a strong family history of kidney disease, even though no genetic testing was performed. He had been on hemodialysis for 6 months before transplantation. He had no previous blood transfusions, his panel reactive antibodies (PRAs) was negative and he had 5 mismatches in class I and was fully matched in class II. He received an induction therapy with Basiliximab and was maintained on tacrolimus, mycophenolate mofetil (MMF), and low- dose steroids. His immediate post-operative period was uneventful with a serum creatinine of 1.1 mg/dl upon discharge. He continued his regular out-patient follow-up, with no major events, a stable kidney function, and no proteinuria up until August 2020. In September 2020, he presented with fatigue, fever and tested positive with COVID-19 infection. His respiratory symptoms were mild with no oxygen requirements; therefore, he was treated with acetaminophen and oral hydration. His low-grade fever persisted for more than one week, so a chest CT was ordered and showed multiple well-defined ground-glass opacities in both lungs consistent with COVID-19 infection. A blood test was done then and showed a c-reactive protein of 14 mg/l, white blood cells of 5.3 × 109/L with 70% neutrophils and 20% lymphocytes, and a serum creatinine level of 1.4 mg/dl. Since the patient presented with a mild case of COVID-19 he was not treated with dexamethasone, monoclonal antibodies or any other medications. His MMF was decreased from 1500 to 1000 mg per day for a total of 10 days, and his tacrolimus trough levels were kept within target range (6.8 ng/ml). His serum creatinine returned to its baseline of 1.2 mg/dl after resolution of the infection. Later on, it started to fluctuate on higher values reaching 1.6 mg/dl in April 2021, with no evident explanation. There was no introduction of new medications, no intercurrent infections, and again a stable tacrolimus trough level. He was therefore admitted for a kidney biopsy.
+Light microscopy showed histological evidence of global glomerulitis (g2), moderate capillaritis (ptc2) and thrombotic microangiopathy (TMA) affecting arterioles and glomeruli . A single focus of tubulitis was noted (t0). These histopathological findings were consistent with an active AMR. Interestingly, there was no C4d staining of peritubular capillaries or vasa recta upon immunohistochemistry (C4d0). Only focal interstitial inflammation (i0, < 10% of unscarred cortical parenchyma) was noted with CD3 and CD20 immunostaining. Capillaries contained mainly CD3+ and CD4+ T-cells, with some CD56+ cells . Direct immunofluorescence studies showed IgM, C3, and C1q deposition in a segmental distribution in the lesioned glomeruli, consistent with focal and segmental glomerulosclerosis. Some podocytes protein resorption droplets were highlighted by IgA, Kappa, and Lambda. There was no significant IgG deposition nor mesangial IgA deposits. Donor-specific antibodies came back positive for class I, HLA-Cw17, with an MFI of 6689 confirming the diagnosis of late active c4d negative AMR.
+The patient was also tested for killer cell Ig-like receptors (KIRs) genotyping using the KIR SSO Genotyping Test (One Lambda) which applies Luminex® technology, and came back positive for the expression of KIR2DS1.
+The patient was treated with pulse steroids, five sessions of plasma exchange and IVIG with a total dose of 2 g/kg, with a good response to treatment and a creatinine at 1.3 mg/dl upon discharge. His DSA decreased three months later to an MFI of 2710, with a delta MFI of 60%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2561_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2561_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..93af7b55a693c1fcc8b3896c4b2c34d5ba9b7f8a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2561_en.txt
@@ -0,0 +1,10 @@
+In our detailed case presentation of the 4-year-old female patient with FLH, we observed and documented specific clinical signs and symptoms that warranted our attention. Upon examination, the patient exhibited pronounced enlargement of the index finger and thumb of the right hand, a hallmark sign of macrodactyly associated with FLH. This enlargement was not uniform; the thumb and index finger were disproportionately larger compared to the other fingers, with noticeable swelling and a firm texture upon palpation, indicating the presence of fibroadipose tissue.
+The patient reported pain, which was more pronounced at night, and a tingling sensation along with occasional episodes of bluish discoloration of the affected fingers, suggesting compromised vascular supply or nerve compression. These symptoms were particularly evident in the anatomical areas surrounding the median nerve's path through the wrist and hand, which is commonly affected in FLH. The anatomical distribution of symptoms, coupled with the physical manifestations in specific fingers, provided crucial insights into the condition's localized impact on the hand's structure and function.
+On examination the first and second fingers of the right hand appear larger than the adjacent fingers, with finger 2 measuring 6 × 1.9 cm and finger 1 measuring 6 × 2 cm. Angulation is present measured at 20 degree, directed towards the ulnar side on the distal dan middle phalanx There is discontinuity observed, no tenderness, the sensation is detectable at the base, middle, and tip of the second finger, as well as at the base and tip of the first finger. Range of motion within normal limits, grasping ability present. Sensory within normal limits, comparable to the surrounding and contralateral side. Comparison with patient's mother, size of the patient's mother first finger is 4 × 1,5 cm, and the second finger is 5 × 1,5 cm . Radiographs indicated widespread edema and heightened soft tissue density in the 1st and 2nd finger of the right hand, specifically on the palm side.
+Before surgery, we performed the pre-operation examination a week after first admission, the condition is still the same as when it was first examined . We did a radiologic examination to examine the size of the bone . In addition to the initial X-ray imaging, further diagnostic evaluations were carried out to confirm the diagnosis of FLH with Macrodactyly and assess its extent. The X-ray images of the patient's right hand revealed an increase in soft tissue density around the affected fingers, indicative of fibroadipose tissue proliferation. Furthermore, the images showed enlargement of the phalanges in the index finger and thumb, consistent with macrodactyly. These findings align with the characteristic radiological features of FLH, including the disproportionate growth of soft tissues and bones in the affected digits. While Magnetic Resonance Imaging (MRI) is recognized as a superior diagnostic tool for assessing soft tissue lesions and was indeed planned for a comprehensive evaluation of the fibrolipomatous hamartoma, the availability of MRI was significantly limited due to long waiting lists. This constraint necessitated prioritizing immediate clinical assessment and intervention based on available diagnostic resources, such as X-ray imaging, which provided initial insights into the condition's impact on bone and soft tissue.
+A month after clinical assessment, the surgical intervention for the patient was meticulously planned and executed with the aim of addressing the significant enlargement of the right second finger, while ensuring the preservation of hand function and minimizing potential complications. The procedure comprised several key steps. Debulking: During the surgical debulking of the patient's right hand, specifically targeting the enlarged second finger affected by FLH, careful attention was paid to the composition and location of the tissue being excised. The procedure focused on removing excessive fibroadipose tissue that had proliferated around the median nerve and within the soft tissue matrix of the finger, characteristic of FLH. The excised mass predominantly consisted of a mixture of soft fibrous and adipose tissues. These components are typical of FLH, where fibrous tissue represents the proliferative fibroblasts and collagen deposition around the nerve sheath, and adipose tissue indicates the abnormal fat accumulation within and around the nerve bundles. Notably, the tissue exhibited a soft, pliable consistency, with areas of harder fibrous nodules interspersed within the fatty matrix, reflecting the heterogenous nature of FLH lesions. No significant portions of hard tissue, such as bone, were involved in the debulking process, as FLH primarily affects the soft tissue surrounding the nerve structures. The surgical removal was carefully executed to avoid damage to the nerve itself, ensuring that only the overgrown fibroadipose tissue contributing to the patient's symptoms and functional impairment was excised. This surgical debulking aimed to alleviate the mechanical pressure on the nerve, reduce the bulk of the finger to improve its function and appearance, and, importantly, to obtain tissue for histopathological examination, although, as previously noted, histological analysis was not pursued in this case.
+Wedge Osteotomy of the Middle Phalanx: To correct the angulation and disproportionate enlargement of the second finger, a wedge osteotomy was performed on the middle phalanx. This involved making precise, angular cuts in the bone to remove a wedge-shaped segment, allowing for the realignment of the finger. The osteotomy was carefully planned based on pre-operative imaging to ensure the correction of angulation while maintaining the finger's length and functionality. K-Wire Insertion: Following the osteotomy, stabilization was achieved by inserting a Kirschner wire (K-Wire) into the middle phalanx. The K-Wire was used to secure the bone in its newly aligned position, ensuring proper healing and consolidation of the osteotomy site. The wire was inserted in a manner that allowed for optimal bone positioning while minimizing interference with finger movement. . Intraoperative mass was found at palmar region with a suspicion of fibro lipoma, it was decided that the mass was not resected. The patient was scheduled for MRI examination for further work up. , shows the clinical appearance after the surgery.
+After the surgical intervention, which included debulking, wedge osteotomy, and K-Wire insertion, the patient underwent a structured post-operative follow-up schedule designed to monitor healing, evaluate the functional recovery of the affected fingers, and mitigate potential complications. The first follow-up, conducted two weeks post-surgery, focused on wound care and the assessment of any immediate post-operative complications. Subsequent follow-ups were scheduled monthly for the first six months, during which the progress of finger function recovery and the effectiveness of the surgical intervention were closely monitored.
+The decision to perform surgical intervention on the second finger as a priority was informed by its considerable enlargement, which was more pronounced than other affected areas. This enlargement of the second finger had a significant impact on the patient's hand function, manifesting as impaired gripping ability and dexterity. Addressing the second finger first aimed to alleviate the most immediate functional limitations and discomfort experienced by the patient, with a view to improving quality of life and hand usability in daily activities.
+A comprehensive rehabilitation program was initiated early in the post-operative period to enhance the patient's hand functionality and alleviate stiffness. This program, tailored to the patient's specific needs, included physical therapy sessions emphasizing range of motion exercises, strengthening exercises for the hand and fingers, and sensory re-education activities. The patient was also provided with home exercise routines to encourage continuous improvement outside of therapy sessions. Special attention was given to incorporating play-based therapy techniques suitable for the patient's age to maintain engagement and compliance with the rehabilitation process.
+Throughout the rehabilitation phase, the patient demonstrated a gradual improvement in grip strength, finger mobility, and a decrease in the stiffness of the right hand. These improvements were significant milestones in the patient's recovery, contributing to an enhanced ability to perform daily activities and an improved quality of life. The patient continues to be monitored regularly to assess long-term outcomes and the potential need for additional interventions.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2563_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2563_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dc2e44bd070c87ac2c36a192e01b6f8ce97e4af1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2563_en.txt
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+A 54-year-old woman presented at our hospital with left flank discomfort and palpebral edema of 1-week duration. She underwent abdominal postcontrast computed tomography (CT) in a local hospital, which showed a low-density renal pelvic mass and hydronephrosis of the left kidney and indicated renal pelvic cancer (Figure ). Her past medical history included sicca complex for 5 years previously. In her laboratory examination, a routine urine test revealed a red blood cell count of 118.4/μl (normal reference range, 0 to 25/μl), a white blood cell count of 127.3/μl (normal reference range, 0 to 25/μl) and an epithelial cell count of 13.4/μl (normal reference range, 2 to 10/μl). No remarkable findings in the complete blood count or urine cytology were observed. A retrograde pyelogram showed a dilated left renal pelvis and stricture of the upper ureter, which had a regular surface and a filling defect (Figure ). On postcontrast magnetic resonance imaging (MRI) scans, the wall of the ureteropelvic junction was irregularly thickened and showed isointensity on T1-weighted images and hypointensity on T2-weighted images. On both T1- and T2-weighted images, the thickened wall of ureteropelvic junction showed homogeneous enhancement. Furthermore, multiple enlarged retroperitoneal lymph nodes were visualized by MRI (Figure ). Positron emission tomography/CT findings indicated that the renal pelvic mass was a malignant tumor, because the glucose metabolism was very high (Figure ). PET/CT also revealed multiple enlarged hypermetabolic lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions. All of these findings together led us to consider a possible diagnosis of a renal pelvic malignant tumor with multiple lymph nodes metastasis.
+A few days later the patient underwent a left-sided nephroureteral cystectomy and retroperitoneal lymph node dissection, in which part of the bladder was removed. The surgery was performed to establish a definitive diagnosis and for treatment if the mass was malignant.
+Gross examination of the kidney showed a 5 × 2.5–cm, pale, whitish-tan, ill-defined mass located in the renal pelvis near the renal hilum. Histologic examination of the mass showed lymphatic tissue hyperplasia and diffuse infiltration of plasma cells. The plasma cells were IgG- and IgG4-positive. The IgG4/IgG ratio was approximately 40% (Figure ). Two retroperitoneal lymph nodes were dissected, which represented as reactive hyperplasia. The pathological findings did not reveal malignancy.
+After the diagnosis of IgG4-RD was made, a further laboratory examination was performed. The patient’s serum IgG4 level was 18.6 g/L (normal reference range, 0.03 to 2 g/L), and her high-sensitivity C-reactive protein test result was 26.3 mg/L (normal reference range, 0 to 3 mg/L). The patient underwent steroid therapy in a local hospital for 1 year. At the fourth month of her steroid therapy, her high-sensitivity C-reactive protein level had descended to 8.76 mg/L (normal reference range, 0 to 8 mg/L). Her enlarged lymph nodes in the supraclavicular, retroperitoneal, peritoneal and pelvic regions diminished with the steroid therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2626_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2626_en.txt
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index 0000000000000000000000000000000000000000..4a6cc033bbd04e5a58ad55149290e9633daa85f1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2626_en.txt
@@ -0,0 +1,3 @@
+A 64-year-old woman underwent phacoemulsification surgery in her right eye. Surgery was uneventful until the irrigation/aspiration stage during which engagement of the central area of the detached DM in the aspiration port was suddenly noted. Intraocular movement of the aspiration port had created three pieces of large DM tears and aspiration of the central piece had led to loss DM in the central area. A posterior chamber intraocular lens was implanted and the procedure was terminated. Postoperatively, the patient was referred to our cornea service for management of corneal edema.
+One day after phacoemulsification, in July 2012, visual acuity was counting fingers at one meter and slit lamp examination revealed diffuse corneal stromal edema with deep corneal folds. Extensive corneal edema obscured the view of DM and anterior chamber. Due to scattering in the edematous cornea, a clear view of DM was not obtained by Scheimpflug imaging. Only in a few images, an indistinct view of DMD was noticeable. Pachymetry revealed a central corneal thickness of 1344 mm . Topical dexamethasone eye drops (Maxidex, Alcon, Fort Worth, TX, USA) were administered every 1 h for a total of 4 days. After 2 days of treatment, the corneal edema decreased and after 4 days, DM was visible and multiple tears with and without DMD were seen. Scheimpflug images showed partial reattachment of DM in some parts of the cornea .
+On the following day, air was instilled into the anterior chamber of the same eye through a corneolimbal paracentesis track. Air injection was repeated the day after, due to insufficient attachment. Visual acuity and central corneal thickness gradually improved to 20/32 and 642 mm, respectively, over the course of 5 weeks. Despite partial loss of DM, corneal edema largely disappeared 5 weeks after air bubble injection .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2659_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2659_en.txt
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index 0000000000000000000000000000000000000000..f8167445b2e952e5805ee6622f1e5bcff2562828
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2659_en.txt
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+A 19-year-old Asian man presented at our hospital’s emergency department with reduced consciousness and seizures. He had a Glasgow Coma Score of 11 to 12, and was agitated and confused during the first 2 days. He experienced two to three general tonic–clonic seizures of approximately 15 to 30 seconds’ duration each within hours of each other, and he was awake between seizures. His seizures started with stiffness in his whole body and his eyes were rolled back during seizures. His Glasgow Coma Score was reduced to 8 on the third day and he was intubated and sent to our intensive care unit (ICU). He had a continuous high fever, ranging from 39 °C to 40 °C, headache, confusion, and vomitus. His fever began to decline to 38.0 °C several hours before hospital admission. He and his family had no history of epilepsy, weakness and paralysis of limbs, drug abuse, tobacco smoking, or alcoholism.
+A physical examination showed nuchal rigidity and tetraparesis with accentuated tendon reflexes. Cranial nerves and ophthalmoscopy examinations were normal. An immediate electroencephalography (EEG) showed periodic epileptogenic waves at his right temporal area and general bitemporal cortical dysfunction. These findings suggested an acute structural lesion at his right temporal area or an epileptic state, and a possible viral cause.
+Evaluation of hematology showed dynamic changes of leukocytes and C-reactive protein (CRP) level during his illness. His white blood cell count and CRP reached peak level at day 70 when ventilator-associated pneumonia and pleural effusion occurred . Coagulation parameters and a liver function test showed normal values. A cerebral spinal fluid examination showed a white blood cell count of 16/mm3, polymorphonucleocytes (PMN) of 13/mm3, mononuclear (MN) cells of 87/mm3, glucose level of 42/dL, and an increased protein level of 216 mg/dL, which suggested a nonspecific viral infection. Gram, India ink, and Ziehl–Neelsen stains were negative. Computed tomography (CT) scans were performed twice, on 2 September 2014 (day 6) and 22 September 2014 (day 26). The first CT scan result was normal but the second showed a smeared bright area in ependymal cells at the lower area of the third ventricle . Serology tests were performed against herpes simplex virus and varicella zoster virus. These tests showed negative results for immunoglobulin (Ig) M and IgG. The possibility of human immunodeficiency virus was eliminated by a CD4 count of 750 cells/mm3. Different results were found in the serology test for CMV. First, a serology test showed negative results for IgM and IgG anti-CMV. A second serology test showed a borderline positive result for IgG anti-CMV with a titer of 0.9 U/mL. The last two serology tests showed positive results for IgG anti-CMV with titers of 5.0 U/mL and 3.8 U/mL. The four-fold increase in IgG anti-CMV from 0.9 U/mL to 5.0 U/mL within 8 days is an important finding . Serial images of his thorax and clinical pulmonary infection score assessment accompanied by blood and sputum cultures were regularly performed, and confirmed a diagnosis of pneumonia in our patient. Based on his medical history, physical examinations, laboratory results, and supporting examinations, the diagnosis of CMV meningoencephalitis was made.
+His clinical condition deteriorated even though therapy with cefixime, acyclovir, dexamethasone, and phenytoin was administered intravenously. His cranial reflexes started to become reduced after 1 week in our ICU. On day 19, spontaneous respiration disappeared, cranial reflexes became negative, and BSD was suspected because he had no response to all brain stem tests, including an apnea test . A vasopressor was used to maintain his hemodynamic stability. His family insisted life support should be continued indefinitely. This condition lasted for almost 2 weeks with no improvement and brain stem tests were regularly performed with negative results.
+On day 30, he provided a vague response to painful stimuli at his supraorbital nerve. On day 35, he opened his eyes. Respiration started to appear on day 37, followed by gradual movement of his fingers. His consciousness improved from day 37, and he became fully conscious on day 50. Ganciclovir replaced acyclovir based on a four-fold increase of IgG anti-CMV serology in a test result on day 27. Other therapies on days 19 to 30 included antibiotics based on culture, corticosteroids, antibiotics, antipyretics, and antifungal agents. He also had pleural effusion and a water-sealed device was installed on day 75. A higher positive end-expiratory pressure (PEEP) on the ventilator was applied to maintain oxygenation and prevent alveoli collapse. After day 80, his respiration improved. On day 85, he was weaned from the ventilator and was able to breathe without it. He started to move his arms but his legs were still paralyzed. On day 90, he was moved from our ICU to in-patient care where he stayed for 10 days until he went home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2665_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2665_en.txt
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index 0000000000000000000000000000000000000000..9c03c9db186435155611345a233e782359524d97
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2665_en.txt
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+We report a 70-year-old male patient who presented to our emergency room with fever and altered mental status for 24 hours before presentation. The patient was also complaining of increasing left flank pain, nausea, and emesis. There was no history of trauma. On physical examination, the patient appeared to be in distress and minimally responsive. Initial vital signs revealed a temperature of 103.3°F, tachycardia, but stable blood pressure. Abdominal examination revealed distended abdomen and left flank tenderness to palpation. He was found to have severe leukopenia with white blood cell count of 0.7 K/μL and a serum creatinine (sCr) of 1.64 mg/dL with a normal coagulation profile. A computed tomography (CT) scan of the abdomen/pelvis with intravenous contrast showed a large intracapsular hematoma (13.3 × 10.0 cm), which deformed and compressed the kidney anteriorly ( and ). There were multiple areas of curvilinear hyperdense material within the hematoma, indicating vascular extravasation consistent with active bleeding. Marked left perinephric stranding with extension of the extracapsular hematoma to the distal aorta, iliac vessels, presacral space, and along the left prerenal space was seen . A 1.1 cm stone was identified within the proximal left ureter, and a 6 mm stone was identified within the inferior pole of the left kidney. The proximal left ureter was dilated ( and ).
+Despite ongoing resuscitative measures with intravenous fluid boluses and intravenous antibiotics, the patient became hemodynamically unstable 1 hour after presentation to the emergency room. His blood pressure decreased to 70/40 mmHg and Hgb dropped to 9.5 g/dL (from 11.3) that required initiation of blood transfusion and infusion of vasoactive pressor medications. The patient remained critically ill, tachycardic, and hypotensive with a blood pressure of 80/60 mmHg despite 8 L of intravenous crystalloid fluid, 4 U of blood, and pressure support. Interventional radiology was consulted. If managed nonoperatively, it appeared the patient would need both a nephrostomy tube and selective arterial embolization. Given the large hematoma with minimal hydronephrosis combined with the patient's rapid clinical deterioration, interventional radiology did not think they would be able to help with both of these problems. Because of the complicated nature of the combined issues of active renal hemorrhage with hemorrhagic/septic shock, the patient was subsequently taken for emergent exploratory laparotomy and left nephrectomy. During the exploration, active bleeding was encountered with a (2.4 × 2.0 cm) shaggy defect at the interpolar lateral aspect of the kidney . Vascular control of the renal pedicle was obtained and a nephrectomy was performed. Postoperatively, the patient made a steady progress until he was discharged with sCr 1.38 mg/dL, estimated glomerular filtration rate 51 mL/min/1.73 sqM, and stable Hgb 9.6 g/dL. The initial blood and urine cultures revealed growth of Escherichia coli that was treated with appropriate antibiotics. Histopathologic examination of the kidney showed acute and chronic interstitial and intratubular inflammatory infiltrate with acute hemorrhage with no evidence of malignancy .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_268_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_268_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f089948716d3c4b613b7717151e550d946d2717
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_268_en.txt
@@ -0,0 +1,4 @@
+A 46-year-old woman had undergone mastectomy for breast cancer (estrogen receptor 2+, progesterone receptor 3+, and HER2 3+) 5 years before presentation and had subsequently remained under observation without any postoperative adjuvant therapy. Multiple lung, liver, and bone metastases were identified in year 3 postoperatively, and systemic chemotherapy was introduced. The chemotherapy regimen included docetaxel, trastuzumab, pertuzumab, and bisphosphonates, and radiotherapy for lumbar spinal bone metastases (20 Gy/5 Fr). However, she developed multiple brain metastases (BM) 1 year later, which were treated with whole-brain radiotherapy (30 Gy/10 Fr) and placement of a ventriculoperitoneal shunt for hydrocephalus. The systemic chemotherapy regimen was subsequently switched to trastuzumab emtansine, but further LM developed, and the patient was referred to our hospital.
+At the time of referral, Eastern Cooperative Oncology Group (ECOG) performance status was 4, level of consciousness as assessed by Glasgow coma scale score was E3V4M6, and she was suffering from intractable headaches, severe nausea and vomiting, and cerebellar ataxia. T1-weighted gadolinium- enhanced magnetic resonance imaging (MRI) revealed diffuse contrast enhancement of the meninges, mainly in the posterior cranial fossa, with compression of the cerebellum by the significantly thickened meninges [,]. In light of the clinical course, treatment options were limited, and best supportive care was presented as an option.
+However, the patient requested further therapy, and given her good karnofsky performance status (KPS), an aggressive treatment strategy was pursued. The first step in the treatment was to relieve intracranial hypertension, and decompression of the posterior cranial fossa was performed . After surgery, headaches, nausea, and vomiting were immediately improved and her performance status improved.
+Treatment with lapatinib at 1250 mg and capecitabine 1200 mg was started on postoperative day 14. As early as 2 weeks later, the diffuse abnormal signal enhancement across her tissues shrunk dramatically on T1-weighted gadolinium- enhanced MRI after starting this new regimen [,]. Further imaging revealed that the LM had almost disappeared on MRI by 2 months of therapy [,]. At present, no recurrence has been observed more than 1 year after the treatment. The patient is continuing to attend our hospital unit for treatment under the same regimen and currently remains well with an ECOG Performance Status 1.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2691_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2691_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2e35ed112e969581a50cd9ae3073c2fecf3d2457
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2691_en.txt
@@ -0,0 +1,5 @@
+A 67-year-old man identified an enlarging heterogeneous mass in the posterior segment of his right up lobe. The patient had symptoms of shortness of breath after activity and physical examination revealed a grade 3–4 of 6 holosystolic murmur. Echography of the abdomen, Computed tomography (CT) scan of the brain, bone scintigraphy and Positron Emission Tomography (PET) were performed to define the pulmonary malignancy and excluded distal metastases , tumor was classified and staged T2N0M0. An electrocardiogram (ECG) revealed examination demonstrated severe prolapse of the posterior mitral leaflet with flail of the middle scallop (P2, P3 segment) , the left atrial (LA) and left ventricle (LV) was extensive (LA 46 mm, LV 55 mm), the patient was severe mitral regurgitation with New York Heart Association (NYHA) class II. Lung function tests and coronary angiography were unremarkable. The patient denied family history of related diseases. Patient elected the option of a one-stage ipsilateral VATS and minimally invasive cardiac surgery as definitive diagnostic and therapeutic procedures.
+After general anesthesia, double-lumen tube intubation, and insertion of routine monitoring catheters, the patient was positioned supine with the right chest slightly elevated first for MIS of mitral valve (MV) . Cardiopulmonary bypass (CPB) was instituted via femoral arterial and venous cannulation. Anterior axillary ports were inserted in the third, fifth intercostal spaces for assist port and camera port. A right lateral, fourth intercostal space, < 1 cm below and posterior to the nipple, 5 cm mini-thoracotomy was performed . An additional venous cannula was inserted in the superior vena cava from the assist port and the aorta was cross clamped with a Chitwood clamp from the same port. Myocardial protection was achieved with mild hypothermia and antegrade delivery of hyperkalemic cold sanguinous cardioplegia (1 L), then the cardioplegia was reinfused every 20 min (500 ml). The left atrium was then opened posterior to the interatrial groove, and a left atrial retractor was used to expose the MV.
+Gore-Tex loops were attached to felt pledgets. The correct loop length was estimated by measuring the distance from the papillary muscle to the level of the mitral annulus. The anteroposterior diameter of the anterior MV leaflet and the distance of the commissures for appropriate ring sizing (Edward 28 mm).Valve competency was tested by injecting saline into the left ventricle . Heparin reversed with protamine.
+The patient was then placed in the left decubitus position. The same intercostal space ports were used for working port. A wedge resection was performed and the frozen biopsy result came back as lung adenocarcinoma. We performed right upper lobectomy . Upper lobe vein was dissected. Stapler Echelon 60 2.5 mm was used for cutting the vein. After the upper lobe bronchus was fully freed by right angle clamp, the bronchus was exposed and identified. The stapler pin was locked into position and the residual lung expansion test was examined, then the stapler was fired and removed. The fissures were completed by means of blunt dissection, cautery and stapler Echelon 60 3.5 mm. The diseased lobe was carefully maneuvered into an endobag. Systematic nodal dissection of stations R2 to R10 was performed by ultrasonic scalpel Harmonicc Ace and lymph node biopsy clamp . The inferior lung ligament was freed so that the residual lung could get a well reexpansion.
+The patient recovered smoothly after operation, who was free from infusing blood during hospitalization and discharged from hospital on the tenth day after operation. This patient have not complications during follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2696_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2696_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64a4bd76a8426d1b18087b37002b6496a0ce623d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2696_en.txt
@@ -0,0 +1,86 @@
+A 7-year-old neutered male, mixed-breed cat presented with subcutaneous oedema and
+erythema of the right axilla extending to the abdomen, and swelling of the right
+forelimb .
+Clinical examinations revealed mild fever (39.7°C) and a subcutaneous soft mass (3.0
+× 2.0 cm) on the back. A complete blood count revealed anaemia (packed cell volume
+[PCV] 26%) and thrombocytopenia (96,000 platelets/μl) . A blood smear examination
+revealed a small number of large atypical round cells. The cells had
+small-to-moderate amounts of basophilic cytoplasm and large nuclei with finely
+diffused chromatin and several nucleoli. The cells rarely contained fine azurophilic
+granules in the cytoplasm . Examinations for feline immunodeficiency
+virus antibodies and feline leukaemia virus antigens were not performed. Thoracic
+and abdominal radiography and abdominal ultrasonography showed no significant
+findings. Cytological analysis with fine-needle aspiration from the subcutaneous
+lesion of the right axilla and the dorsal subcutaneous mass revealed the presence of
+large atypical round cells. The cells had small-to-moderate amounts of basophilic
+cytoplasm and irregular nuclear membranes, and were occasionally binucleated . The nucleus had one
+or several distinct nuclei with finely diffused chromatin. Azurophilic granules were
+not observed in the cytoplasm. The cells were thought to be lymphoid cells and the
+presumed diagnosis was lymphoma. A PCR-based clonality analysis for TCR-gamma (TCRγ)
+and immunoglobulin heavy chain (IgH) genes with DNA extracted from the subcutaneous
+lesions revealed no clonal rearrangement of both genes. All PCR products were
+assessed by heteroduplex analysis as previously described.
+The cat was treated with prednisolone at a dose of 1.0–1.5 mg/kg/day and
+L-asparaginase at a dose of 400 U/kg, four times in total at various intervals. The
+treatment led to a transient improvement of oedema and regression of the dorsal
+mass. However, the cat died after 78 days of initial treatment owing to loss of
+appetite, severe anaemia (PCV 8.9%) and liver dysfunction. A complete necropsy was
+performed on the day. At necropsy, the cat presented with severe jaundice and an
+oedematous subcutaneous mass in the right chest. Moderate hepatomegaly,
+splenomegaly, lymphadenopathy of the mediastinal (1.2 × 0.8 cm) and left axilla (0.8
+× 0.8 cm), and haemorrhage in multiple organs were also observed .
+The subcutaneous tumour tissue, visceral organs and brain were fixed in 10%
+neutral-buffered formalin, embedded in paraffin, sectioned at 4 μm thickness, and
+stained with haematoxylin and eosin. Immunohistochemistry was performed using
+primary antibodies listed in . The following normal tissues without lesions were used as
+positive controls: normal thymus, spleen, lymph node, bone marrow, liver, intestine
+and brain. A horseradish peroxidase (HRP)-labelled polymer system (EnVision+ System;
+Dako) was used as a secondary antibody. Labelled complexes were visualised with the
+3,3′-diaminobenzidine chromogen, and the sections were counterstained with
+haematoxylin. Double immunofluorescence was performed on normal thymus, spleen and
+liver tissues of cats to detect CD56+ and CD3− cells. Alexa
+488-conjugated donkey anti-mouse IgG (1:200; Invitrogen) and Alexa 594-conjugated
+donkey anti-rabbit IgG (1:200; Invitrogen) were used as secondary antibodies and
+counterstained with 4′,6-diamidino-2-phenylindole (Vector Laboratories). Western
+blotting analysis was performed to confirm the reactivity with an appropriate
+molecular weight antigen of anti-CD56 and anti-CD57 antibodies using feline and
+canine brain tissues. The membranes were incubated with each antibody (1:1000) at 4°C overnight,
+and then incubated with HRP-conjugated sheep anti-mouse IgG (1:5000) (Bethyl
+Laboratories, Montgomery, TX) at room temperature for 1 h.
+Histologically, extensive necrosis, oedema and focal infiltration of large atypical
+round cells were observed in the subcutaneous mass . The tumour cells had scarce
+cytoplasm, an irregular nuclear membrane, coarse nuclear chromatin and a distinct
+nucleolus. The cells were occasionally binucleated, and anisocytosis and
+anisokaryosis were moderate. The nucleus of the tumour cell was approximately three
+times the diameter of a red blood cell. The tumour cells were also observed in the
+liver, spleen, bone marrow and lymph nodes of the mediastinal and left axilla. In
+the liver, the tumour cells were diffusely infiltrated . Multifocal haemorrhage and bile
+plugs in the capillary bile duct were also observed. In the spleen, neoplastic cells
+were diffusely infiltrated and replaced the red pulp, with multifocal haemorrhage.
+The bone marrow was hypoplastic and the tumour cells were diffusely infiltrated,
+comprising approximately 10% of nucleated cells . The tumour cells diffusely
+infiltrated the sinus with haemorrhage in the mediastinal and left axilla lymph
+nodes. The number of mitotic figures was two per field (× 400 magnification).
+Immunohistochemically, in normal cat tissues, CD3 labelling was detected in the cell
+membrane and cytoplasm of lymphocytes . CD56+ lymphoid cells were
+detected in the thymus , spleen and liver. CD57+ lymphoid cells were detected in
+the thymus ,
+intestinal mucosa, spleen and lymph node. In the brain, neuropil was positive for
+CD56 and CD57 . CD34+ lymphoid cells were
+detected in the thymus , spleen and lymph node. CD10+
+lymphoid cells were detected in the thymus, spleen, lymph node and bone marrow. Monocytes, macrophages and
+interstitial dendritic cells were positive for CD204 . Myeloid cells in bone marrow , neutrophils, monocytes and macrophages
+were positive for myeloperoxidase. In the present cat, the cell membrane of tumour
+cells was strongly positive for CD56 but negative for a
+T-cell-associated marker (CD3) , B-cell-associated markers (CD20, CD79a, Pax5 and BLA36),
+macrophage/histiocyte markers (Iba-1 and CD204), a major histocompatibility complex
+class II antigen presenting cell marker (HLA-DR), mast cell-associated marker
+(CD117), a myeloid cell-associated marker (myeloperoxidase), haematopoietic
+progenitor-associated marker (CD34), lymphocyte precursor cell-associated markers
+(CD10), mature NK cell marker (CD57) and cytotoxic cell markers (granzyme B and
+perforin).
+In double immunofluorescence, CD56+ CD3− lymphoid cells were
+detected in the thymus , spleen and liver. By Western blotting
+analysis, in both brain samples of cat and dog, anti-CD56 antibody labelled bands of
+100–120 kDa, 140 kDa and 180 kDa, and anti-CD57 antibody labelled a band of 110 kDa,
+consistent with the molecular weights of CD56 and CD57 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2736_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2736_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bcdf7d8c96fb619e5b5424e6f3c44dc60d15096f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2736_en.txt
@@ -0,0 +1,5 @@
+A 58-year-old Japanese man was referred to our hospital with a three-month history of a painless swollen mass in his right sub-mandibular region. Physical examination revealed an elastic hard mass in his right sub-mandibular gland. The gland was not fixed to adjacent tissue. Several enlarged elastic hard movable lymph nodes were palpable in the region. Salivary flow from his right sub-mandibular gland was poor. Our patient had a history of a recurrent gastric ulcer from 21 years of age. His laboratory data were in the normal range except for lactate dehydrogenase (214 U/L; normal range: 105-210 U/L), γ-glutamyl transpeptidase (88 U/L; normal range: 11-80 U/L), triglyceride (199 mg/dL; normal range: 42-168 mg/dL), leucine aminopeptidase (83 U/L; normal range: 19-69 U/L), and serum immunoglobulin (IgG, 924 mg/dL; normal range: 870-1700 mg/dL). Regarding the measurement of the serum IgG subclass, only his IgG4 level (16.9 mg/dL; normal range: 4.8-105 mg/dL) was evaluated with the consent of our patient. Other serological data regarding the Ig levels and auto-antibodies were not evaluated.
+Contrast-enhanced computed tomography of the neck revealed a 2.8 × 2.8 cm homogeneously hyper-dense enhanced mass in the right side of his neck which invasively extended to the tissue of his sub-mandibular gland. Several enlarged lymph nodes were enhanced. In the sub-mandibular region, magnetic resonance imaging (MRI) showed a 3.0 × 3.0 × 4.0 cm mass with hypointensity on fat-saturated T1-weighted images, and heterogeneous hyperintensity and mid-hyperintensity on gadolinium-enhanced and fat-saturated T2-weighted images, respectively . Positron emission tomography showed an area of high uptake in the same region. No other uptake lesions were detected. The clinical and radiological appearance suggested a diagnosis of malignant neoplasms of the sub-mandibular gland and metastatic spread from a malignant tumor. Reactive follicular hyperplasia was found on an excisional lymph node biopsy at level II. CD45 gating for routine flow cytometric analysis revealed 40.1% and 27.1% of kappa and lambda light chain expressing cells, respectively.
+His right sub-mandibular gland was completely excised along with lymph nodes in the sub-mandibular region. Our patient has been well and there have been no marked changes in his condition at 16 months post-operatively.
+Pathological and immunohistological findings The sub-mandibular gland: The cut surface of the surgical specimen showed a solid, yellowish tumor occupying the sub-mandibular gland space . At low magnification, marked parenchymal loss with severe fibrocollagenous changes and numerous inflammatory cells were noted . At higher magnification, scattered lymphocytes, eosinophils and plasma cells were observed in the peri-ductal fibrosis area . A few foreign body cells were noted in necrotic tissue . No EBER-positive cells were seen, and no acid-fast bacilli were detected by Ziehl-Neelsen staining. No lympho-epithelial lesions were detected. In the fibrosis area, small and large-sized lymphoid follicle-like nodular lymphocytic proliferations were observed . Paraffin-embedded tissue sections, fixed in formalin, were stained with the antibodies listed in Table . An lmmunohistochemical study revealed that the lymphoid follicle-like nodular lesions were occupied by small round to oval shaped lymphocytes. These cells tested positive for CD20 and Bcl-2 , and negative for CD3, CD5, CD10 and cyclinD1. IgG4-positive plasma cells infiltration was observed. On a highly magnified slide checked at five points, 30% of IgG positive plasma cells expressed IgG4 .
+The lymph nodes: The lymph node architecture was replaced by prominent fibrocollagenous tissue with scattered lymphocytes and plasma cells. Except for lymphoid follicles with a reactive germinal center, small and large-sized lymphoid follicle-like lymphocytic proliferations were observed. These nodular lesions lacked a definitive germinal center and mantle zone , and were occupied by small round to oval cell lymphocytes . These cells were positive for CD20 and Bcl-2, and negative for CD3, CD5, CD10 and cyclinD1.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2739_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2739_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..91a21e1a376c19938add0eab55477429508b74e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2739_en.txt
@@ -0,0 +1 @@
+A 42-year-old woman with progressive exertional dyspnoea and World Health Organization functional class (WHO FC) III–IV and a recent episode of haemoptysis was referred to our Pulmonary Hypertension Centre. She had no cardiovascular risk factors and family medical history was not available because the patient was adopted at the age of 12. She had no history of human immunodeficiency virus infection, no exposure to drugs or toxins involved in the development of PAH, no history of chronic liver disease, deep vein thrombosis, or connective tissue disease. At our first physical examination, the patient did not have elevated jugular venous pressure, hepatomegaly, ascites, or peripheral oedema; but the auscultation revealed an accentuated pulmonary component of the second heart sound. The electrocardiogram showed sinus rhythm and right bundle branch block. Transthoracic echocardiography confirmed the suspicion of pulmonary hypertension (PH): systolic pulmonary arterial pressure was estimated to be 80 mmHg, the pulmonary artery trunk was dilated and the right ventricular (RV) outflow tract acceleration time was shortened. No pericardial effusion was detected. Six minutes walking test (6MWT) showed impairment in functional capacity (220 m). Cardiac magnetic resonance (CMR) imaging showed a hypertrophic, normal-volume right ventricle with mild depressed global systolic function (RV ejection fraction 51%) and no evidence of congenital heart disease. The left ventricle ejection fraction was normal with flattening of the interventricular septum . High-resolution computed tomography excluded parenchymal lung disease and perfusion lung scan was negative for mismatched perfusion defects, ruling out the suspect of chronic thromboembolic PH . Although the patient had never been complaining of angina coronary angiography was performed to exclude left main stem coronary artery compression by the dilated pulmonary artery trunk. The exam did not demonstrate any coronary artery abnormality. Finally, right heart catheterization (RHC) confirmed pre-capillary PH with severe reduction of cardiac index and a remarkable increase of pulmonary vascular resistance . The patient was non-responder to acute vasoreactivity testing performed by inhaled nitric oxide and a conclusive diagnosis of IPAH was made. After a comprehensive clinical assessment, based on ESC/ERS table risk stratification, the patient was classified as high risk and an initial combination therapy including a parenteral prostacyclin analogue (PCA) was proposed. However, the patient refused PCA for personal concerns about the potential side effects. Consequently, oral therapy including low-dose diuretics (furosemide 50 mg once daily) and specific drugs acting on the three separate signalling pathway involved in PAH were used. So a phosphodiesterase-5 inhibitor (Sildenafil 20 mg three times daily), an endothelin receptor antagonist (Macitentan 10 mg once daily), and selexipag were started under strict medical supervision. Selexipag was started at dosage of 200 μg twice daily and titrated up to 1200 μg twice daily over 30 days. The therapy was well tolerated without hypotension. At 3- and 6-month follow-up on the same medication we found a significant clinical and haemodynamic improvement as confirmed by a comprehensive revaluation including echocardiography, CMR , brain natriuretic peptide, 6MWT, and RHC . So the patient was reclassified as low risk . After 6 months clinical conditions were still stable on the same medical regimen, referral for lung transplantation is under evaluation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2751_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2751_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9668a581da9b9a25aefe2c6ca3863c53c8ad389a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2751_en.txt
@@ -0,0 +1,3 @@
+A 39-year-old young female with no history of heart disease was admitted with palpitation, shortness of breath for 2 years and aggravation for 6 months. On admission, her blood pressure was 110/60 mmHg and her heart rate was 68 beats/min without cardiac murmurs. Her lower limb were not swollen. Electrocardiogram and laboratory examinations were normal range.
+Chest radiography revealed that her cardiac shadow was enlarged to the left. Echocardiography showed a mass of the pericardium. Coronary computed tomography angiography (CCTA) demonstrated that the distal segment of the LCX was significantly dilated with contrast agent filling and with huge thrombi in the pericardium. Volumetic reconstruction showed that distal segment of the LCX were remarkably dilated . The left anterior descending branch and left coronary trunk were normal. The patient underwent the coronary angiography and selective micro catheter angiography of the LCX, which revealed a distal fistula of the LCX communicating with the pericardium . The right coronary artery and the left ventriculography were normal. Therefore, a diagnosis of the LCX fistula complicated with false aneurysm was confirmed.
+The patient was admitted to the department of cardiac surgery for the LCX repair, partial resection of pseudo aneurysm wall and for coronary aneurysm thrombectomy after all examinations were complete. During the operation, a mass with a size about 25 × 20 mm was found in the left rear of the left ventricle, which was located under the epicardium. Then cardiopulmonary bypass was established, a massive thrombi inside the pseudoaneurysm were observed after the left rear of the mass was opened . And the total amount of thrombi was about 250 g . After that, the CAF was explored. It was found that the CAF opened on the outer wall of the pseudoaneurysm, with a length of about 3 mm. Finally, the fistula was sutured with 4–0 silk thread and most of the pseudoaneurysm wall was resected. The excised lesions were sent for pathological examination. The pathological diagnosis was pseudoaneurysm and mixed thrombi. Follow-up has been carried out for six years, the patient was in good condition after surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2760_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2760_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b856336dc95edb28818843a841716612afa6bf69
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2760_en.txt
@@ -0,0 +1,2 @@
+An 18-year-old female patient noticed a dull red mass on her left leg three years ago, which developed without any clear cause. The mass was occasionally tender and exhibited slow growth. The patient has no family history of tumors, no surgical history, and no chronic diseases. In July 2022, she underwent a B-ultrasound examination at our hospital, revealing a hypoechoic nodule in the subcutaneous soft tissue of the proximal left leg. The nodule measured approximately 1.2 × 1 cm, with a distinct boundary, uneven internal echo, and enhanced posterior echo, CDFI shows no clear blood flow signal. Initially, a benign lesion was suspected, and no significant lymphadenopathy was detected in the bilateral popliteal fossae or groin . The patient underwent subcutaneous tumor resection, followed by an extended resection due to incomplete initial removal.Postoperative pathology indicated a small residual tumor in the dermis, approximately 0.3 cm in diameter, with negative resection margins. A six-month postoperative follow-up revealed no local recurrence or metastasis.
+Under low power magnification, a well-circumscribed nodular mass was observed in the dermis. High power magnification revealed the neoplasm to be composed of nests, fascicles, bundles, or sheets of epithelioid cells. The tumor cells displayed round or oval nuclei, abundant cytoplasm, prominent nucleoli, and visible mitosis, with local nevus cell clusters . The basal margin of the lesion was positive. Immunohistochemistry (IHC) results were positive for S-100, SOX10, MelanA, and focally positive for HMB45. INI1 and H3K27Me3 showed retention of nuclear expression, and the proliferation index hotspot area was approximately 10% . Initially, the tumor was considered a melanocyte-differentiated neoplasm with local nevus cell clusters. Primary and metastatic melanoma, Clear cell sarcoma (CCS), or malignant transformation of a Spitz nevus were considered as differential diagnoses. However, tests for EWSR1 rearrangement (FISH) and BRAF V600E mutation (PCR-ARMS) were negative. Consequently, we concluded that this was a rare melanocyte-differentiated tumor, distinct from melanoma, CCS, or malignant transformation of Spitz nevus. Next-generation sequencing (NGS) detected a CRTC1::TRIM11 fusion, and CRTC1 FISH confirmed positive fracture rearrangement , leading to the final diagnosis of a cutaneous melanocytic tumor with CRTC1::TRIM11 fusion.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2764_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2764_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5258ef0378930c2f13595df8a6387f8b7d5c63d0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2764_en.txt
@@ -0,0 +1,2 @@
+A 21-year-old woman presented with left upper quadrant pain. She underwent routine blood tests and non-contrast computed tomography (CT). The blood tests did not show any abnormalities, and the CT showed the presence of three, similarly sized spleens, but no other abnormalities. As the patient did not have any other symptoms, she was sent home with a prescription for an analgesic. However, the abdominal pain did not improve and she returned to the hospital 2 days later. Her inflammatory markers were somewhat elevated, and an enhanced CT showed that one of the multiple spleens did not pick up the contrast . We diagnosed her with splenic infarction; however, the cause of the infarction was unclear, and torsion or embolism was considered possibilities. The patient was admitted and began conservative therapy, including fasting and antibiotic administration. However, neither her abdominal pain nor inflammatory marker levels improved . Hence, we performed a follow-up enhanced-CT scan, 2 days after admission, which showed that the splenic infarction had not improved and that ascitic fluid was present around the spleen and in the pelvic space . At this point, we decided to surgically remove the infarcted spleen. Considering that the patient was a young woman, we elected to perform a laparoscopic splenectomy after receiving informed consent.
+The surgery was performed under general anesthesia, with the patient in a supine position and her legs spread apart. We created an umbilical incision and inserted three operating ports along the left subcostal margin (5 mm, 12 mm, and 5 mm in size), and a 5-mm operating port on the left side of the abdomen . The port sites were selected along the lines of a left subcostal incision, in case conversion to open surgery became necessary. These port sites were also in a co-axial position to the surgeon. There were no adhesions observed in the abdominal cavity. First, we incised the omentum and opened the bursa, detecting two non-infarcted spleens in front of the pancreas. Behind these spleens, there was an infarcted spleen surrounded by fluid. We incised the inflamed adipose tissue around the spleen to expose the pedicle, which was twisted; consequently, we diagnosed splenic torsion . Using an automatic suturing device, we dissected the pedicle of the infarcted spleen. The umbilical incision was extended to remove the resected spleen (78 × 57 × 35 mm) . After confirming the absence of active bleeding, we sutured the incisions. The surgical time was 119 min, and there was little blood loss. The patient did not experience any complications and was discharged 4 days after surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2765_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2765_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..659da9e098d5bb714f0dc7b970187734a8e83bcf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2765_en.txt
@@ -0,0 +1 @@
+We report the case of a 75-year-old North African woman with no notable medical history, admitted for pelvic pain lasting for the last 4 months and unrelieved by analgesics; the transit was undisturbed. The symptoms were aggravated by melena and asthenia that motivated the medical consultation. A clinical examination at admission found a patient with a stable hemodynamic status, an abdominal examination revealed a palpable and mobile pelvic mass. Laboratory tests showed a hypochromic and microcytic anemia with low hemoglobin and hematocrit levels rating at 7.3 g/dL and 21%. An abdominal computed tomography (CT) scan showed a large pelvic mass measuring 11 × 9 cm involving the distal small bowel loops, the bladder dome, and the uterine body without peritoneal effusion . After primary care, our patient underwent an exploratory laparotomy. The intraoperative finding was a brownish pseudoaneurysmal mass of the small bowel located 80 cm from the Treitz’s angle; this mass was invading the bladder dome and the left ovary and closely adhering to the uterus . Limited small bowel resection with 10 cm margins on both sides of the tumor extended to the left annexes and to a portion of the bladder with end-to-end anastomosis was achieved. The postoperative management was uneventful and our patient was discharged on day 6. The surgical specimen was 18 cm in length and included a black solid tumor with exophytic growth infiltrating the small bowel wall until the mucosa . A histological examination revealed a malignant proliferation of large cells with prominent round nuclei and a cytoplasm with eosinophilic spots or the seat of melanin pigments. Tumor necrosis was estimated at 30%, the rest of the ileum was the seat of chronic ileitis . The immunohistochemical profile showed an intense and diffuse cytoplasmic positivity for HMB-45 antigens and for PS-100, suggesting a malignant melanoma . An etiological investigation in search of a primary tumor of the small bowel melanoma was negative, an anoscopy, examinations of eyes and skin with multiple cutaneous biopsies were performed without finding any melanoma lesion.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_27_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_27_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fde74d2b16ca7932c7f68c8a63af9b358c66dd29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_27_en.txt
@@ -0,0 +1,5 @@
+A 63-year-old Caucasian male presented to our hospital with mild dyspnea that had been present for years, and a recurring pain exacerbation in his left thoracic wall. His previous history included intravenous drug abuse, continued smoking for more than 30 years, and untreated hepatitis C infection. When similar symptoms had occurred a few months previously, X-ray scans performed at another hospital showed suspicious masses at the left costal pleura. Therefore, pleural mesothelioma was considered. However, the patient was discharged and did not follow-up on this diagnosis before presenting to us.
+After exclusion of myocardial ischemia, our X-ray scans showed the previously described lesions on the left costal pleura . A subsequent contrast-enhanced computed tomography (CT) scan revealed two additional masses in the anterior mediastinum adjacent to the right atrium, measuring 2 and 4 cm in diameter and recapitulated two lesions on the left costal wall measuring up to 5 cm in diameter . At this point, pleural mesothelioma, which had already been suspected elsewhere, was a plausible diagnosis.
+However, multiple similar lesions were detected intraabdominally, whereas the spleen was missing . Specifically, two foci were found between the left diaphragm and the stomach (5.6 × 3.8 cm and 4.6 × 2.6 cm, Fig. b, c), between the liver and abdominal wall (4.1 × 1.7 cm, Fig. d), and in the small pelvic cavity next to the M. iliopsoas sinister (3 cm in diameter, Fig. e), among others. Curiously, the patient had to his knowledge never worked in an asbestos-polluted environment and the CT scans did not show any pleural effusions, which would typically be expected for mesothelioma . Furthermore, the presence of abdominal masses is a possible, but not a common condition in mesothelioma . Therefore, we considered a diagnostic biopsy to determine whether the lesions were metastases of a cancer of unknown origin.
+However, we decided to first conduct an extensive interview with the patient that revealed an important, previously unknown part of his medical history: When asked for previous injuries, the patient remembered an incident in the early 1970s. At this time he had engaged in drug trafficking and got involved in an argument about a drug delivery that had not gone as planned. In the course of the argument, our patient suffered an abdominal gunshot wound with extensive injury. Unfortunately, there were no medical reports available from that time due to the patient very rarely visiting a doctor. However, the patient recalled that his spleen and diaphragm were severely damaged and needed surgical repair. Indeed, our CT scans showed that a splenectomy had been performed.
+Instead of biopsy, we then utilized contrast-enhanced ultrasound (CEUS) of the pleural and abdominal masses. On CEUS, a bolus of ultrasound contrast medium containing gas microbubbles is rapidly injected intravenously, followed by another bolus of saline solution for immediate dispersion via systemic circulation. When ultrasound waves are then directed at microbubbles flowing through the organ of interest, the compressible gas cores oscillate and show an increased echogenicity compared with surrounding tissue. Compared with other tissues, splenic tissue has the property to sequester microbubbles from circulation, causing an avid and persistent late-phase enhancement of up to 7 minutes after application, whereas malignant masses are characterized by early wash-out and late-phase hypoenhancement . In our case, the application of sulfur hexafluoride microbubbles revealed circumscribed lesions that showed the characteristic pattern of splenic tissue, with persistent late-phase enhancement unlike malignant masses . Together with the very specific patient history and the medical imaging we performed, we were now convinced that we found the correct diagnosis and decided on a conservative approach without additional, invasive diagnostic measures. Follow-up examinations after 12 months showed no progress of the lesions, confirming the diagnosis of abdominal and thoracic splenosis based on detailed patient history and CEUS. Importantly, we were able to refrain from diagnostic biopsy, which otherwise might have led to serious complications considering the highly perfused splenotic tissue and the deranged coagulation due to hepatitis C-related liver dysfunction. Since splenosis is a benign condition, no specific treatment was necessary. Instead, treatment for hepatitis C and chronic obstructive pulmonary disease was initiated to improve his prognosis and the patient received oral pain medication, which resolved his pleurisy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_281_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_281_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3bbca7edd8356b9db01a222a02c9337b384b404
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_281_en.txt
@@ -0,0 +1,5 @@
+A 59-year-old Japanese man complained of pain in his lower right leg. Abdominal magnetic resonance imaging (MRI) revealed a right pelvic tumor compatible with histological findings of non-Hodgkin diffuse B-cell lymphoma. CODOX-M/IVAC (CODOX-M: cyclophosphamide, vincristine, doxorubicin, and high-dose MTX; IVAC: ifosfamide, etoposide, and high-dose cytarabine) was started, and shrinkage of the tumor was achieved. At 5 months after CODOX-M/IVAC therapy, he complained of dysesthesia of his bilateral feet. He began taking methylcobalamin, but there was no improvement. Spinal MRI revealed another mass anterior to the 2nd to 3rd sacral vertebral bodies. Cerebrospinal fluid (CSF) cytology showed malignant findings after 20Gy radiation therapy. CODOX-M/IVAC was administered a second time, and two administrations of intrathecal MTX (15mg) were started, with the addition of calcium folinate. Because flaccid paresis of his lower limbs and fecal and urinary incontinence appeared 1 month later, he was referred to our department.
+His blood pressure was 102/72mmHg and body temperature was 36.7°C. A neurological examination revealed that he was alert and well oriented. His mental status was normal, and his cranial nerves appeared intact. He showed flaccid paresis of his lower limbs with an absence of tendon reflexes and both fecal and urinary incontinence. Extensor plantar responses were noted on the left side. Pinprick, light touch, vibration, and proprioception sensations were impaired below the Th10 dermatome level. Cerebellar ataxia was not observed.
+Laboratory results revealed normocytic anemia. His serum vitamin B12 levels were 2788pg/mL and all other tests showed unremarkable results (copper, 132μg/dL; total homocysteine, 8.7nmol/mL; and folic acid, 7.6ng/dL). A CSF examination showed cytoalbuminic dissociation (mononuclear cells, 1/mm3; protein, 123mg/dL) and a glucose level of 47mg/dL (blood sugar, 98mg/dL). Myelin basic protein levels were 3087pg/mL and his CSF homocysteine levels were 1.2nmol/mL. Negative results were obtained for CSF oligoclonal bands, soluble interleukin-2 receptor, CSF cytology, and polymerase chain reaction testing for various viruses. Our patient denied all genetic analysis including homocysteine metabolism.
+Findings from brain MRI were unremarkable, but spinal MRI revealed signal hyperintensity on T2-weighted imaging in the posterior funiculus of his cervical spinal cord and in the lateral and posterior funiculi of his thoracic spinal cord .
+Leucovorin calcium at 60mg/day and high-dose vitamin B12 replacement therapy were administered for 2 weeks, but no improvements were observed. He died 3 months later due to progression of the primary disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2820_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2820_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cfd11cd67174e905a186633a524ffd78e4ad9101
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2820_en.txt
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+A 4-year-old white girl from Greece was attacked by a dog owned by her neighbour while playing unsupervised in front of her yard. The child was transported to the emergency department by the dog owner.
+On admission, she was confused and lethargic, presenting findings compatible with hypovolemic shock (heart rate 130 beats per minute and hemoglobin level of 7.8 g/dl) secondary to traumatic blood volume loss. Hemodynamic compromise required an aggressive intravenous fluid administration and blood transfusion. Physical examination revealed multiple deep scalp lacerations. After rigorous disinfection, surgical repair was performed in the hospital's operating unit. Due to the extensive nature of the traumatic lesions and the subsequent high risk of infection, the healing process required two weeks of intravenous antibiotic therapy. Rabies prophylaxis was not administered due to the documented rabies vaccination status of the dog.
+On the second day of hospitalization, the child was in a depressed mood and displayed mild withdrawal from contact with others. A psychiatric evaluation was performed. During consultation, the child was apparently agitated and refused to participate in any conversation. Non-verbal communication was used instead, including gestures and shaking of the head. The behaviour had not been present before the dog attack. On the sixth day of hospitalization, the child talked for the first time to her mother and asked her: "Where were you when the dog attacked me?".
+After a complete suture removal 15 days after the injury, she was discharged. Psychiatric monitoring was arranged after two months. During this interval, the child refused to speak to physicians and other children in the neighbourhood, and used only gestures to communicate while engaging in normal conversation in the home setting. Her memories of the dog attack remained remarkably clear. For six weeks as an outpatient, the child had recurrent traumatic memories when questioned about dogs. After this interval, the girl manifested a persistent avoidance of thoughts and conversations associated with the event. Remarkably, the parents reported that the child was avoiding the dog owner as well as the place where the dog attack occurred. Feelings of estrangement from her neighbours were also present. Hyperarousal occurred in the form of outbursts of anger and anxiety when left alone. She also had difficulty concentrating.
+A limited expression of emotions and a reluctance to play with toy dogs were observed during psychiatric consultation. This case fulfilled all diagnostic criteria for selective mutism and PTSD according to the Diagnostic and Statistical Manual of Mental Disorders, (4th edition) . Psychological treatment consisted of supportive psychotherapy for the child and consecutive sessions of counseling for her parents. On her six-month follow-up appointment a symptomatic improvement was evident, with decreased levels of anxiety and normal rates of social and verbal interaction. During consultation, the girl was clearly less anxious and able to communicate her needs verbally. According to her parents, she had become more comfortable speaking in environments out of the home setting and playing with other children in the place where the dog attack occurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2847_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2847_en.txt
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index 0000000000000000000000000000000000000000..f96e636109ad5912d2e0816464b3943a8f8a7f82
--- /dev/null
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+A 34-year-old Iranian man presented to the clinic with redness and impaired vision in the right eye for many months, despite topical corticosteroid treatment. His prior medical history was unremarkable. His best-corrected visual acuity (BCVA) in the right eye was 4/10 (+5.00 sphere) and 10/10 (−0.50 sphere) in the left eye at the time of presentation. The examination of the left eye was normal. During a slit-lamp examination, the right eye revealed chemosis as well as a nodular salmon patch in the bulbar conjunctiva and 1+ vitritis. The fundus examination of the right eye revealed near-total shallow serous retinal detachment, multifocal yellow choroidal infiltrates, and widespread mid-peripheral retinal pigment epithelium (RPE) changes .
+Enhanced-depth-imaging optical coherence tomography (EDI-OCT) showed macular retinal folds and a “seasick” appearance on the choroidal surface with compression of the choriocapillaris. OCT images also revealed intraretinal and subretinal fluid, as well as clumps of optically dense material at the level of the RPE .
+Fluorescein angiography (FA) disclosed diffuse patches of choroidal hyperfluorescence. In the posterior pole, blue autofluorescence (BAF) and FA imaging exhibited a nonspecific “leopard-spot” appearance .
+Incisional biopsy of the conjunctival lesion was performed; histological and immunohistochemistry studies revealed a dense infiltrate of small lymphocytes with positive staining for CD20 and CD79, with coexpression of BCL2. The diagnosis was atypical monoclonal lymphoid infiltration suggestive of low-grade extranodal marginal zone B-cell lymphoma.
+Magnetic resonance imaging (MRI) of the orbit was negative for extrascleral extension; his systemic workup for extraocular involvement including laboratory data, chest and abdomen computed tomography (CT) scans, and bone marrow aspiration results were all negative.
+Ultra-low-dose radiation, termed “boom-boom radiotherapy” (4 Gy delivered in two fractions over two consecutive days) was used in conjunction with intravitreal injections of methotrexate and rituximab. To reduce radiation scatter to periocular tissue, orbital rim bones, and midfacial soft tissues, the beam was delivered through a bolus shell of 42-mm water-equivalent thickness placed 3 cm from the patient.
+Intravitreal methotrexate injections were started at a dosage of 400 µg in 0.1 ml per week for 6 weeks, then monthly for 6 months. Rituximab was administered intravitreally once a month for 3 months at a dosage of 1 mg in 0.1 ml. The intravitreal injections were started just 1 week after the last radiotherapy session.
+Serous retinal detachment was resolved 2 months following ultra-low-dose radiation, and subretinal fibrosis and widespread RPE alterations were observed at the location of the detachment. On EDI-OCT, the lymphoid infiltration, flattening of the macular fold, and resolution of subretinal and intraretinal fluid were all observed. Hyperreflective deposits were observed under the retina that correlated to fibrosis. The RPE–choroidal interface changed to a “calm sea” appearance. At 1-year follow-up, the results remained consistent, the subconjunctival lesions were regressed, and the BCVA improved to 6/10. During this time, there was no recurrence or radiation-associated complications. The patient was scheduled for regular follow-up visits.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2848_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2848_en.txt
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index 0000000000000000000000000000000000000000..ba487eba59a7d06d4faf60288c539e0d3ebf8621
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2848_en.txt
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+The patient was an 87-year-old healthy female with only a medical history of hypertension. One month earlier, she experienced blunt chest trauma. During this period, general malaise and intermittent fever occurred.
+Initially, the patient was admitted to another emergent hospital because of excruciating chest pain and severe dyspnea. Emergent computed tomographic (CT) scan demonstrated a transverse mid-body fracture of the sternum with surrounding fluid collection. The patient was transferred to our institution with a diagnosis of traumatic sternal fracture with mediastinal abscess.
+On admission to our institution, the patient had high grade fever. Initial laboratory data demonstrated a white blood cell (WBC) count of 25,100/uL and C-reactive protein (CRP) of 340 mg/L. Blood culture was positive for Gram-positive cocci in clusters and vancomycin was immediately started. A few days after admission, her inotropic requirement increased progressively as her hemodynamic status deteriorated. She was endotracheally intubated and follow up images showed progressive changes. The abscess could be seen extending to both the anterior and posterior aspects of the fractured sternum and to the left pectoralis muscles and subcutaneous tissues . Moreover, transesophageal echocardiography was done because of her bacteremia and it showed a large vegetation in the mitral valve with moderate insufficiency . We believed that definitive surgical treatment involving aggressive debridement, probably followed by vegetectomy, is the only effective method of saving our seriously co-infected patient with extensive mediastinitis and concomitant mitral valve endocarditis with large vegetation.
+The patient was taken to the operating theater the next day. We performed a median incision and drained the mediastinal abscess, debrided her fractured sternum, including the cartilaginous portions of the transverse second and third ribs, the left internal mammary artery and the left pectoralis muscles with necrotic subcutaneous tissues. The manubrium of the sternum was spared from debridement since there was no gross evidence of infection, leaving a 12-cm defect in the mid-portion of the sternal body. After the debridement, vacuum-assisted closure (VAC) therapy with continuous saline washing was performed. The first wound culture demonstrated the presence of Methicillin-sensitive S. aureus (MSSA), and the antibiogram was identical to that of the MSSA isolate from the blood. Intravenous vancomycin was changed to intravenous cefazolin.
+Over the next week, she underwent two wound irrigation procedures. Although subsequent cultures at dressing changes were all negative in this period, she had continuously high grade fever and her laboratory data still demonstrated high. After extensive discussion of the benefits and risks of the surgical intervention because of the significant co-morbidities, we decided to perform the vegetectomy and mitral valve repair. The cardiopulmonary bypass was established through lower partial sternotomy. Surgery revealed perforation with a large vegetation of the posterior mitral leaflet, which was completely resected and successfully repaired with an autologous pericardial patch . The aortic crossclamp time was 98 min and cardiopulmonary bypass time was 132 min. After 4 days, the lower sternum was apposed using sternal wires and the chest wound was completely closed with an omental flap .
+There were no pulmonary complications and the patient received intravenous cefazolin for 8 weeks. At the 8th month follow-up period, the patient showed no signs of infection and was doing well without any significant mitral insufficiency.
+There are some reports of sternal fractures with osteomyelitis as a complication of closed chest cardiopulmonary resuscitation , and are not uncommon in the setting of antecedent chest wall trauma, such as thoracic surgery [, ]. However, a mediastinal abscess because of a primary traumatic sternal fracture is uncommon [, ]. Cuschieri et al. identified the presence of hematoma, intravenous drug use, and a source of staphylococcal infection as risk factors for developing a posttraumatic mediastinal abscess . Of note, the majority of these patients have an underlying systemic disease such as diabetes mellitus, liver dysfunction, or compromised host . In our case, the patient had no remarkable co-morbidity, experienced only a traumatic episode 1 month earlier and she was accompanied by the native valve endocarditis. To the best of our knowledge, this catastrophic situation is extremely rare and has not been previously reported, nor has a successful strategy been employed to manage this situation; hence, we described this case.
+Once diagnosed this serious co-infected case, the primary concern of any surgical procedure is to control the bacteria infection . Treatment of mediastinitis may depend on the degree severity of the infectious; conservative therapy for mild infections, or single staged intervention such as debridement and primary wound closure for moderate infections, or leaving the wound open and second-stage closure using the several closure techniques available for severe cases [, ]. Urbanski et al. reported a case of chronic sternal osteomyelitis after radiation and severe aortic valve stenosis . The patient was treated simultaneously by sternal debridement and concomitant aortic valve replacement, and single-stage primary wound closure. This was a case of chronic non-severe mediastinitis; therefore, the single staged intervention could be performed. In our case, the mediastinal abscess was already extensive and progressed in a few days; furthermore, the patient had concomitant endocarditis with uncontrolled infection and considerable risks of embolism from the lerge vegetation. Thus, we decided on a staged strategy: first, open drainage for mediastinitis; second, cardiac operation for endocarditis; and finally, primary wound closure with omental flap.
+It remains unclear when the endocarditis with the vegetation should be treated in this co-infected situation. For example, Kang et al. demonstrated that early surgical intervention in patients with large vegetation (a diameter greater than 10 mm) may significantly decrease embolic events and in-hospital mortality . Moreover, the risk of embolism has been reported to be particularly high during the first week after diagnosis. However, cardiac operations performed too early had the disadvantage of increasing the risk for recurrent mediastinitis. In our patient, although she had VAC therapy for about 2 weeks and underwent four procedures from initial debridement to cardiac operation, the infection was not controllable because of the large vegetation. We thought this timing was best to perform the vegetectomy.
+In treating the mitral valve endocarditis, several surgical approaches may be employed. The right thoracotomy approach could avoid going through the infected field and decrease the recurrence of the bacteria. However, the major disadvantage is the need for an additional right-sided thoracotomy incision, which requires a longer mechanical ventilation period, as is often the case with our older patients after aggressive debridement of the sternum. With partial sternotomy, Kaneda et al. reported the usefulness of a lower partial sternotomy for acutely infected endocarditis in patients with tracheostoma . When the manubrium of the sternum could be spared from debridement, the lower partial sternotomy approach was associated with benefits, including thoracic stability because of preservation of the sternoclavicular joint and the upper ribs. In our case, we believe that lower partial sternotomy could be performed and sparing the manubrium of sternum led to a favorable result.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2863_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2863_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f8d36c0f9663cc707dc770945278547b0211230a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2863_en.txt
@@ -0,0 +1,6 @@
+A 3-year-old Arabic boy from Yemen presented with intermittent episodes of shortness of breath, lethargy, fatigability, vomiting, and "cyanotic" discoloration of his skin, lips, mucous membranes and nail beds for the past two years. He was thought to have methemoglobinemia due to persistent cyanosis. He was born in Yemen and moved to the USA for further treatment one year prior to his visit to our clinic. He was evaluated in several institutions in Yemen, Europe and the USA for these problems but no specific diagnosis was ever made. He had one maternal uncle who died suddenly at 35 years of age and 4 full siblings (all males) who died of unknown causes between 2 and 4 years of age. His deceased siblings had similar symptoms and discoloration of mucous membranes. None of them had autopsies. He had 4 other siblings (2 brothers and 2 sisters) who were alive with no medical problems. He had normal electrolytes, blood urea nitrogen (BUN) and creatinine (Cr) levels on several occasions. He had normal results for cardiac examination, echocardiogram, hematologic evaluation and hemoglobin electrophoresis.
+He was referred to our center for further evaluation of his cyanosis. The result of his physical examination was normal, except for the noted discoloration of his lips and nail beds. His arterial blood showed mild hypoxemia as follows: pH 7.32, PaCO2 37.1 mmHg, PaO2 86 mmHg, and HCO3 18.9. His methemoglobin and carboxyhemoglobin levels were 1.10% and 0.3%, respectively. He had a previous chest X-ray during one of his prior admissions which was interpreted as normal. However, upon further examination of the film at our clinic, we identified a subtle parenchymal hyperlucency of a large part of his right mid-lung area . His chest computed tomography (CT) scan showed multiple cystic lesions in his right lung that was compatible with CPAM . CT scan of the abdomen showed no abnormalities of the adrenal glands, or other abdominal organs.
+Before the surgical removal of his CPAM, he was admitted with lethargy, vomiting, dehydration, hypotension, and drowsiness. Laboratory results during this hospitalization were as follows: glucose, 2.42 mmol/L (44 mg/dl); sodium, 132 mmol/L; potassuim 3.8 mmol/L; chloride, 101 mmol/L; bicarbonate, 13 mmol/L; BUN, 7.5 mmol/L (21 mg/dL); Cr, 17.68 umol/L (0.2 mg/dL); calcuim, 2.17 mmol/L (8.7 mg/dL); magnesium, 0.57 mmol/L (1.4 mg/dL); and phosphorous, 1.2 mmol/L (3.7 mg/dL).
+After the initial resuscitation with boluses of 25% dextrose and normal saline solutions, a repeat glucose test showed a value of 21.78 mmol/L (396 mg/dL). One hour after that, his glucose level dropped again to 2.1 mmol/L (39 mg/dl), and a second 25% dextrose solution bolus was thus given. Our patient had low serum cortisol level, normal aldosterone, and normal growth hormone concentrations . His serum adrenocorticotropic hormone (ACTH) concentration was elevated at 2,630 pg/ml. ACTH stimulation test did not result in an increase in his cortisol levels . He had no detectable anti-adrenal antibodies and a non-reactive purified protein derivative skin test. He was started on hydrocortisone and fludrocortisone and had a surgical removal of the CPAM a few weeks later.
+Our patient's serum ACTH concentration decreased to 13 pg/ml six months after the treatment. A pathological examination of the lung cysts showed multiple thin-walled cysts that ranged from 0.3 cm to 1.5 cm in diameter and filled with clear fluid. The cysts appeared to occupy approximately 90% of our patient's parenchyma. Microscopically, the cysts were lined with columnar (respiratory type) epithelium. This was compatible with the diagnosis of CPAM.
+One year later, he was readmitted with a seizure and loss of consciousness. A brain magnetic resonance imaging (MRI) revealed bilaterally diffuse symmetric high T2 and FLAIR signal abnormality involving the white matter of several parts of his brain, which was suggestive of a diffuse and active demyelination process . He had elevated VLCFA levels, which was compatible with the diagnosis of X-ALD. His VLCFA levels were as follows: C22:0 of 20.02, C24:0 of 33.61, C26:0 of 1.2, C24 and C22 of 1.679, and C26/C22 of 0.06. Consequently, he was started on anti-seizure medications N-acetyl-L-cysteine, and was continued on corticosteroids. He was also referred for bone marrow transplant evaluation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2869_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2869_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..02e608e3fb3041767c8fe0d3034cc1695b12a492
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2869_en.txt
@@ -0,0 +1,6 @@
+A 29-years-old female experienced an episode of mild upper respiratory tract infection followed by a slowly developing dysphagia and dyspnea. This led to impaired exercise tolerance lasting several months, with recent subacute exacerbation. There was no significant history of travel or exposure to infectious agents. She had not suffered from fever or other acute or chronic infectious symptoms. Her palatine tonsils had been removed in childhood. She was diagnosed with epilepsy at age 17 and had been free of epileptic symptoms for over 5 years with levetiracetam (500 mg two times per day) and lamotrigine (150 mg two times per day). Her family history was unremarkable.
+She spoke with hoarse voice, without signs or findings that would have suggested systemic involvement. There were no signs of generalized mucosal disease. Fiberoptic examination showed swelling of the lingual tonsil, epiglottic and arytenoid mucosa, causing airway obstruction . C-reactive protein concentration and blood sedimentation rate were low, and anti-nuclear, anti-neutrophil, anti-glomerular basement membrane, anti-myeloperoxidase, anti-proteinase 3, tissue transglutaminase and cyclic citrullinated peptide antibodies were negative. Thyroid function was normal and thyroid peroxidase antibodies were 34 IU/ml (normal value < 60 IU/ml). Plasma parathyroid hormone (39 ng/l; normal 18–80 ng/l) and serum vitamin D-25 (77 nmol/l; normal > 50 nmol/l) were normal. No evidence for acute or chronic viral, bacterial, mycobacterial or fungal infections, including hepatitis B and C, human immunodeficiency virus and tularemia, was found.
+Due to her swollen lingual tonsil and laryngeal mucosa causing airway obstruction, she was hospitalized and received empiric cefuroxime (1.5 g thrice daily) and methylprednisolone (75 mg once daily, height 173 cm, weight 63 kg, prednisolone dose 1.2 mg/kg) intravenously. After a transient positive response, she was discharged from the hospital after 6 days. Soon after, she was readmitted to due to a rapid reoccurrence of the symptoms. A modest positive response was seen after per oral clindamycin and oral prednisolone (60 mg/days) with dose reduction for 14 days. Lingual tonsil and epiglottis were biopsied. Histology showed granulomatous reaction in lingual tonsil with CD68+ (Kp-1) epithelioid histiocytes . The CD20+ B lymphocyte count was increased while Pax-5+ positive B lymphocyte count was normal. CD138+ plasma cells were scarce, and they showed polytypic kappa- and lambda light chain expression. The number of CD3+ T cells was normal, and most T cells were CD4+. Eosinophils were practically absent and well-formed follicles were not seen. Epstein–Barr virus in situ hybridization (EBER), p16, cytomegalovirus and mycobacteria were negative. Morphology, immunohistochemical staining, serum electrophoresis and bone marrow aspirate did not raise suspicion of lymphoid neoplasia, thus, no clonality studies were done.
+Due to granulomas, sarcoidosis was considered. However, chest X-ray, computerized tomography of chest and ultrasound of neck and abdomen were unremarkable. Positron emission tomography/computed tomography (PET/CT) showed increased fluorodeoxyglucose (FDG) uptake in the lingual tonsil, without evidence of widespread sarcoidosis . No other pathological FDG foci were found. Focal physiological FDG accumulation was seen in ureters on both sides of the spinal column. This is a common finding due to ureteral peristalsis and pooling of radiotracer in the recumbent patient. The patient had no neurological symptoms and brain magnetic resonance imaging was normal. Serum angiotensin converting enzyme (ACE) was within normal range (11–20 U/l; reference range 9–65 U/l) while daily urine calcium output was normal or slightly elevated (5.0–6.31 mmol; reference range 1.2–5.5 mmol).
+Subsequently, an unusual presentation of primary or secondary immunodeficiency was considered. There was no consanguinity; the patient or her family had no history of repeated infections or autoimmunity. White cell, lymphocyte, and B, T and NK lymphocyte subset counts were within normal limits. CD19+ B cell count was 153 × 109/l (normal range 80–616 × 109/l). Proportions of memory CD27+ B-cells (30.3%) and IgD−IgM−CD27+ switched memory B cells 7.2%; (normal range 6.5–29.2%) were normal and the percentage of activated CD21low B cells was high (6.6%; normal range 0.6–3.5%). Percentages of various CD3+CD4+ and CD3+CD8+ T cell subsets appeared normal. Serum total IgG (3.5 g/l; normal range 6.77–15.0 g/l) and all IgG subclass concentrations were low: IgG1 2.45 g/l (normal range 4.9–11.4 g/l), IgG2 0.91 g/l (normal range 1.5–6.4 g/l), IgG3 0.18 g/l (normal range 0.2–1.1 g/l) and IgG4 0.02 g/L (normal range 0.08–1.4 g/l). Anti-polysaccharide response to Pneumovax® were impaired, with only 3/10 serotypes reaching a level of 0.35 µg/ml after immunization. However, serum IgA (0.90 g/l; normal range 0.52–4.02 g/l) and IgM concentrations (0.57 g/l; normal range 0.47–2.84 g/l) were normal. Dihydrorhodamine test excluded chronic granulomatous disease. These findings were thus consistent with either granulomatous CVID or most likely secondary drug-induced hypogammaglobulinemia with a novel clinical presentation [–]. Genetic analysis (Blueprint Genetics, Primary Immunodeficiency Plus panel. ) did not find known mutations causative of CVID-like or other primary immunodeficiencies.
+Due to symptomatic upper airway obstruction, dysphagia, lack of evident infection and unsatisfactory response to prednisolone treatment and possible granulomatous CVID, the patient received immunoglobulin replacement and rituximab therapy (Mabthera® 100 mg, 200 mg and 500 mg on three consecutive days combined with 100 mg hydrocortisone and 1 g paracetamol), with a favorable response within 2 weeks accompanied by significant improvement in dysphagia and respiratory symptoms. Seven months later, her exercise capacity was good. She has remained asymptomatic for over 16 months after rituximab treatment. Her fiberoptic pharyngeal findings improved . She continues to receive subcutaneous immunoglobulin replacement with serum IgG levels in the range of 10 to 12 g/l.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2889_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2889_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0d0a47f00e504140861b16e525a80f417f49b2e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2889_en.txt
@@ -0,0 +1,10 @@
+A 33-year-old Bangladeshi woman with hypertension and diabetes had initially presented to a different hospital with intermittent episodes of palpitations for 2 years, with documented electrocardiographic (ECG) evidence of AF during the episodes. She had previously been on oral propafenone, amiodarone, and metoprolol, at separate times, but continued to experience paroxysmal AF.
+She had a 2-year history of hypertension that was well controlled with metoprolol 50 mg twice daily and ramipril 5 mg once daily. She had type 2 diabetes mellitus, diagnosed 3 years previously, that was well controlled with metformin 500 mg twice daily. There was no evidence of diabetic nephropathy or microalbuminuria. Furthermore, other etiologies of AF, such as thyrotoxicosis, were excluded by her thyroid profile, which comprised normal levels of TSH, free triiodothyronine, and free thyroxine. Ischemic heart disease was excluded by a CT coronary angiogram, which revealed normal epicardial coronary arteries.
+Given the indication of drug-refractory AF, our patient had undergone EPS at a different hospital from which she had been discharged 24 hours after the procedure. The EPS has comprised right femoral venous catheterization followed by the insertion of three venous sheaths into her femoral vein.
+Because an inducible arrhythmia could not be reproduced, her pulmonary vein (PV) potentials were mapped and complete PV isolation was planned. But, because there was difficulty in isolating some of the PVs along with an extended procedural time, the procedure was abandoned. A plan was made to identify all PVs more specifically using other imaging techniques such as magnetic resonance imaging (MRI), prior to attempting the procedure again.
+She presented to our hospital 48 hours after the EPS with shortness of breath and chest heaviness, associated with palpitations and recurrent episodes of syncope. When queried, she confirmed that these symptoms were not like those she had previously experienced during her paroxysms of AF, and reiterated that they only developed after the EPS.
+She had no prior history of thromboembolic events, long flights, prolonged immobilization, or oral contraceptive use, and she denied any family history of thrombophilia. There was no evidence of either hypertensive or diabetic nephropathy. A urine dipstick test was negative for protein. A thrombophilia work-up revealed normal levels for protein C and S, antinuclear antibody, and anticardiolipin antibody, thus eliminating other causes of hypercoagulability as possible etiologies of thrombosis.
+On examination, she was hemodynamically stable and heart and lung auscultation was unremarkable. There was no unilateral leg swelling. An ECG showed T inversions in leads III, aVF, and V1–4. It also revealed mild tricuspid regurgitation and a pulmonary artery systolic pressure (PASP) of 50 mmHg. Her right ventricle (RV) was dilated, with diameters measuring 38 mm at the basal level and 40 mm at mid-level, with a longitudinal measurement of 90 mm on the apical 4 chamber view. Tricuspid annular plane systolic excursion (TAPSE) was measured at 12 mm. Her left atrium (LA) was of normal size and measured 33 mm. Qualitative assessment revealed that right atrium was larger than her LA. There was no evidence of left ventricular (LV) hypertrophy. Her LV ejection fraction (EF) was 65 % and there were no regional wall motion abnormalities of her LV. There was no evidence of thrombus in any of the cardiac chambers.
+A CT coronary and pulmonary angiogram revealed normal coronaries with filling defects in the descending branch of her left pulmonary artery extending into the segmental arteries, suggesting thrombus .
+Subsequently, a duplex ultrasound study of her lower limb venous system showed absent blood flow in her right external and common femoral veins, confirming acute DVT affecting her right ilio-femoral segment without signs of recanalization .
+Given the sequence of events and their temporal relationship with the EPS, and in the absence of other risk factors for DVT, it was established that the acute DVT occurred as a consequence of the femoral vein catheterization and multiple venous sheaths inserted for EPS, subsequently leading to PE. She was treated with subcutaneous enoxaparin 60 mg twice daily for 5 days along with the administration of oral warfarin. She continued taking the warfarin for 6 months, with a target therapeutic international normalized ratio of 2.5–3. She was asymptomatic at follow-up at six months, and, due to the resolution of the DVT, oral anticoagulation was discontinued.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_292_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_292_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7b35556f48c5cc73447b623d21c1ed30d80f2a3e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_292_en.txt
@@ -0,0 +1 @@
+A 24-year-old male patient who recently arrived in Burhakaba town of Somalia from Sa’ada in northwest of Yemen, was referred to our hospital with complaint of left upper hypochondrium mass. He was presented with high grade fever; headache and abdominal pain associated with nausea, vomiting, and weight loss for two months. The patient claimed he had experienced a similar clinical condition three months ago. Before reporting to our hospital, he had visited a local hospital in the region, where they administered him local symptomatic treatment of antipyretics, antibiotics and transfused with 2 units of whole blood, after which he felt mild improvement. However, two months later, his clinical signs recur but this time with loss of appetite, weight loss and generalized weakness. In general physical examination on presentation at our hospital, the patient appeared ill, thin, febrile and pale. Abdominal examination revealed splenomegaly. The other system examinations were normal. Following his admission, the vital signs were blood pressure 110/78 mmHg, pulse rate 110 beat/minute, respiratory rate 16 beat/minute, temperature 38.9°C, and blood glucose was 110 mg/dl. The initial laboratory investigation showed white blood cell count 1.03 x10^9/L (normal 4.00–10.00 x10^9/L), hemoglobin 6.6 g/dl (normal 12.0–16.0 g/dl), hematocrit 0.203 (normal 0.400–0.540), platelet 70x10^9/L (normal 100–300x10^9/L), C-reactive protein 45.73 mg/L (normal 2.5–10 mg/L), aspartate transaminase (AST) 104.5 U/I (normal 6–38 U/I), alanine transaminase (ALT) 112.5 U/I (normal 6–40 U/I), serum creatinine 1.4 mg/dl (normal 0.4–1.4 mg/dl), and serum urea 54.3 mg/dl (10–50 mg/dl). In addition, a rapid diagnostic test (RDT) for plasmodium parasite antigen was conducted and was found to be positive. Abdominal ultrasound revealed enlargement of the liver (20cm) and enlargement of the spleen (30cm). The patient was admitted initially for treatment of malaria starting with four doses of intravenous artesunate 120mg, symptomatic treatment of antipyretics of paracetamol, dextrose-normal saline fluids and also transfused one unit whole blood. On the third day of admission after administering antimalarial treatment, no significant improvement was observed. Hence, further investigations including infectious disease tests such as the human immunodeficiency virus, viral hepatitis, and Brucella serological tests were conducted and found to be negative. Also, an anti-Leishmania antibody with an enzyme-linked immunosorbent assay (ELISA) was not detected. On the fourth day, peripheral blood smear and bone marrow aspiration were performed, and the peripheral blood smear result showed only pancytopenia and no evidence of malaria parasite seen . The bone marrow aspiration also did not indicate any abnormality. However, a tru-cut biopsy of the spleen was performed and the result of the histopathology examinations of tru-cut biopsy revealed consistent features with visceral leishmaniasis . Following this outcome, an urgent combination therapy of sodium stibogluconate 800mg/day with paromomycin 600mg/day for 17 days was given. After the fourth week of treatment, significant improvement was observed on the patient based on the clinical and the laboratory results. At the end of the fifth week the patient was fully recovered as seen from the clinical signs and lab results , hence he was discharged following normal results of another true cut biopsy of spleen .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2950_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2950_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..512b9511882371d7ce71530f3b1aa9cf07461a37
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2950_en.txt
@@ -0,0 +1,14 @@
+A 6-year-old girl, was born to healthy parents with third-degree consanguinity. This family of Indian origin was referred for investigation and genetic counseling for facial dysmorphy with global developmental delay, and behavioral issues of the proband. Maternal history revealed intra-uterine growth retardation during the antenatal period that ended with a full-term female baby born through cesarean section due to breach presentation. Her birth weight was 2.75 kg.
+The proband had normal feeding history, and there were no neonatal concerns. At approximately 5 months of age, the proband attained her neck control. She could stand with support by 3 years and could walk independently by 5 years of age. She could utter only a few bi-syllable words. Despite being hyperactive, no abnormal hand movements were observed. She had a history of two episodes of febrile seizures at 8 months and 2 years of age. During these episodes, she was observed with other symptoms such as cough, cold, and fever. Her physical examination revealed craniofacial disproportion, which included microcephaly with a narrow bifrontal diameter and a flat forehead. Other anomalies such as facial dysmorphy including epicanthal folds, hypertelorism, depressed and low nasal bridge with bulbous nasal tip, flaring nares, prominent philtrum, and pointed chin were also observed . However, no oro-dental anomalies were observed in the proband.
+She also had hallux valgus with increased gap between the first and second toes (sandal gap deformity), clinodactyly of toes, and pes planus (flat feet). No other deformity of the trunk or limbs was observed. She had dark pigmentation in armpits, genitalia, and on the knuckles. She had mild hypotonia with brisk and deep tendon reflexes. Her expressive communication was good but her verbal communication was affected. Her social responses seemed to be fair. The proband was diagnosed with attention deficit hyperactivity disorder (ADHD) with psychomotor developmental delay. Sample collection and written informed consent was obtained according to the need of the institutional ethics committee in accordance with Helsinki declaration. CARE guidelines were followed for reporting.
+On investigation, low hemoglobin with normal serum calcium (10 mg/dl) and Vitamin B12 levels were detected. Her sleep electroencephalogram (EEG) was normal. Radiographic studies of the proband showed small sclerotic areas in the lower part of the right femur, and abnormally shaped skull with minimal sclerosis in the lower occipital region . However, the bone density was normal and there were no features of fracture or dislocation of the bones. Corticomedullary differentiation was maintained and no periosteal reaction was noted. CT scan of the brain revealed prominent sulcal pattern with enlarged cisternal spaces in the brain parenchyma. These changes were prominently observed in the frontoparietal region. In addition, mild cortical atrophy was also detected. There was no evidence of focal hypo– or hyperdense lesion. Moreover, subdural, extradural or intracerebral hemorrhage, or subarachnoid bleeding was not observed. The pons, midbrain, both cerebellar hemisphere, and brain stem appeared normal. No mass lesion was observed in the posterior fossa.
+MRI revealed a significant hypoplastic appearance of posterior part of the brain. It also showed corpus callosal dysgenesis with the absence of rostral area. Moreover, a mild paucity of the peritrigonal white matter was seen surrounding the trigones of bilateral lateral ventricles. However, no obvious gliosis, extra-axial collection or lesions were noted. Her echocardiogram showed normal systemic and pulmonary venous drainage, normal valves, and normal sized cardiac chambers. The Ophthalmological evaluation revealed bilateral intact vision with healthy macula.
+Chromosome banding study showed a normal female karyotype i.e. 46, XX at 550-bands resolution . The fluorescence in situ hybridization (FISH) study was performed using LSI ELN (7q11) (orange) /LSI 7q22 (green) (Kreatech dual color probe). Since two signals were observed in all the cells, clinical prediction of Williams syndrome was ruled out. The proband DNA was further investigated with array comparative genomic hybridization (aCGH) using [Agilent 60 K], with an average resolution of 150 kb. No copy number variations i.e. deletions and/or duplications of pathogenic significance were detected [arr(1–22,X)× 2]. Thus, cytogenetic aberrations with resolution of 150 kb or greater were unlikely to be responsible for the clinical features in the proband.
+The genomic DNA (gDNA) of the proband was isolated from the peripheral blood using the salting-out technique . This DNA sample was processed for clinical exome sequencing (CES) on Illumina NextSeq 500. A detailed protocol is mentioned in the Additional file . Sequencing detected a homozygous missense variation c.1228 T > A in the exon 6 of the FAM20C gene (OMIM*611061) (GenBank accession number NM.020223.3; coding sequences NP_064608). This variation resulted in the amino acid substitution of threonine for serine at codon 410 (p.Ser410Thr; ENST00000313766), confirming the clinical diagnosis of RS (OMIM # 259775).
+The functional effect of this variant was studied using the in silico analysis tools. The variant was predicted to be disease-causing by Mutation Taster , with a score of 58. The impact of the substitution of serine to threonine was predicted to be probably damaging (score of 0.972) by Polyphen2 (PolymorphismPhenotypingV2) . Scale-invariant feature transform (SIFT) predicted that the variant was tolerated with a score of 0.51, and PROVEAN anticipated that the variant had a deleterious effect on the protein function. This variant was reported as a likely pathogenic allele (SCV000583504.1) and benign (SCV000343602.2) in ClinVar. Its reference SNP number is rs148276213. The minor allele frequency of the rs148276213 variant is 0.0034 in the 1000 genomes database and 0.006108 in the ExAC database for the South Asian population.
+CES also revealed another compound heterozygous variant in the tubulin gamma complex associated with protein 6 (TUBGCP6) gene (OMIM*610053) in the proband. The compound heterozygous variant in exon 24 [c.5327C > G (p.Ser1776Cys)] and exon 16 [c.3383G > A (p.Arg1128Lys)] is associated with microcephaly and chorioretinopathy-1 (OMIM#251270). In silico analysis predicted the first variant (c.5327C > G/p.Ser1776Cys) to be disease-causing using the Mutation Taster, tolerated by SIFT (score 0.07) and probably damaging by PolyPhen (score 1.00). While second variant (c.3383G > A /p.Arg1128Lys) found to be a polymorphism by Mutation T@ster, tolerated by SIFT (score 0.65), and benign by PolyPhen (score 0.023). Second variant was dismissed as the cause of disease in the proband, because this genotypic variation did not correlate with the phenotypic features of the proband, and also because various bioinformatics prediction softwares could not predict it as damaging.
+The variant has an autosomal recessive mode of inheritance. Its confirmation in the proband and her parents was carried out using bi-directional Sanger sequencing with primers covering both the exon and the intron-exon boundary of exon 6 of the FAM20C gene (Additional file ). Sequencing confirmed both the parents to be heterozygous, and the proband to be homozygous for c.1228 T > A (p.Ser410Thr) variant in exon 6 of FAM20C gene . This variant was submitted to ClinVar database (accession ID is SCV000583504.1). During a subsequent pregnancy, the same family approached again for genetic counseling. The prenatal diagnosis revealed a heterozygous state of the fetus for the c.1228 T > A (p.Ser410Thr) variant, and a normal carrier child was delivered (data not shown).
+Using NCBI Basic Local Alignment Search Tool (BLAST), the native and mutated sequences of the FAM20C gene were studied to understand the effect of the variant, and also to predict the protein structure against PDB with default parameters . The template PDBID: 5WRR was considered for modeling the protein structure. Additional details regarding the homological modeling is mentioned in the Additional file [–].
+A root mean sequence deviation (RMSD) of 0.3 Ao was observed between native and mutant structure, indicating changes in the loop regions of the superimposed structure. A decrease instability was predicted by iStable with a confidence score of 0.605. Furthermore, I-Mutant predicted a large decrease in protein stability due to the variant p.Ser410Thr with ΔΔG value of − 1.37 Kcal/mol .
+The protein sequence of Homo sapiens (NP_064608) was aligned along with other species using an online multiple sequence alignment program known as Clastal Omega . It is observed that the orthologs protein sequences of the FAM20C gene were highly identical to H. sapiens FAM20C gene protein sequence suggesting a highly conserved locus .
+Using PCR technique of amplification-refractory mutation system (ARMS), 200 unrelated control samples (100 males and 100 females) were studied to demonstrate the pathogenicity of c.1228T>A (p.Ser410Thr) variant. Amplification of the PCR product was confirmed by 2.5% agarose gel electrophoresis. From the 200 subjects screened for the above genotype, no carriers for the c.1228T>A (p.Ser410Thr) variant were found (Additional file ).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2962_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2962_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8e112a947fa78c6a7bf7a691f57c672afe4c34fa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2962_en.txt
@@ -0,0 +1,7 @@
+A 52-year-old female was referred to our ophthalmology clinic with decreased vision and increased tearing.
+She was diagnosed with stage III Alport syndrome two years prior which was currently stable per her nephrologist. During these two years had gradual decline in her visual acuity that was not correctable to 20/20.
+She had a past medical history of asthma, diabetes mellitus, and hypertension.
+Family history was positive for Alport syndrome in her mother and brother but without any known ocular or hearing abnormalities.
+On initial examination , uncorrected distance visual acuity was 20/60 on the right and 20/30 on the left, with a corrected visual acuity of 20/30 bilaterally.
+Slit lamp examination showed bilateral eyelid laxity, papillary conjunctival changes, prominent nerves, superficial punctate keratitis, unilateral (OD) anterior basement membrane changes, with no guttata, apical scarring, or corneal striae. Dilated fundus exam revealed bilateral floaters in the vitreous humor and normal retinal vasculature.
+Initial Pentacam (Oculus, Wetzlar, Germany) tomography revealed mean keratometry of 47.9 D in the right and 48.3 D in the left, with a 2 mo follow-up scan revealing a mean keratometry of 48.1 D and 48.5 D respectively . During this 2 mo period progressive corneal thinning occurred bilaterally. There was also bilateral anterior curvature steepening with no appreciable changes in the posterior curvature.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_296_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_296_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18af33d72a1a8b2203a8f4bf79433e5fbe2152cc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_296_en.txt
@@ -0,0 +1 @@
+A 65-year-old man was referred to our hospital in October 2006 with a huge abdominal tumor. A firm mass was palpated extending from the epigastrium to the left hypogastrium. There were no laboratory abnormalities, except a slight elevation of the total bilirubin (1.3 mg/dl) and lactate dehydrogenase (LDH: 217 IU/L) levels in the serum. The tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen (CA19-9) were within the normal range. Ultrasonography showed that the mass occupied almost the entire upper abdomen anterior to the bowel loops. On computed tomography (CT), a mass behind the left hepatic lobe showed heterogeneous low density with faint enhancement . Abdominal angiography revealed that the tumor was vascularized mainly from the right epigastric artery . We suspected liposarcoma, leiomyosarcoma, mesothelioma, or gastric GIST. At laparotomy on October 2006, a well-encapsulated tumor was found in the greater omentum. There was no adhesion to adjacent organs and structures but a pinpoint adhesion to the stomach. The right gastroepiploic artery and vein were prominent and stretched by the tumor, and a major supply vessel diverged from it in one stalk . There was no evidence of metastasis in the abdominal cavity. Grossly, a well-demarcated reddish-gray solid tumor, 20 × 17 × 6 cm in size, showed irregular modularity . The cut surfaces were tan-colored and contained focally necrotic areas and a cystic nodule. Histopathologically, the tumor was composed of proliferating epithelioid cells and myxoid cells with an interlacing bundle pattern . The cellularity was relatively high and the frequency of mitotic figures was 2 of 50 high power fields (HPF). The MIB-1 index was 4.4% . The tumor cells were diffusely immunoreactive for myeloid stem cell antigen (CD34), weakly or focally positive for c-kit proto-oncogene protein product (CD117) and slightly positive for neuron-specific enolase (NSE). However, there was no staining for cytokeratin (CK), alpha-smooth muscle actin (SMA) or S-100 protein. Direct sequencing demonstrated mutations in the platelet-derived growth factor alpha (PDGFRA) gene exon 12, codon 561, encoding a thymine to adenine substitution . These findings were consistent with a myxoid epithelioid GIST lacking myogenic features and neural attributes. The patient had a complete tumor resection and an uneventful postoperative course. He was treated by per os administration of Glevec® 300 mg/day as an adjuvant postoperative molecular targeting chemotherapy and has been living disease-free for 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2970_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2970_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fae7353c7c46bfec5bc4f1140a632a41ff82deb3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2970_en.txt
@@ -0,0 +1,2 @@
+A twenty-year-old Sri Lankan female presented following self-ingestion of 20 ml of amitraz (12.5 W/V) following a family dispute leading to the compulsive act. She was 66 kg in weight and 144 cm in height, resulting in 37.8 mg/ kg of amitraz poisoning. She recalled being alert for about 20 min following ingestion and was found unconscious by her parents. Four hours following ingestion, on admission to the hospital, her Glasgow coma scale (GCS) was 10/15. Pupils were equal and 3 mm in size. Deep tendon reflexes were normal. She had bradycardia with a heart rate of 55 beats per minute, hypotension with a blood pressure of 80/60 mmHg and a respiratory rate of 18 cycles per minute. Gastric lavage was performed along with intravenous fluid boluses. Intravenous dopamine 5 μg/kg/min was given for four hours to maintain blood pressure. Her bradycardia persisted for 36 h and she was drowsy for 48 h. She had nausea but not vomiting and did not open her bowels for 3 days. However the bowel sounds were normal. She did not develop respiratory depression, convulsions or hypothermia and the urine output was normal.
+ECG revealed sinus bradycardia with a normal QT duration and the blood sugar was normal throughout. Full blood count, liver function tests, Urine full report, serum creatinine and electrolytes were normal . Arterial blood gases revealed mild respiratory alkalosis with a pH of 7.47, pCO2 of 30 mmHg and a HCO3− of 21.6 mmol/L. There was no hypoxia. She recovered fully within 48 h and was discharged on day 3.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2983_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2983_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b192e620c35fc09be7a9d314460c2658c5c51cde
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2983_en.txt
@@ -0,0 +1 @@
+A 26-year-old man presented with complaints of nasal obstruction for 2 years. He was having nasal obstruction on and off as was on repeated use of topical nasal drops He also complained of an associated headache on and off which was more localized in the right side. He also complained of swelling of the right cheek for the same duration of time. The swelling was insidious in onset and progressively enlarging in size. There was no history of pain, nasal congestion, facial numbness, or any oroantral surgery in the past. However, he gave a history of blunt trauma over his right cheek 5months back. There was no significant family history relevant to the disease. On Inspection, we could see a diffuse swelling of the right cheek with the mild erythematous change of the overlying skin . On palpation, the swelling was firm, nontender and slightly mobile. Examination of the oral cavity revealed a bulge over the right gingivobuccal sulcus. He was then planned for a CT scan of the paranasal sinus which revealed opacified and expanded right maxillary sinus withlow-density lesion ∼53*44 mm and scalloping and resorption of posteroinferior, medial and superolateral walls and widening of osteomeateal complex . The features were suggestive of right maxillary mucocele.With the diagnosis above he was planned for Caldwell Luc sinusectomy by a team of Otorhinolaryngology Head and Neck Surgeons under General Anesthesia. Intraoperatively cystic mass containing thick mucopurulent content was identified and the around 25 ml of fluid was drained out. All walls of the maxillary sinus appeared thinned out. A large middle meatal antrostomy was performed after exenterating the anterior ethmoidal cells. The histopathological report was consistent with the diagnosis of mucocele.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3039_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3039_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5aeda1d545ca78ba68533dd6b7ae75eeedb5cbf1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3039_en.txt
@@ -0,0 +1,5 @@
+A 71-year-old woman was diagnosed with a branched intraductal papillary mucinous neoplasm (IPMN) of the pancreatic body. She was regularly followed up at a hospital for IPMN. MRI revealed no signs of high-risk stigmata until 2023. However, in 2024, MRI revealed a rapid dilation of the MPD. Endoscopic ultrasonography also showed dilation of the MPD and a contrast-enhanced mural nodule 10 mm in size in the proximal area of the IPMN. A biopsy performed during the endoscopic retrograde cholangiopancreatography revealed cellular atypia. The patient was referred to our hospital for treatment. In our hospital, CT and MRI revealed IPMN of pancreatic body and the dilation of MPD to 13 mm, which was a factor of high-risk stigmata in IPMN diagnosis. Her height and weight were 161.8 cm and 57.65 kg, respectively. The carcinoembryonic antigen: 1.9 ng/mL, carbohydrate antigen 19-9: 4.1 U/mL, duke pancreatic monoclonal antigen type 2: 25 U/mL, s-pancreas-1 antigen: 6.8 U/mL, hemoglobin: 13.7 g/dL, leukocytes: 6730/µL, c-reactive protein: 0.04 mg/dL, creatinine: 0.68 mg/dL, asparate aminotransferase: 20 U/L, alanine aminotransferase: 19 U/L, total bilirubins: 0.7 mg/dL, amylase: 38 U/L, platelets: 201000/µl, prothrombin time international normalized ratio: 0.80, and hemoglobin A1c: 6.9%. She had a history of pulmonary tuberculosis, Sjögren syndrome, colonic polyps, and facial paralysis. The American Society of Anesthesiologists physical status classification system score was 2. Preoperative CT showed that the rCHA branched from the SMA and that the pancreatic parenchyma surrounded the rCHA. The main pancreatic duct meandered and ran behind the rCHA.
+
+To maximize the surgical margin of the nodular lesion in the IPMN, robotic pancreaticoduodenectomy with D1 lymph node dissection was planned and performed. The operative time was 442 min and the estimated blood loss was 50 mL. The left posterior approach was used for SMA dissection, and the root of the rCHA was identified on the left side.11–13) Pancreas transection was performed with the transection line positioned to the left of the SMA at the point the dilation of MPD normalized. Intraoperative frozen sections confirmed that the pancreatic stump was negative for carcinoma. During dissection of the upper side of the duodenum, the peripheral part of the rCHA was identified, and the gastroduodenal artery branching from the rCHA was dissected. At the time of dissection between the rCHA and pancreatic parenchyma, we divided the cranial part of the pancreatic parenchyma along the rCHA and cut the MPD again. The main pancreatic duct was clipped bilaterally and divided to excavate the rCHA. Two thin arterial branches extending from the rCHA to the pancreas were identified, ligated, and divided. The remaining steps were performed as usual.
+
+Postoperative course was good. There was a postoperative pancreatic fistula of Grade1 (Clavien–Dindo classification) and biological leakage (International Study Group of Pancreatic Surgery classification). The patient was discharged on the 13th day after the operation. The pathological findings included intraductal papillary mucinous carcinoma, noninvasive nature of the pancreatic body, and no lymph node metastases.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3047_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3047_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..612f848d8d248a289a1f2112f5560c1fe1e103de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3047_en.txt
@@ -0,0 +1 @@
+A 27-year-old female smoker with no regular medication, with no previous history of SARS-CoV-2 infection, vaccinated with BCG at birth in her left arm, received the first dose of the COVID-19 mRNA vaccine (Moderna®), also in her left arm, without symptoms or immediate intercorrerences, reporting no additional changes in the following days, namely, redness, heat, change in pigmentation or exudate. Eight days after administration of the anti-SARS-CoV2 mRNA vaccine, the young woman developed a reaction of a round shape and poorly defined edges with about 2 cm in diameter at the site of the BCG scar, characterized by erythema, induration and pain, and distanced about 4 cm from the site of inoculation of the anti-SARS-CoV2 vaccine. The patient did not report fever, myalgia or other symptoms. No changes were detected in the objective examination, namely, adenopathies. The symptoms persisted for three days, and the patient opted not to be medicated. After 11 days since the onset of symptoms, a complementary analytical study was performed, revealing a positive result for anti-SARS-CoV2 IgG, with the remaining values within the normal range, including lymphocytes and viral serologies. The incident was submitted as a possible adverse reaction to medicines in the National Pharmacovigilance System.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3061_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3061_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1542513851fe665ff2cbbdef354de75ec3c54139
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3061_en.txt
@@ -0,0 +1,11 @@
+50-year-old female patient with a history of dermatomyositis and antisynthetase syndrome associated with secondary diffuse pulmonary disease (EPD), on treatment with mycophenolate and corticosteroids. She progressed with weight loss of 18 kg, night sweats and progressive increase in volume of the upper left eyelid. Orbital CT scan was performed which showed an increase in volume of the lacrimal gland.
+
+He was admitted to our center electively for biopsy, with a presumptive diagnosis of MALT lymphoma of the lacrimal gland. Twenty-four hours after the procedure he presented clinical signs of acute abdomen. A TAC showed multiple nodular lesions in the liver, spleen, adrenal glands and subcutaneous tissue, as well as thickening of the colonic walls. An emergency exploratory laparotomy was performed, where peritonitis of 4 quadrants was evident, as well as perforated transverse colon tumour and 3 implants in the omentum. A hemicolectomy and terminal ileostomy were performed and the surgical piece was sent to pathological anatomy.
+
+Other infectious or rheumatologic etiologies that could explain the picture in the context of immunosuppression were discarded. In addition, a myelogram was performed, in which a sample was obtained for myeloculture and universal PCR of bacteria and fungi, which were negative. The immunophenotype of the bone marrow sample showed 9% of polyclonal lymphocytes. A CT scan of the brain, neck, thorax, abdomen and pelvis was performed to extend the study of the nodules found in surgery, which did not show new lesions to those already described. The presumptive diagnosis was unknown primary neoplasm.
+
+Finally, the biopsy result of the lacrimal gland tumor showed extensive necrosis and lymphoid infiltration, mixed with CD68-positive histiocytoid cells and some plasma cells. Occasionally, a multinucleated cell was recognized. The lymphocytes were predominantly small, although larger around the vessels. Medium to large lymphocytes were present with angiocentricity, causing infiltration and necrosis of blood vessels. These cells were CD20 positive and EBER positive, with the majority of lymphocytes being small T-cell lymphocytes. The biopsy of the colon tumor showed the same histology.
+
+Given the clinical picture and results described in the biopsies, the diagnosis of atypical presentation of lymphomatoid granulomatosis (GL) was concluded in the first instance. The case was presented to the haemato-oncological committee, and given the patient's nutritional and functional status, and high risk of intestinal perforation with chemotherapy, it was decided to initiate the R-COP protocol as a prephase to be able to progress to the R-CHOEP scheme after stabilisation. The patient completed 6 cycles of R-CHOEP, without complications, and has been in complete remission for 1 year.
+
+In 2022 in light of new classifications and definitions of lymphoid neoplasms, it was concluded that both clinically and histologically, the case is more like a GL-type, polymorphic B-LPD.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3069_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3069_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f9c75e1ba7ee1f6aa216825f7adf4539d7fb37d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3069_en.txt
@@ -0,0 +1,15 @@
+29-year-old patient, Congolese, with no significant history, seen in consultation in June 2022 for bilateral epistaxis of moderate abundance that occurred spontaneously. She has had progressive abdominal swelling with an intra-abdominal feeling of heaviness, weight loss and hyperhidrosis for more than 3 years. The diagnosis of cirrhosis was initially considered. The clinical examination noted a conscious patient, slightly icteric and with a good haemodynamic status. The liver was enlarged with a hepatic arrow at 17 cm, painless, firm, with an irregular surface. There was a splenomegaly measuring 16 cm. The anterior rhinoscopy, cardiac and pulmonary auscultation were normal.
+
+Paraclinical findings included cytolysis with ASAT 421.5 IU/L, ALT 204.3 IU/L, and cholestasis with alkaline phosphatase 670 IU/L. The bilirubin level was increased (50.4 µmol/L) at the expense of the conjugated form (30.8 µmol/L). The erythrocyte sedimentation rate was 150 mm in the first hour, and the serum level of angiotensin converting enzyme (ACE) was increased to 130 IU/L. The blood count showed moderate microcytic and hypochromic anaemia. The intradermal tuberculin reaction was negative and the alpha-fetoprotein level was normal. The creatinine level, coagulation profile, ferritin level and serum protein electrophoresis were normal. The viral serologies were negative (Ag HbS, anti-HCV antibodies) indicating the absence of hepatitis B and C.
+
+An abdominal ultrasound revealed a nodular hepatomegaly, a splenomegaly, a low-grade ascites and a dilated portal vein.
+
+The chest radiograph was normal.
+
+The preoperative exploration for splenectomy revealed a large, 18 cm, bulging splenomegaly, a multi-nodular hepatomegaly, and very dilated splenic and portal vessels. There were no adenopathies.
+
+Histological examination of the liver biopsy noted signs of chronic inflammation without signs of cirrhosis. Histological examination of the splenectomy piece noted hemorrhagic remodeling. Microscopy revealed an inflammatory granuloma without caseous necrosis, in favor of a hepatic and splenic sarcoidosis. However, we were unable to carry out additional immunohistochemical analyses.
+
+Treatment consisted of oral corticosteroid therapy with 60 mg prednisone daily, then tapered to less than 20 mg daily, and marrow support (200 mg daily).
+
+The clinical and paraclinical evolution after more than 18 months is satisfactory.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3086_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3086_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c48d20b4b7ba6c74255f5dd491a11cf092f9a42b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3086_en.txt
@@ -0,0 +1,3 @@
+We present a 22 year old male patient who presented with abdominal distension and vomiting of ingested matter of two to three episodes per day of one month duration. He has significant weight loss. He is a known schizophrenic patient for the past three years and has followed up at a nearby hospital, after which he has been off his medication for the past two months. He swallowed metallic nails in an attempt to kill himself. On presentation his vital signs were, blood pressure 110/70, pulse rate 128, respiratory rate 20, axillary temperature 36.5 and oxygen saturation 92%. On abdominal examination there was distension, epigastric tenderness and no signs of fluid collection. On admission his blood tests were, white blood count 15,000, hemoglobin 14 gm/dl, platelet 138,000 and granulocytes 77%. Serum electrolytes, random blood sugar and organ function tests (liver and renal) were in normal range. On the other hand, his plain abdominal x-ray showed multiple radiopaque foreign body namely nail in the stomach. Similarly, abdominal ultrasound showed thickened gastric wall and multiple linear foreign bodies in the stomach.
+
+Eventually, with the impression of complete gastric outlet obstruction secondary to foreign body in the stomach, laparotomy plus gastrotomy plus foreign body removal and repair were done under general anesthesia. Intraoperative findings were dilated stomach, palpable mass on distal stomach and first part of duodenum, and adhesion between stomach, abdominal wall and liver. Subsequently, gastrotomy was made proximal to the foreign body area. Foreign bodies consisting of sixty curved, and straight nails of various sizes, needle and wire were removed with sponge forceps. Gastrotomy incision was repaired with two layers. Abdominal cavity was washed with warm normal saline. The abdominal incision was closed with two layers. The patient was then transferred to surgical ward with stable vital signs and put on antibiotics. Postoperative hematocrit was 36%. The patient was discharged after four days of hospital stay and linked to psychiatric department for further evaluation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3091_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3091_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1ca1afad201e3e0563b69e8c6fc4e5cda4f61a1d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3091_en.txt
@@ -0,0 +1,25 @@
+A 67-year-old lady was admitted with confusion, right sided weakness and right arm shaking.
+
+Comorbidities included a duodenal ulcer, diabetes mellitus and hypertension, but importantly no prior personal or family history of neurological disorders or cerebrovascular events. Medications included Metformin, Ramipril and Lansoprazole.
+
+She was also suffering from a non-healing ulcer on her left 5th toe. Bone fragments grew Enterococcus and Proteus. Skin swabs grew Staphylococcus Aureus. Osteomyelitis of the 4th and 5th metatarsals was suspected. As co-existing cellulitis not responded to co-amoxiclav, the patient was switched to Linezolid 600 mg twice daily was commenced for four weeks. Full Blood Count after 3 weeks of treatment with Linezolid showed Hb 104 g/L, WCC 6.1 ×10 9/L, platelets 119 ×10 9/L and MCV 85 fL. Her platelet count was last checked three years prior and was within normal range at 245 ×10 9/L. She finished her full five-week course of linezolid to which her osteomyelitis responded well.
+
+Two days after the last dose of Linezolid she noticed right arm shaking and weakness.
+
+Admission blood pressure was 189/63. Her Glasgow Coma Scale (GCS) was 14/15 (E3, V5, M6). She had mild global weakness and was unable to finger count. However, she had power of 4/4 in all limbs, normal tone and plantar responses were flexor. There was evidence of right sided neglect.
+
+CT head was unremarkable. Her haemoglobin (Hb) was 69 g/L, but white cell count (WCC) and platelets were within normal limits. On admission, aspirin was given while a MRI Head was requested to investigate the considered differentials, including progressive multifocal leukoencephalopathy, Posterior Reversible Encephalopathy Syndrome, and encephalitis.
+
+She developed a progressive decline in consciousness in the next 24 h. MRI Head revealed bilateral alteration of signal seen within the deep white matter of the posterior frontal and parietal lobes. These areas showed some mild diffusion restriction. The altered signal extended into the midbrain on the left side and there was also some involvement of the cortex in the right parietal lobe. Normal flow was seen in the basilar artery. Differential diagnoses of bilateral ischaemia, and progressive multifocal leukoencephalopathy were suggested. Posterior reversible encephalopathy syndrome was less likely due to the restricted diffusion. In the following 36 h, Hb had improved to 88 g/L, WCC remained at 5.0 × 10 9/L but Platelets had dropped to 1 × 10 9/L. Twelve hours later, her Hb was 78 g/L and platelets remained at 2 × 10 9/L. The blood film showed a few left shifted neutrophils but with a lack of red cell fragments. During this period, the CRP rose from 22 mg/L to 132 mg/L. Reticulocyte count was 146. Bilirubin was normal. Direct antiglobulin test was negative. Lactate dehydrogenase sample unfortunately haemolysed. A Heparin-induced Thrombocytopenia Antibody assay was not done as the patient was not on anticoagulants on admission and had not been prior to admission.
+
+Bone marrow biopsy or a therapeutic intravenous infusion of immunoglobulin was not indicated so instead she was transferred to a tertiary centre for urgent plasma exchange due to the strong suspicion of TTP. This suspicion was suggested by neurological symptoms, anaemia, unexplained thrombocytopenia. Her PLASMIC score was 6 (high-risk; however, please note that the INR component missing).
+
+Cerebrospinal fluid analysis showed negative viral polymerase chain reaction testing, white cell count 12, red cell count 14, no organisms seen on microscopy, protein 0.53, and cytology acellular.
+
+Electroencephalogram suggested an encephalopathic pattern with anterior sub-cortical slowing present. ADAMTS13 was normal and vWF cleaving protease was 106. Reticulocyte count was 3.98% and Fibrinogen 2.12 g/L. CT Thorax, Abdomen and Pelvis showed no abnormality.
+
+A diagnosis of Linezolid induced Leukoencephalopathy was made.
+
+She was discharged 8 weeks following presentation; making a complete recovery by 4 months.
+
+MRI Head repeated at 9 months showed gradually reducing signal intensity in abnormal areas described earlier consistent with leukoencephalopathy. In addition her platelet count improved to 219 × 10 9/L upon discharge.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3112_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3112_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..44c54e959497905d676baef35d1ed9a842a0c1e1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3112_en.txt
@@ -0,0 +1,13 @@
+27-year-old female patient, native and resident of Mexico City, who presented with symptoms 18 days prior to admission. She presented a clinical picture characterized by odynophagia accompanied by non-productive, non-dyspnoeic, non-emesis inducing cough, no fever, treated symptomatically (not specified), no clinical improvement. Eleven days prior to admission, she reported paresthesia of the right pelvic limb, hypoesthesia and weakness of both pelvic limbs and the right thoracic limb, as well as clumsiness in the right upper limb, which prevented her from performing her daily activities, as well as a decrease in the fluency of speech and dysarthria. Eight days prior to admission, in addition to the previous symptoms, she presented gait instability, requiring unilateral support for ambulation. On the night of that day, she presented loss of postural tone with palpebral opening, tonic gaze to the right, no response to verbal or tactile stimuli, no loss of control of sphincters. Subsequently, she presented flexion of the left arm and extension of the right arm, with forced cephalic version to the right, followed by guttural sounds and generalized tonic-clonic movements, with postictal period without recovery of alertness. The patient presented several events, with an estimated duration of 60-90 minutes, for which she was taken to the hospital, where she was admitted on suspicion of status epilepticus, advanced airway management and sedation were performed. During her hospital stay, a simple skull tomography study was performed, and an approach was initiated as a probable cerebrovascular disease, due to hypodens and hyperdense cortical and subcortical lesions. On physical examination, the Glasgow scale was 4 points, the nociceptive stimulus was the absence of ocular opening, bobbing of the eye, absence of oculocephalic reflexes, photomotor and consensual bilateral reflexes, absence of corneal and nasal reflexes, no response to the Marie-Foix maneuver, generalized decreased tone, dense pyramidal syndrome, bilateral and incomplete, muscle stretch reflexes (REMs) 3 (+++) in the thoracic and left pelvic limbs, REMS 1 (+) right patellar reflex, decerebration posture to the nociceptive stimulus. The cerebellum was not assessable due to neurological status.
+
+The MRI study showed multiple lesions in the white matter, cortical and subcortical of both cerebral hemispheres, diffuse hyperintensity in subcortical white matter, multiple hyper and hypointense cortical and subcortical lesions in both cerebral hemispheres in the T2 sequence and attenuated inversion recovery of fluid (FLAIR).
+
+In addition, there were infratentorial lesions in both cerebella and the right cerebellar peduncle, which were hyperintense on T2 and FLAIR.
+
+With contrast administration, enhancement is observed in various cortico-subcortical lesions of both cerebral hemispheres, with no enhancement in infratentorial lesions.
+
+Multiple areas of absence of susceptibility consistent with hemorrhages are observed in the T2-weighted gradient echo sequence, and areas of restriction in several subcortical lesions in both hemispheres are observed in the diffusion weighted imaging (DWI) sequence.
+
+Cerebrospinal fluid (CSF) showed non-infectious inflammatory characteristics: colorless, leukocytes: 0-1, erythrocytes: 1-2, glucose: 61 mg/dL, microproteins: 2775 mg/dL. Gram stain and Chinese ink were negative. Bacteriological cultures, by polymerase chain reaction (PCR), for tuberculosis and for viruses in CSF were negative. Studies of blood count, blood biochemistry, chest radiography, coagulation parameters, toxoplasmosis profile, rubella, cytomegalovirus, herpes simplex (TORCH) and immunological profile were reported normal.
+
+Based on the above, an immunological origin was suspected, so treatment with methylprednisolone was initiated, and although there was no major progression, there was no clinical improvement, so it was decided to initiate treatment with immunoglobulin, with which the patient presented discrete clinical improvement in the motor system, but no improvement in mental functions. A control skull tomography was performed 12 days later, and a decrease in hemorrhagic lesions was identified. A brain biopsy was taken 15 days after admission and infiltration of macrophages, necrosis of small vessels and non-specific hemorrhage was found. The convulsive state subsided after 72 hours, so sedation was withdrawn, keeping the patient awake, without interaction to the environment and without response to the pain stimulus. With persistence of supplemental oxygen. In the follow-up, the patient continued in the same neurological state, and in persistent vegetative state.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3113_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3113_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7129163acc8d97cb6b1ec9cd62cfaf70e36ac83e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3113_en.txt
@@ -0,0 +1,5 @@
+A 41-year old male was in good health before. He suffered from progressive exertional dyspnea and visited an outpatient department of local hospital, but then was transferred to our hospital because of LV thrombus which was found on transthoracic echocardiogram. After admission to our ward, transthoracic echocardiogram showed global hypokinetic LV (the EF of LV was 28%), dilated LV size and a pedunculated apical thrombus measuring 1.75 × 1.68 cm. Coronary angiogram was performed to rule out ischemic cardiomyopathy and it subsequently revealed no significant obstructive lesion. He was discharged from our hospital and had taken warfarin 3.75 mg/day for AF and LV thrombus since then.
+
+However, he developed sudden onset of right-hand clumsiness and expressive aphasia after 1 month and was sent to our emergency department immediately for help. Right eye blurred vision and drooling from the right mouth angle were noted at the same time. The blood examination in the emergency department showed supratherapeutic range of prothrombin time and international normalized ratio (INR) 7.64. His symptoms totally recovered within 1 day, but the brain magnetic resonance imaging (MRI) showed multiple acute infarctions in the cortex of the bilateral frontal lobes, left parietal lobe, and bilateral central semiovale, which highly suggested embolic stroke. The transthoracic echocardiogram performed on the same day of stroke still revealed LV thrombus (1.27 × 0.90 cm). Due to acute infarction even under high INR level, we discontinued warfarin first and shifted to edoxaban (60 mg/day) use after INR decreased to less than 2.
+
+To our surprise, follow-up echocardiography showed resolution of LV thrombus after receiving edoxaban for 23 days. The patient tolerated edoxaban well and did not get recurrent stroke in the following 6 months.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3118_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3118_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c0a33193414a7be4b462adf3fbc5853fd7d145ed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3118_en.txt
@@ -0,0 +1,17 @@
+Case history
+The patient was a 67-year-old male patient. His chief complaint was that six hours before arriving at the hospital, he suffered a car accident which caused his persistent neck pain with no effective measures of pain relief and his neck could not move. There were no such accompanying symptoms as nausea, vomiting, dizziness, and headache.
+
+Physical examination
+Physical examination showed that the patient's limbs had no obvious limitation of movement and no symptoms of nervous injury. However, the right side of the patient's neck was significantly swollen, and the trachea was shifted to the left, The patient had no history of chronic diseases such as hypertension, diabetes, and coronary heart disease.
+
+Image analysis
+The Neck Disability Index (NDI), JOA score, operation time, intraoperative blood loss, and perioperative complications were recorded before and after the operation. The improvement of the height of the injured intervertebral space, the situation of the reattachment of the facet joint, and the improvement of the Cobb angle of the C2–7 cervical lordosis (the acute angle formed by the vertical line of the lower edge of the C2 vertebral body and the vertical line of the lower edge of the C7 vertebral body, see 1b) before and after surgery was compared by imaging. The situation of interbody fusion was evaluated by imaging according to the modified Brantigan criteria.
+
+Operation
+Skull traction was performed immediately after admission. The traction weight of the patient was 4–10 Kg, and the average traction weight was (6.0 ± 2.0) Kg. At the same time, the patient's neck arterial-venous CTA examination was immediately performed, the result showed that did not find obvious contrast agent leakage. Subsequently, we closely observed the patient's condition and gave the patient symptomatic treatment. After continuous skull traction, we reexamination the patient's neck CT again, it was confirmed that the locked facet joints of the patient had been reattached. With the patient's condition tended to be stable, an elective operation of ACDF was performed on the injured segment of the cervical spine, and intravenous inhalation combined with anesthesia was used during the operation. The patient was placed in a supine position, and a right anterior cervical transverse incision was made about 5 cm in length. The skin, subcutaneous tissue, and platysma were cut. The gap between the cervical vascular sheath and the visceral sheath was isolated, and the trachea esophagus and esophagus were pulled to expose the anterior fascia of the vertebra. The C-arm X-ray fluoroscopy was used to determine the intervertebral disc of the injured segment, and the target intervertebral disc was confirmed under direct vision. The outer annulus fibrosus was incised with a sharp knife to observe the deep intervertebral disc injury. A spatula and nucleus pulposus forceps were used to completely remove the injured intervertebral disc from the endplate. The bilateral uncinate joints were examined and bitten with a thin-mouth plier. Under the microscope, we carefully handled the posterior edge of the vertebral body to fully expose the posterior longitudinal ligament, then picked up the posterior longitudinal ligament with a thin hook and cut it with scissors to expose the cerebral dura mater, and fully decompress the head and tail. The cerebral dura mater and the nerve roots on both sides were explored and confirmed again without compression. The bone graft beds on both sides of the endplate were repaired and rinsed with normal saline, and the gelatin sponge was used to stop bleeding. The size of the intervertebral fusion cage was determined, and the Cage loaded with autologous bone particles was inserted into the intervertebral space. Through C-arm fluoroscopy, the Cage position was good. The appropriate length of the anterior cervical titanium plate was selected, and the titanium plate was locked by locking screws. The internal fixation position was determined to be satisfactory by fluoroscopy again. Finally, the incision was washed with physiological saline, and we put a drainage tube in the incision before closing the incision.
+
+Postoperative management
+After the operation, antibiotics, hormones, and dehydration drugs were routinely used for 4–5 days, and atomization inhalation was performed for 3 days. The drainage tube was removed 48–72 h after operation. X-ray and CT were reexamined after the operation to understand the reduction of vertebral body and internal fixation. The patient was suggested to wear neck circumference external fixation for 3 months, and the function training of the cervical spine was performed according to the patient's recovery.
+
+Follow-up/imaging
+The Neck Disability Index (NDI) score was 41 before the operation and 24 one year after the operation. The preoperative JOA score was 14, and the JOA score was 15 at 1 year after operation. The Cobb angle of C2–7 cervical lordosis was about 11° before the operation. The Cobb angle of C2–7 cervical lordosis was about 27° at 1 year after operation. The intervertebral height of the injured segment was about 2.6 mm before operation. The intervertebral height of the injured segment was about 4.4 mm at 1 year after operation. Compared with the preoperative image, the Cobb angle of C2–7 cervical lordosis, the intervertebral height of the injured segment, and the NDI score were significantly improved.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_312_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_312_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..484a8d88a2dd4c8e47444e9b589d8db0e42906e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_312_en.txt
@@ -0,0 +1,3 @@
+A 49-year-old man (122.9 kg, BMI 39.1 kg/m2) presented to our hospital wishing to undergo LSG and VHR. His medical history included diabetes mellitus, hypertension, and hyperlipidemia. He had undergone urgent surgery for an umbilical hernia with incarcerated small bowel 18 months ago. The surgery included small bowel resection and direct closure of the defect without mesh reinforcement. Six months later, the umbilical hernia recurred. Physical examination revealed a tennis ball-sized lower midline defect. Computed tomography (CT) scans revealed a hernia orifice 5 cm in width and 10 cm in height in the infra-umbilical region . As mesh reinforcement was essential to repair the ventral hernia, we planned for him to undergo VHR after LSG.
+LSG was performed using a standardized surgical technique with a 37.5 Fr bougie. Intraoperative findings revealed adhesion between the omentum and the hernia sac, which was not dissected during LSG. His postoperative course was uneventful, and after 9 months, he showed satisfactory weight loss (84.2 kg, BMI 26.8 kg/m2) and his comorbidities such as diabetes mellitus, hypertension, and hyperlipidemia were in remission. We then performed VHR using the eTEP technique.
+After induction of general anesthesia and intubation, he was positioned with the bilateral upper extremities tucked at his sides. Figure shows the port placement in this case. A 1.5-cm skin incision was made just below the left costal margin, and the anterior rectus sheath was identified and incised sharply. A 12-mm trocar was inserted posterior to the rectus abdominis muscle, and the left retrorectus space was developed followed by insertion of two 5-mm trocars at the port 2 and port 3 positions medial to the linea semilunaris. The left posterior rectus sheath was incised close to the linea alba, and then the right posterior rectus sheath was opened over the falciform ligament. After the preperitoneal and two retrorectus spaces were connected, a 12-mm trocar was inserted at port 4, and lateral dissection of the right posterior rectus sheath was done. Two 5-mm trocars were inserted at the port 5 and port 6 positions. The sac was opened, and intraabdominal adhesions were dissected . Bilateral transversus abdominis muscle release was performed . The posterior layer defect was closed with 3-0 multifilament suture material . Then, the linea alba was restored with 1-0 barbed sutures . BARD™ Mesh (Davol Inc., Warwick, RI, USA 02,886), a medium-weight small-pore (0.44 mm) polypropylene mesh of 26 cm width × 35.5 cm height, was positioned to cover the dissected area with no fixation . A 19 Fr drain was placed over the mesh. The operating time was 452 min, and the amount of blood loss was nearly 0 g. The patient’s postoperative course was uneventful, the drain was removed 4 days after the surgery, and he was discharged on the same day. A CT scan 4 months after eTEP repair did not show recurrence or seroma . At 1-year follow-up, he was doing well.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3149_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3149_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..be0c5dc6b56d5ffc6d5a76686b3c57f5c2a425bf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3149_en.txt
@@ -0,0 +1,30 @@
+A 38-year-old female patient without a significant past medical history presented to the emergency department of our hospital in September 2019 with a history of exertional shortness of breath and regular palpitations since 1 month before admission. She had 2 attacks of syncope during this period. She also reported easy fatigability and 8-kg weight loss within the last 2 months.
+
+On physical examination, at the time of admission, she looked healthy without shortness of breath or cyanosis. She was afebrile and normotensive. Her heart rate was 112 beats/min (bpm) and regular in rhythm. O2 saturation at room air was 93%. Heart examination revealed a pansystolic murmur at the lower left sternal edge that increased with inspiration concordant with tricuspid regurgitation (TR).
+
+Her chest was clear to auscultation. Abdominal examination revealed a firm and tender palpable liver edge 2 to 3 cm below the right costal margin. There was no raised jugular venous pressure or lower limb edema.
+
+Electrocardiography (ECG) showed sinus tachycardia, right bundle branch block, and frequent ventricular ectopic rhythm.
+
+Holter ECG monitoring (24-h) showed sinus tachycardia reaching 136–140 bpm and frequent ventricular premature complexes. Chest X-ray showed borderline cardiomegaly with clear lung fields.
+
+Transthoracic and transesophageal echocardiography (TTE and TEE respectively) revealed a large mass measuring 5.6×3.8 cm in the right atrium originating below the fossa ovalis, affecting the tricuspid valve, leading to severe TR and extending to the RV wall causing RV outflow obstruction and pulmonary hypertension.
+
+The right side of the heart was dilated; RV dimension was 3.2 cm (N=1.2–2.3 cm), with TR grade 2–3 and RV systolic pressure (RVSP) of 50–55 mmHg (n=8–20 mmHg).
+
+
+Laboratory workup showed the following values: hemoglobin (Hb) 11.3 g/dL (n=12–14 g/dL); erythrocyte sedimentation rate (ESR) 53 mm/h (n=13–27 mm/h); C-reactive protein 145 mg/L (N=0–5); international normalized ratio 1.6 (n=0.9–1.2); alanine and aspartate transaminases 61 and 94 IU/L, respectively (n=35–38 IU/L), serum albumin 26 g/L (n=35–52 g/L), and brain-type natriuretic peptide 822 pg/mL (n<100 pg/mL).
+
+Liver ultrasound revealed a homogenously enlarged liver (18 cm) with no focal defects.
+
+Thyroid function tests, fasting blood sugar, blood urea nitrogen, urinalysis, and serum lipids were within normal limits. Hepatitis markers hepatitis B surface antigen and hepatitis C virus antibodies were nonreactive. Also, human immunodeficiency virus antibodies were negative.
+
+An initial diagnosis of cardiac myxoma was made and surgical resection of the mass was planned as soon as possible.
+
+The patient underwent cardiac surgery after 4 days of admission. Intraoperatively, 400 mL of pericardial effusion was found and drained. The right atrium and right ventricle were enlarged. A 12×8-cm huge dark-red to gray color, vascularized, gelatinous mass filling both the right atrium and the right ventricle was found. It was attached to the interatrial septum below the fossa ovalis by a thin stalk. It was extending down through the tricuspid valve with part of the mass adherent to the interventricular septum. We delivered and freed the mass, identified and resected the stalk, and then cauterized the base of the stalk.
+
+The patient came out of cardiopulmonary bypass without the need for direct-current shock. She was intubated for 12 h postoperatively and kept in the intensive care unit for 24 h, where she was given 1 unit of packed red blood cells and 5 units of fresh frozen plasma.
+
+The mass was sent for histopathologic examination and showed macroscopically a gray-colored mass measuring 9×4.5×3 cm. Gross sectioning showed myxoid areas with other areas of hemorrhage and necrosis. Microscopic examination showed stellate myxoma cells with abundant eosinophilic cytoplasm in the background of abundant mucopolysaccharide (myxoid) ground and areas of hemorrhage and necrosis and no evidence of malignancy. The intrapericardial drain was removed on the third postoperative day and the patient was discharged without any complications.
+
+She was seen in the clinic at 1-month, 2-month, 5-month, and 1-year intervals postoperatively. She was doing well without any complaint. Her liver transaminases returned to normal levels. Repeated TTE 5 months and nearly 1 year postoperatively was free of any cardiac masses. It showed grade 1 TR; the right atrium and right ventricle were still dilated, with RVSP of 35 mmHg.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3162_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3162_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1f114d2aa1369bc74eea0d8acbef621f3b237203
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3162_en.txt
@@ -0,0 +1,19 @@
+The patient was a 33-year-old Caucasian man with a history of untreated AIDS for 1 year who presented to the emergency department with progressive dyspnoea for 3 weeks followed by treatment with levofloxacin for 5 days and amoxicillin + clavulanic acid for 7 days with no adequate response. On admission, he presented with tachypnoea, fever of 39.1ºC, dry cough and hypoxaemia. Chest radiography and computed tomography revealed bilateral pulmonary infiltrates with no localized alveolar opacities. Non-invasive ventilation (NIV) was immediately established and sputum, blood and urine samples were collected and empirical antibiotic therapy was initiated.
+
+The patient was admitted to the intensive care unit (ICU) on NIV with a Glasgow Coma Scale of 15/15, respiratory rate of 28-34 breaths per minute (bpm), dyspnea score of 8/10 (zero for no dyspnea and ten for worst possible dyspnea), comfort 8/10, accessory muscle use and a four-point Heart Rate, Acidosis, Consciousness, Oxygenation, and Respiratory Rate (HACOR) score. After 1 hour on NIV, arterial blood gas revealed a pH of 7.38, carbon dioxide partial pressure (PaCO2) of 38 mmHg, oxygen partial pressure (PaO2) of 78.1 mmHg, bicarbonate (HCO3) of 22.2 mEq/L, base excess (BE) of -2.4 mEq/L, and PaO2/FiO2 ratio of 156.2 mmHg.
+
+Considering the initial clinical picture, it was decided to change from NIV to nasal cannula of high flow (NCHF) using flow of 60L/minute with FiO2 of 0.50. Initially the patient had a decrease in respiratory rate to 23rpm and improvement in oxygenation, dyspnea and comfort. The ROX index after 1 hour of NCHF was 8.33.
+
+After 48 hours with CNAF, the patient had increased RT and worsened oxygenation, requiring endotracheal intubation and invasive MV.
+
+First period of ventilation in controlled mode
+Advanced monitoring of SR mechanics was performed during the time of invasive VM by esophageal manometry. Initially, protective VM was instituted with use of tidal volume (TV) of 4-6L/kg predicted body weight (PBW), titration of end-expiratory positive pressure (PEEP) to best SR compliance (Crs), target plateau pressure (Pplat) > 30cmH2O, driving pressure in the airways (∆Paw) < a 15cmH2O, driving transpulmonary pressure (∆PL) < a 12cmH2O, deep sedation, use of neuromuscular blocking agents (BNM) and prone position (PP).
+
+On day 4 of invasive VM, after a marked improvement in oxygenation, the sedation levels were reduced in an attempt to initiate the partial ventilatory support phase, with ventilation changed from controlled VM to pressure support ventilation (VPS).
+
+First period of partial ventilatory support
+An attempt was made to titrate PEEP down to optimize the ventilatory strategy. It was observed that higher levels of PEEP did not improve the esophageal pressure oscillation (∆Pes) or ∆PL and even seemed to increase them; thus, low PEEP values were given priority to reduce the stress and mechanical energy applied to the lungs.
+
+On the sixth day of invasive MV, the patient met the classic criteria for weaning; thus, a spontaneous breath test (SBT) was performed with a support pressure level of 5 cm H2O to assess the chance of extubation. The patient failed the SBT after 20 minutes due to hypoxemia.
+
+On the 7th day of invasive VM, due to persistent worsening of oxygenation, a new computed tomography was performed, which showed clear progression of the pulmonary lesion, with the appearance of bilateral diffuse alveolar infiltrate, primarily in pulmonary regions. In this context, it was decided to reinstitute controlled VM and deep levels of sedation.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3166_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3166_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cbec3ddbe7998d5d4f18e07eb2dab5605a837dc7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3166_en.txt
@@ -0,0 +1,2 @@
+49-year-old male with a history of severe bicuspid aortic disease type 1, symptomatic for syncope, angina and dyspnoea, who consulted for progression of dyspnoea from class II to class IV of 3 weeks evolution. The case was interpreted as a secondary retrograde biventricular heart failure due to progression of the underlying disease. On admission to the coronary unit, he was stable hemodynamically, with a negative balance and a good response to intravenous furosemide. In order to determine the appropriate therapeutic conduct, a transthoracic Doppler echocardiogram was performed, which showed a dilated left ventricle with a ejection fraction of 20%, areas of non-compaction of the myocardium from the middle segments to the apex, a pulmonary artery systolic pressure of 51 mmHg, a dilated right ventricle with preserved systolic function, a bicuspid aortic valve with calcified raphé at 2 o'clock and a severe valvular stenosis, with a low flow-low gradient (aortic valve area of 0.8 cm2). The maximum gradient was 23 mmHg and the mean 16.7 mmHg, and the patient also had moderate aortic and mitral insufficiencies and a severe tricuspid insufficiency. The coronary angiography showed coronary arteries without significant angiographic lesions. Subsequently, during the hospital stay, he developed a cardiogenic shock requiring dual inotropic support and continuous infusion of furosemide, with an improvement in the hemodynamic condition. He was evaluated by the cardiac transplant service, which determined, in accordance with the required histocompatibility studies, that the patient had a high probability of rejection of the graft. A stress echocardiogram with dobutamine was performed to evaluate the contractile reserve of the left ventricle, which reported a severe aortic stenosis with a severe deterioration of the systolic function of the left ventricle with contractile reserve. In the presence of a patient with a high surgical risk (EuroScore: 4.76%, STS: 2.47%, ArgenScore: 26) and an increased risk of rejection of the cardiac implant, an interdisciplinary team (Heart Team) was formed between the Cardiology, Cardiovascular Surgery and Haemodynamic services, where the treatment was decided by means of a TAVR. Aortic balloon valvuloplasty No. 25 was performed and, subsequently, a successful and uncomplicated percutaneous implant of a self-expandable aortic valve (CoreValve - Evolut-R®) No. 34, with peak pre- and post-procedural gradients of 41 mmHg and 0 mmHg, respectively).
+In the control ETT, a transaortic prosthesis with normal gradients and no signs of regurgitation was observed, with no changes in the rest of the parameters evaluated. Due to good clinical evolution, the patient was discharged for outpatient follow-up. After 6 months of follow-up, the patient is asymptomatic, with no record of new admissions and no significant changes in the control ETT, although with a decrease in the PSAP to 29 mmHg.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3168_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3168_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..753c14e0d9164c95296d7422507a9b840c9939d8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3168_en.txt
@@ -0,0 +1,21 @@
+A 32-year-old previously healthy female patient from the North Central Province of Sri Lanka presented with gradual onset of visual impairment in both eyes for 2 months. The blurred vision was initially unilateral, involving the right eye, and within the next few weeks, it progressed to involve the left eye. Both near and far visions were impaired, however, her color vision remained unimpaired. It was later associated with persistent, mild frontal headache without aura, photophobia, or focal neurological deficits. There was no redness or pain in the eyes. Over the following weeks, her symptoms progressively worsened to a degree that affected her instrumental activities of daily living.
+
+Eye examination revealed a best corrected visual acuity (BCVA) of 6/36 in both eyes. Fundoscopic examination revealed bilateral cotton wool spots, predominantly over the posterior pole and along the vascular arcades; arteriolar narrowing; venous segmentation; and a few areas of flame-shaped hemorrhages. The pupils were normal in size without evidence of relative afferent pupillary defects. The visual fields and color vision were normal. The rest of the neurological examination results were normal. A fundal fluorescein angiogram (FFA) revealed retinal vasculitis with occlusive retinal arteriolitis and phlebitis.
+
+A total of 2 months after the onset of her initial symptoms, while undergoing evaluation for retinal vasculitis, the patient developed a constellation of constitutional and musculoskeletal complaints. This included low-grade fever (101 °F) with chills, fatigue, and loss of appetite. She also experienced arthralgia, involving both small and large joints bilaterally, without objective signs of joint inflammation. Then, 1 week later, the patient developed an erythematous malar rash and a painless ulcer on the hard palate. It was then followed by bilateral periorbital and ankle swelling, which were worse in the morning.
+
+She did not have a history of chronic cough, hemoptysis, or a past or contact history of tuberculosis. She had no history of valvular or congenital heart disease, and she did not have a history to suggest inflammatory bowel disease. She denied a history of contact with household pets or livestock or recent foreign travel. She also denied high-risk sexual behaviour, unhygienic tattooing, or intravenous drug abuse.
+
+She also did not have photosensitive rashes, increased hair loss, Raynaud’s phenomenon, proximal muscle weakness, sicca symptoms, painful or red eyes, recurrent oral or genital ulcers, neck pain, or limb claudication. She had no symptoms suggesting thyrotoxicosis or diabetes mellitus. She had regular menstruation since menarche. She experienced an uneventful pregnancy 1 year prior. She did not have a history of recurrent miscarriages or intrauterine death. There was no family history of autoimmune diseases. She is a non-smoking teetotaler. She had good family support and no significant psychosocial stressors.
+
+On examination, her body mass index was 19 kg/m2. She was febrile but not pale. There were bilateral erythematous rashes over the malar area of the face sparing the nasolabial folds suggestive of acute cutaneous lupus. Oral examination revealed an oral ulcer over the hard palate of the mouth. She did not have redness in her eyes. Mild periorbital swelling was noted along with bilateral pitting ankle edema. Examination of the neck revealed a few subcentimeter, nontender, enlarged lymph nodes. There were no clubbing or peripheral stigmata of infective endocarditis. None of the joints were actively inflamed, nor were there any joint deformities.
+
+Her blood pressure was 112/78 mmHg, and her pulse rate was 82 beats per minute and regular. The radial, carotid, and femoral pulses were palpable in normal volume, and there were no audible bruits or radio-radial or radio-femoral delays. The rest of the peripheral pulses were palpable. There was no tenderness in the carotid artery. Cardiac examination was normal, with no audible murmurs or pericardial rubs. The lung fields were clear. Abdominal and neurological examinations were unremarkable. There were no genital ulcers.
+
+Rheumatological work-up revealed a high antinuclear antibody (ANA) and anti-double stranded DNA (anti-dsDNA) titers with low complement levels.
+
+The urine-protein-to-creatinine ratio (UPCR) showed a nephrotic range proteinuria. The renal biopsy confirmed class III LN. Blood and urine cultures were sterile. A transthoracic echocardiogram excluded infective endocarditis. A comprehensive workup was undertaken to exclude infectious and inflammatory aetiologies of retinal vasculitis. This included evaluation for Epstein–Barr virus (EBV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), hepatitis B and C viruses, toxoplasmosis, syphilis, and tuberculosis. Additionally, the rheumatologic workup excluded Behçet's disease, antineutrophil cytoplasmic antibodies (ANCA)-associated vasculitis, sarcoidosis, Sjögren's syndrome, and rheumatoid arthritis.
+
+The patient fulfilled the 2019 European League Against Rheumatism/American College of Rheumatology (EULAR/ACR) classification criteria for SLE with a score of 37 points on the basis of the constellation of fever, leukopenia, oral ulcers, acute cutaneous lupus, arthralgia, class III LN on biopsy, low C3 and C4 levels, and anti-dsDNA antibody positivity. Furthermore, the Systemic Lupus Erythematosus Disease Activity Index 2000 (SLEDAI-2 K) score of 29 points, driven by fever, visual disturbance, evidence of vasculitis, proteinuria, inflammatory rash, oral ulcers, low complement levels, and high DNA binding, categorized the disease activity as severe.
+
+The patient was started on pulsed intravenous methylprednisolone (1 g per day) for 3 days followed by oral prednisolone (1 mg/kg/day) with a tapering regime. She was simultaneously treated with hydroxychloroquine (HCQ) and mycophenolate mofetil (MMF) at the discretion of the rheumatology, ophthalmology, and nephrology teams. Treatment resulted in a favorable clinical response within 1 month. The patient experienced an improvement in systemic symptoms and proteinuria, with UPCR falling below 2.5 mg/kg. Additionally, BCVA improved from 6/36 to 6/12 at 2 months, accompanied by a corresponding resolution of retinal changes. A total of 3 months after initiating treatment, the patient achieved disease remission, as evidenced by a SLEDAI-2 K score of two points. Following the initial management, steroid dosages were gradually tapered off. MMF and HCQ were continued for long-term disease control. The patient underwent regular monitoring for HCQ-induced retinal toxicity. At the 1-year follow-up, the patient demonstrated excellent long-term disease control, with significant improvement in vision (BCVA improving to 6/6) and no evidence of HCQ-induced retinal toxicity. Additionally, LN remained in remission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3184_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3184_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..863306b76a1eb05ecec87242cdf7599ccbf57816
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3184_en.txt
@@ -0,0 +1,18 @@
+Past Medical History
+The patient had a longstanding history of occasional exertional chest pain dating back to youth, intensifying over the years with physical activity. Otherwise, the patient was healthy, not taking any medicines.
+Differential Diagnosis
+Differential considerations included the following: 1) myocardial ischemia due to coronary artery disease; 2) coronary artery anomaly; and 3) microvascular angina.
+
+Investigations
+
+1. Coronary angiography: demonstrated a thin, tortuous left main artery with minimal calcification. The left coronary artery showed tortuosity and diminished branching as it formed the left anterior descending artery.
+
+2. Coronary physiology and intravascular ultrasound (IVUS): physiological measurements indicated flow limitation (diastolic flow ratio: 0.88, fractional flow reserve: 0.76). IVUS revealed a half-moon sign, a marker of myocardial bridging (MB).
+
+3. CT angiography: confirmed a deeply tunneled course of the left main coronary artery (LMCA) within the myocardium.
+
+Management (Medical/Interventions)
+The patient was started on a pharmacologic regimen including acetylsalicylic acid 75 mg daily, metoprolol 50 mg twice daily, amlodipine 10 mg daily, and rosuvastatin 40 mg daily. Nitrates were avoided due to potential adverse effects in MB.
+
+Outcome and Follow-Up
+Over 6 months, the patient experienced complete symptom resolution, improved exercise tolerance, and reported reduced chest pain.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3190_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3190_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4b137b75c4cbe41f1cdfd312f4654b7e150ddfdd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3190_en.txt
@@ -0,0 +1,5 @@
+In December 2017, a 50-day-old female Caucasian infant was admitted to the neonatal intensive care unit due to acute bronchiolitis with severe respiratory distress. Multiplex real-time reverse transcription polymerase chain reaction (RT-PCR) analysis on a nasal swab sample for the qualitative detection of RNA was positive for respiratory syncytial virus. Simultaneously, influenza A virus (flu A) and influenza B virus (flu B) infection were excluded with the same method. The girl was the firstborn of unrelated healthy parents who did not suffer from any respiratory illnesses and denied exposure to sick people. The infant was delivered by uneventful vaginal delivery at 37 weeks and three days. The birth weight was 2980 gr (0.29 SDS, 61st percentile). She did not present any health problems in the first days of life, and showed regular physical growth during the first weeks of life.
+
+Two days before hospitalization, the infant presented with a cough, rhinitis, and inappetence. Upon later appearance of respiratory distress, she was conducted to the emergency department. On admission, the girl was afebrile. Physical examination demonstrated severely compromised general conditions, with wheezing, dyspnea, and decreased breathing sounds on auscultation of lungs. Blood tests showed a clinical picture of severe hypercapnic respiratory failure (on capillary blood sample: pH 7.25, PaCO2 71.4 mmHg, HCO3 -31.3 mg/dL, excess base 3.9). Sepsis was excluded. A chest X-ray showed signs of severe respiratory distress. Echocardiography excluded congenital heart defects. The infant was immediately intubated, and conventional mechanical ventilation with synchronous intermittent positive pressure ventilation (SIPPV) was started, with constant monitoring of vital parameters. After placing a central venous line and a nasogastric tube, adequate sedation was provided and total parenteral nutrition was initiated. Simultaneously, inotropic agents (dopamine and dobutamine) were administered to offer support to the cardiovascular system; this strategy was not adopted with the support of targeted neonatal echocardiography (TnEcho), which was unavailable in the neonatal intensive care unit. Antibiotic prophylaxis with cephalosporine and macrolides (ceftriaxone and clarithromycin, respectively) was started. Despite the ongoing invasive ventilatory strategy, the patient’s general conditions worsened with increased O2 demand. After approximately 20 h of conventional mechanical ventilation, high-frequency oscillatory ventilation was started. Nevertheless, blood gas monitoring showed a progressive increase in CO2 level.
+
+On the third day of hospitalization, exogenous surfactant (poractant alfa; Curosurf, Chiesi Farmaceutici, Parma, Italy) was administered via intratracheal instillation, followed by a bronchoalveolar lavage with exogenous surfactant during the next day. Despite the ongoing medical and ventilator strategies, hypercapnia progressively worsened, reaching a capillary PaCO2 level of 123 mmHg. At this point, rescue treatment with whole-body hypothermia (34.0 °C) was started in an attempt to reduce CO2 production. Of note, the infant showed gradual respiratory improvement with a decrease in CO2 level. To further enhance gas exchanges by increasing lung vasodilatation, nitric oxide by inhalation was started. Overall, whole-body hypothermia was maintained for 48 h, with further lowering of capillary PaCO2 level and no side effects. Afterwards, the baby was gradually warmed up by increasing the core temperature by 0.25 °C/h, without detecting a subsequent CO2 increase. High-frequency oscillatory ventilation was maintained for five days, after which SIPPV was started. The need for O2 therapy progressively reduced. Overall, nitric oxide was provided for 10 days. Extubation was performed after 10 days of hospitalization, with a switch to non-invasive mechanical ventilation (high-flow nasal cannula) for two days. Hemodynamic support lasted six days, while antibiotic prophylaxis was discontinued on day nine. During hospitalization, no neurological deficits were observed. To exclude the injury to the central nervous system caused by severe hypercapnia, the infant underwent a brain ultrasound, electroencephalography, and magnetic resonance imaging, the results of which were normal. Overall, after 20 days spent in the hospital, the patient was discharged due to her good general condition. The infant was followed over the next few months without showing any growth or nervous/cognitive disorders.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3200_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3200_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3732666033b218e04f60d0c31d89c621ef5b2d72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3200_en.txt
@@ -0,0 +1,23 @@
+History of Presentation
+A 58-year-old woman presented to the emergency department with palpitations and diarrhea, which had started 1 day before admission. She reported 5 episodes of watery stools, without associated abdominal pain, nausea, or vomiting. The palpitations were of sudden onset, irregular, and not accompanied by chest pain or shortness of breath.
+Upon initial evaluation in the emergency department, her heart rate was 150 beats/min with an irregular rhythm. During subsequent examination, her heart rate stabilized at 80 beats/min. Blood pressure was 138/70 mm Hg, respiratory rate 20 breaths/min, and oxygen saturation 98% on room air. Physical examination revealed no jugular venous distension, and heart sounds were rhythmic without audible murmurs. The rest of the physical examination was unremarkable. At the time of examination, she was asymptomatic.
+An initial electrocardiogram revealed atrial fibrillation with a heart rate of 150 beats/min and a right bundle branch block. Shortly thereafter, spontaneous conversion to sinus rhythm was observed. A follow-up electrocardiogram showed sinus rhythm with a heart rate of 82 beats/min. Pathological Q waves were noted in leads V1 and V2, indicative of prior myocardial necrosis, along with T-wave inversions in leads I, aVL, V5, and V6.
+
+Upon arrival, a bedside point-of-care ultrasound revealed a large, irregular, hyperechoic, spiculated mass within the left ventricle. The chest radiograph revealed calcification within the cardiac silhouette.
+
+Past Medical History
+Her medical history was significant for type 2 diabetes mellitus and hypertension, both diagnosed in 2019 and managed with insulin, metformin, and losartan. However, she admitted to irregular adherence to her prescribed treatments. A review of her health records revealed 2 episodes of non–ST-segment elevation myocardial infarction (MI) in 2019 and 2022, both medically treated. During her 2022 hospitalization for non–ST-segment elevation MI, renal function was within normal limits, with a creatinine level of 0.8 mg/dL. Additionally, there was no evidence of infections, parasitic diseases, or sepsis in her medical history. Unfortunately, no additional medical records or documentation of these events were available.
+The patient had no relevant family history or gynecological/obstetric background.
+
+Differential Diagnosis
+The differential diagnoses for a left ventricular intraventricular mass include thrombus, primary or metastatic tumors, vegetations, intracardiac calcifications, and parasitic infections such as infectious endomyocardial fibrosis.
+
+Investigations
+A transthoracic echocardiogram demonstrated a normally sized left ventricle with a preserved ejection fraction of 56%. However, regional wall motion abnormalities were present, including akinesia in the anterior, lateral, and inferior walls. Mild diastolic dysfunction was also noted. The right ventricle was normal in both size and function. A hyperechoic, irregular mass, previously identified on point-of-care ultrasound, measuring 3 × 5 cm, was located in the apex and lateral wall of the left ventricle, suggesting myocardial calcification.
+
+Laboratory evaluations revealed normal renal function, electrolytes, and calcium-phosphorus metabolism, with calcium at 9.5 mg/dL, phosphorus at 2.8 mg/dL, PTH at 27 pg/mL, and creatinine at 0.9 mg/dL. Liver function tests and stool analysis were unremarkable, and a normal eosinophil count (0.001 K/μL) excluded parasitic infections. Additionally, there was no documented history of severe sepsis.
+Coronary computed tomography (CT) angiography was performed to further evaluate coronary anatomy and the myocardial mass. Interestingly, the coronary calcium score was 0 Agatston units, with no evidence of obstructive coronary artery disease. However, extensive, thick, and irregular subendocardial calcifications measuring 66 mm in length were identified in the inferior, lateral, and apical walls of the left ventricle, extending into both papillary muscles.
+
+Management
+The characteristics of the mass were consistent with dystrophic myocardial calcification. Rehydration therapy was initiated, and the patient did not experience further episodes of diarrhea. Antiarrhythmic therapy and anticoagulation were started because of evidence of paroxysmal atrial fibrillation, likely precipitated by dehydration.
+Hemodynamic monitoring was maintained throughout her stay. The calcification was considered an incidental finding, because the patient exhibited no signs of systolic dysfunction, and her arrhythmia was well controlled. Given that she had been asymptomatic before this hospitalization, a plan for continued medical surveillance was established.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3201_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3201_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ef4964f5282226505523190166df15096f4154db
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3201_en.txt
@@ -0,0 +1,3 @@
+We report the case of a 48-year-old male who was admitted to the hospital with a 4-month history of back and chest pain, as well as persistent cough and white, mucous-like sputum. The patient did not experience other symptoms such as shortness of breath, fever, chills, night sweats, or hoarseness. Physical examination and laboratory tests revealed no significant abnormalities. The patient has no history of hypertension or diabetes and no history of malignant tumors. No history of smoking or alcohol consumption. A Siemens Sequoia probe was utilized for color ultrasound examination. Gray scale ultrasound identified a hypoechoic mass beneath the right pleura, measuring approximately 6.3 × 4.7 cm. The mass appeared quasi-circular with indistinct boundaries and uneven internal echoes, exhibiting a comet tail sign posteriorly. Shear wave elastography (SWE) indicated a mean Young modulus value (Emean) of 7.9 kPa within the mass. CEUS demonstrated enhancement beginning at 14 seconds, with prominent, tortuous blood vessels penetrating the mass. Peak enhancement was observed at 27 seconds, followed by a gradual decrease starting at 1 minute and 12 seconds. Non-enhancing areas and irregular necrosis were evident within the mass. Ultrasound diagnosis indicated a right subpleural hypoechoic mass consistent with a lung tumor. Under ultrasound guidance, percutaneous puncture of the subpleural mass was performed, avoiding large blood vessel branches and necrotic regions. Three tissue samples were obtained for pathological examination.
+
+CT scans reveal multiple clustered soft tissue density shadows in both lungs, exhibiting mild to moderate continuous enhancement upon contrast-enhanced scans, indicative of lung tumors with widespread metastases. Pathological biopsy, alongside morphological and immunohistochemical findings, supports the diagnosis of ACC of the lung.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3208_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3208_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3aeeac2b16f95f49f1dd63283d78e94df259698
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3208_en.txt
@@ -0,0 +1 @@
+A 44-year-old pediatrician who works in Faryab Province in Afghanistan, presented with compressing chest pain and dizziness while suffering a common cold or sometimes during exertion. The patient had experienced the same symptoms previously when he had an upper respiratory infection and exertions. He had no history of heart disease and or smoking with blood pressure of 120/80 mm Hg, heart rate of 86 beats/minute with normal oxygen saturation (SpO2=97%) and BMI of 30.4 and unremarkable physical examination. The patient tested negative for COVID-19, HIV and HBV and presented no abnormalities on abdominal ultrasonography. Chest x-ray, serial electrocardiography and cardiac enzymes were normal. Echocardiography revealed grade 1 left ventricular diastolic dysfunction with normal structural and valves of the heart (EF=60–65%). His blood examinations did not indicate any abnormalities. The patient underwent coronary angiography showing a MB at the mid-LAD with systolic compression with a significant stenosis. The milking effect, (ie, a systolic narrowing of the artery from a significant MB), was identified. To relieve the problem and prevent complications, we prescribed a calcium channel blocker, Diltiazem 60mg per day. The patient tolerated the medication well and remained asymptomatic during two years of follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3226_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3226_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2c27fc0fa9c156d0cec34f532f921562ba0f055
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3226_en.txt
@@ -0,0 +1,9 @@
+A 19-year-old woman (Gravida2, Para1) arrived at our hospital’s delivery and labor unit with significant vaginal bleeding and uterine contractions. There was no documented medical history for the patient. When being examined, the patient appeared healthy. The patient’s temperature was 35.4°C, oxygen saturation was 98%, her heart rate was 92 beats per minute, her blood pressure was 100/60 mm Hg, and her respiratory rate was 16 beats per minute. Trans abdominal ultrasound revealed fetus heart activity in a fetus at 24 weeks gestation; however, a large, heterogeneous, complex cystic mass was seen on the fundus, which was identified as an abnormal placenta with strong suspicion of molar tissue.
+
+A pelvic examination was performed and seen a 4-cm cervical dilation. On admission, the hemoglobin level was 9 mg/dL, and another laboratory test was all normal. She delivered a alive female fetus within 4 hours after admission. The placenta came out with the membrane and a lot of grape-like cystic within 20 minutes after delivery.
+
+The mother’s vital signs were completely normal and stable.
+
+The newborn weigh was 800 grams. Apgar scores were 4. The baby was referred to neonatal intensive care, but she died within 5 hours after delivery.
+
+The histopathology examination of the placenta was diagnosed as a partial mole. The patient was follow-up weekly for 2 months, and laboratory testing showed a b-HCG level of 0 mIU/mL after those time.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3227_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3227_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..95d8ac93f65103b223c94e55cde9758257033217
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3227_en.txt
@@ -0,0 +1,3 @@
+51-year-old woman with a 4-month history of recurrent episodes of oppressive precordial pain, dyspnoea and palpitations. She had coronary risk factors (hypertension, dyslipidaemia and smoking 15 packs/year), but no cardiovascular history. She was febrile (36 °C), with a blood pressure of 110/70 mmHg, heart rate of 72 bpm, respiratory rate of 16 bpm.
+
+The cardiovascular examination was normal. The ECG revealed sinus rhythm and complete right bundle branch block. The two-dimensional transthoracic echocardiogram showed severe pericardial effusion surrounding the entire cardiac silhouette, without cardiac tamponade, and a round mass of 51 mm in diameter, heterogeneous, without flow inside it and without intracardiac protrusion. The magnetic resonance imaging (MRI) confirmed the solid, heterogeneous mass compromising the apex of both ventricles, 46 × 36 × 40 mm, compatible with a pericardial tumour. She evolved haemodynamically stable. A chest, abdominal and pelvic CT scan was performed, which did not show extra-cardiac compromise. The diagnostic coronary angiography did not show significant coronary lesions. The positron emission tomography with fluorodeoxyglucose-18 (PET-CT with FDG) ruled out extra-cardiac metastases. The tumour and the apex of both ventricles were surgically removed, with the placement of a pericardium patch. The resection was incomplete, because the tumour compromised the myocardium. The histological analysis with immunohistochemical techniques reported a primary synovial sarcoma of the pericardium with infiltration of the myocardium (vimentin +, EMA + and CD 99+) and the infiltration of the anterior wall of the right atrium presented an intracavitary protrusion (18 mm × 22 mm) and the infiltration of the interventricular septum showed a spherical mass protruding towards the left ventricle, 8 × 8 mm. The endomyocardial biopsy of the tumour was ruled out due to the risk of embolism and the poor surgical bed due to the history of previous surgery and radiotherapy. She received chemotherapy using liposomal doxorubicin and the echocardiogram at 9 months confirmed the complete resolution of the metastasis. She remained asymptomatic until 2 years later, when she died due to intestinal metastasis.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_323_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_323_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2c9f7c352e65e752db75d4397ed2e1df35974a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_323_en.txt
@@ -0,0 +1 @@
+A 28-year-old Caucasian woman, gravida 4, para 1, was referred to our high-risk obstetric unit at 24 weeks' gestation for fetal ascites detected during a routine ultrasound examination. Her personal and family history did not reveal any pathology of note. Her first pregnancy ended with an intra-uterine death at 23 weeks' gestation caused by chorioamnionitis. In the second pregnancy, a live baby girl was delivered at 40 weeks' gestation. Four years later our patient had a spontaneous miscarriage. Our patient denied any fever, rash, cold symptoms, or joint pain before and during pregnancy. She did not refer to any vaginal bleeding. Laboratory tests for Toxoplasma and rubeola showed negative immunoglobulin M (IgM). An ultrasound examination performed during the consultation confirmed the presence of abdominal ascites . A borderline monolateral dilation of the cerebral ventricle was also seen. Biometry of the fetal limbs was below the mean in relation to gestational age, while cephalic measurements were normal. No other fetal anomalies were observed. Amniotic fluid was present in adequate quantity, but fetal movements were poor. For these reasons, the woman was admitted to our institution for close pregnancy monitoring. During hospitalization, her blood pressure and heart frequency were measured several times during the day, while cardiotocography was performed twice a day. Maternal blood pressure was normal, and there was no proteinuria. Investigation about the etiology of the fetal ascites were carried out, and a fetal paracentesis was also performed. Both parents had normal mean corpuscular erythrocyte volume with no sign of microcythemia and they both had positive blood group Rh without any pathologic antibodies. A routine blood laboratory assessment did not show any kind of abnormalities. Viral serology markers (cytomegalovirus IgG and IgM, parvovirus IgG and IgM) were negative in the maternal blood, and no viral genome was isolated in her amniotic fluid or the fetal ascites sample. The fetal karyotype was normal (46, XY). A Kleihauer-Betke test showed no evidence of fetal erythrocytes in the maternal circulation. Immunologic markers, lupus anticoagulant anticardiolipin, antinuclear, and anti-RO antibodies were negative; G6PD was also excluded. There was no evidence regarding the cause of fetal ascites (then considered non-immune or hydiopatic). Only a mild increase in inflammation indices was noted (VES 40, PCR 7.325); an antibiotic preventive treatment was performed for five days (sulbactam/ampicillin 1.5 mg three times daily, gentamicin 80 mg three times daily, metronidazole 500 mg three times daily). During hospitalization, detailed ultrasound scans were performed at least every two days to monitor the ascites and general condition of the fetus. Fetal middle cerebral artery peak systolic velocity (PSV) was measured to diagnose fetal anemia. Pulsatility index (PI) of either the umbilical artery (UA) or the MCA as well as the resistance index of uterine arteries were assessed to better evaluate the materno-fetal perfusion. Monitoring scans showed a deterioration of fetal condition. Paracentesis was performed at 25 weeks' gestation, but two days later the fetal ascites occurred again. A restriction of fetal growth and progressive reduction of amniotic fluid were also registered. The value of PSV in the MCA was borderline for moderate to severe anemia according to Mari's chart , whereas fetal Doppler ultrasound parameters were normal. At 27 weeks' gestation, a reverse end-diastolic flow in the MCA occurred . This abnormal waveform pattern persisted for all the ultrasound examinations, and it was not associated with other Doppler abnormalities (PI UA 1.15, PI MCA 1.54). The condition was interpreted as 'at risk', and our patient was submitted to closer monitoring. Fetal echocardiography showed cardiomegaly without significant abnormality of heart structures and a mild tricuspid regurgitation. Cardiotocography monitoring showed fetal bradycardia (fetal heart rate 100 beats per minute). Our patient was submitted to fetal magnetic resonance imaging to investigate in particular the brain edema, and this confirmed the presence of fetal ascites without showing any abnormality of fetal cerebral tissue or signs of hypoxia. Corticosteroid treatment (betamethasone 12 mg for two days) was started because of a high risk for preterm delivery. After one week, ultrasound parameters showed a severe decrease in fetal weight (<fifth percentile), an increase in fetal ascites, and subcutaneous edema. The reversed end-diastolic flow in the MCA persisted, and an increase of PI UA was detected. Alterations of ductus venosus waveform appeared, and an inversion of "a" wave was identified. The amniotic fluid index was below the mean for gestational age. The biophysical profile examination was unsatisfactory. The severe prognosis was explained to the couple, and an active intervention was ruled out. The fetus was in breech presentation at this time. Our patient was submitted to an emergency cesarean section at 28 weeks' gestation. A live baby boy in poor general condition was delivered. The Apgar score was one and five. Intubation was necessary, but despite neonatal intensive care, the baby died a few hours after birth. An autopsy revealed a rare malformation of IHBDs known as DPM. No other anomaly was identified.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3259_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3259_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..27086892a46503d493e3ef8bcb0e84bbaffb8926
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3259_en.txt
@@ -0,0 +1,5 @@
+A 47-year-old male developed heart failure due to dilated cardiomyopathy 12 years ago. A cardiac resynchronization therapy-defibrillator (CRT-D; Medtronic® Viva XT CRT-D; AAI 60) was implanted due to VF 7 years ago, and as a bridge to transplantation, a HeartMate II® LVAD was implanted 4 years ago. No arrhythmia developed immediately after LVAD implantation; thus, his CRT-D shock therapy was turned off immediately after LVAD implantation. At the time of LVAD implantation, his transthoracic echocardiographic study showed a significant decrease in the left ventricular (LV) contractility (ejection fraction; 13%), dilation of left ventricle (51 mm in diastole) and trivial aortic regurgitation (AR) without opening of aortic valve but right ventricular (RV) contraction had maintained well relatively (RV fractional area change; 33%).
+
+Eight months after LVAD implantation, the patient developed palpitations and was admitted to our hospital due to repeated VAs necessitating electrical defibrillation. Echocardiography showed the left ventricle diameter did not change, whereas right ventricle volume was slightly enlarged. The repeated VAs were also refractory to various anti-arrhythmic agents, including amiodarone, nifekalant, mexiletine and lidocain, with eventual progression to sustained VF. The hemodynamic compromise due to sustained VF resulted in liver congestion, which was alleviated with a phosphodiesterase type 5 inhibitor, diuretics, and rotation speed optimization (from 8800 to 9600 rpm). These interventions reduced organ dysfunction, suggesting that minimum-required perfusion to vital organs was maintained even under sustained VF. The patient was followed up on an outpatient basis thereafter.
+
+Approximately 2 years after the development of sustained VF, paroxysmal AF was detected on the monitoring records of CRT-D, with a gradually increasing frequency. After 3 years of sustained VF, the patient was readmitted to our hospital due to worsening of symptoms associated with right heart failure and liver congestion (total bilirubin, 3.9 mg/dl). Although his electrocardiogram remained sustained VF, the CRT-D revealed conversion of the sinus or atrial pacing rhythm to persistent AF. Transthoracic echocardiography revealed that fibrillation of the atrium resulted in the disappearance of not only the mitral flow but also the RV outflow tract doppler flow by the atrial kick. Under sustained VF, RV cardiac output is greatly dependent on atrial kick in which the contribution of atrial kick extraordinary enhanced. The hemodynamic study indicated that the pressure wave from the right atrium (RA) to the right ventricle was significantly flattened resulting that the pulmonary artery pulsatility index, which is defined as the ratio of pulmonary artery pulse pressure to right atrial pressure, was markedly decreased. It suggested a marked reduction in blood flow induced by RA contraction in persistent AF as opposed to sinus rhythm. As the incremental rotation speed lead to an increase in RA pressure (RAP) from 19 mmHg to 22 mmHg, the rotation speed was set to 9600 rpm and the right heart congestion was treated with additional diuretics insufficiently and the enhanced level of total bilirubin was prolonged. Until four months later, heart failure was gradually improved and the level of total bilirubin decreased below 2 mg/dl. The monitoring records of CRT-D revealed the recovery of sinus rhythm during previous four months. Although he had remained sustained VF, the recovery of sinus rhythm finely corresponded to the improvement of heart failure and the level of his total bilirubin decreased to 1.2 mg/dl. It intensely corroborated the contribution of persistent AF on the worsening of right heart failure.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3263_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3263_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4dc18c7647b02600d0ba585361b9666687d37704
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3263_en.txt
@@ -0,0 +1,7 @@
+A 66-year-old Japanese man was consulted to our hospital due to the progression of dyspnea and edema in both legs, which had occurred during the previous week. He presented with a low-grade fever (37.4°C by armpit), productive cough and hypoxemia with 94% of percutaneous oxygen saturation in ambient air. He was an ex-smoker (10 cigarettes per day, for 6 years from 20 to 25 years of age), but had no particular past medical history or medications.
+
+The results of the initial laboratory tests showed hypoproteinemia, proteinuria, and moderate renal insufficiency. On electrocardiography, low voltage and a long QT interval were detected. A chest x-ray showed dilation of a cardiac shadow and bilateral pleural effusion. Echocardiography revealed left ventricular hypertrophy (mean wall thickness, 15 mm) and granular high echoic spots at the septum. His plasma brain natriuretic peptide level was increased (448.7 pg/mL; normal range, < 18.4 pg/mL). These typical observations are compatible with amyloid cardiomyopathy.
+
+Percutaneous kidney and endoscopic gastric mucosal biopsy demonstrated Periodic acid-Schiff (PAS)-positive hyalinization in most of the glomeruli and surrounding vessel walls in the kidney and submucosal stroma. These lesions were congophilic, which is considered a signature of systemic amyloidosis. Immunofluorescent (IF) staining revealed strong deposition of IgA and lambda (λ) chain in mesangial regions, but little IgG and IgM deposition, and no kappa (κ) light chain deposition. The amyloid deposits were composed of randomly oriented fibrils with a mean diameter of 10 nm on electron microscopy. Bone marrow aspiration biopsy showed little atypical plasma cell infiltration (<1%) and no evidence of myeloma.
+
+The patient was referred to hematology for further treatment and moved to another hospital for the administration of chemotherapy using melphalan and dexamethasone. After 15-month follow-up from the initial diagnosis, the patient was still alive.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3281_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3281_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0a0a2961189eb4c0ffff62cc85a300be7a0830d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3281_en.txt
@@ -0,0 +1,17 @@
+We present the case of a 54-year-old woman, who attended a general ophthalmology clinic complaining of painless epiphora in the left eye while speaking or eating, with 6 months of evolution. The patient had been diagnosed with Bell’s palsy on the left side one year earlier but recovered from the motor deficit with physical therapy. She had no other relevant medical history.
+
+The ophthalmological evaluation revealed mild weakening of the left orbicularis oculi and frontal muscles without lagophthalmos. No other abnormalities were found, including inflammation of the ocular surface, ectropion, or obstruction of the tear outlet system.
+
+A Schirmer test was performed under topical anesthesia for 5 minutes and the result was 12 mm for the left eye. The same test was then repeated while the patient was chewing, and the result was 23 mm.
+
+All these clues led to the diagnosis of Bogorad syndrome and treatment with botulinum toxin injection in the lacrimal gland was proposed.
+
+Two weeks after the transconjunctival injection of 6 units of botulinum toxin in the palpebral lobe of the left lacrimal gland, the patient reported a decrease in perceived tearing, and 1 month after the treatment there was an almost complete resolution of the complaints.
+
+Schirmer test was repeated under the same previous conditions, and the result was 5 and 12 mm, respectively.
+
+Munk scale was used for epiphora grading and the patient noted a reduction of the symptoms from a score of 4 to 1 with treatment.
+
+The social impact was also assessed using the lacrimal symptom questionnaire (Lac-Q) and a score of 12 and 4 was reported by the patient before and 1 month after treatment, respectively.
+
+Recurrence of the symptoms was detected 6 months after botulinum toxin treatment, and a new injection was performed with similar reported results.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3290_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3290_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c610e77dc0e2bf05d89f036c76566e2eb34addbd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3290_en.txt
@@ -0,0 +1,18 @@
+History of Presentation
+A 50-year-old man with paroxysmal atrial fibrillation (AF) presented to our institution (University of Illinois-Chicago, Chicago, Illinois, USA) for AF ablation and left atrial appendage occlusion (LAAO) device placement. His blood pressure was 138/81 mm Hg, his heart rate was 73 beats/min, his temperature was 37.1 °C, and his oxygen saturation was 99% on room air. He had unremarkable physical examination findings.
+
+Past Medical History
+The patient’s past medical history was otherwise significant for hypertension and coronary artery disease with previous percutaneous coronary intervention to the left anterior descending and circumflex arteries. His CHA2DS2-VASc score was elevated at 2, but he was hesitant to start therapeutic anticoagulation because he was a boxer and occasionally received blows to the head. An performed echocardiogram in 2021 found mild dilatation of the left atrium (LA) and an ejection fraction of 55% by visual estimate.
+
+Investigations
+While evaluating the left atrial appendage (LAA) for LAAO device closure, a transesophageal echocardiogram (TEE) was performed because computed tomography was not performed preoperatively. The TEE appeared to show a membrane covering the ostium of the LAA. Color Doppler imaging did not reveal any flow in or out of the LAA past the membrane. Further imaging with intracardiac echocardiography (ICE) was performed to confirm this finding.
+
+The ICE catheter was advanced into the LA directly, and color Doppler imaging again demonstrated no flow into or out of the appendage through or around the membrane. A force-sensing ablation catheter was advanced under direct ICE and electroanatomical mapping (EAM) visualization, and stable contact and recordable electrograms were confirmed on the membrane. Intravenous ultrasound contrast material was administered, and no contrast flow was noted into the LAA beyond the membrane. For additional confirmation, an iodinated contrast injection at the mouth of the appendage under fluoroscopy demonstrated no connection to the main body of the LA.
+
+Conventional 3-dimensional EAM was then performed of the LA by using a mapping catheter. Appropriate signals were observed from the pulmonary veins. When the catheter was carefully advanced toward the LAA, it could not enter the appendage ostium. Instead, the catheter detected electrical activity. Electroanatomical mapping of the LAA membrane was performed. Notably, the ablation catheter and the high-density mapping catheter detected normal atrial voltage on the membrane. They demonstrated general atrial capture with low output pacing on the membrane, a finding suggesting atrial myocardial tissue.
+
+Management
+The LAAO device was not implanted in the patient because of the presence of the membrane. AF ablation was still performed with successful radiofrequency pulmonary vein isolation. No ablation was performed directly over the membrane. At the end of the procedure, the membrane covering the orifice of the LAA was confirmed to be still intact and completely obstructed flow into the appendage on the basis of color Doppler and repeat bubble study. The patient was then extubated and had an uncomplicated recovery.
+
+Follow-Up
+The patient was in sinus rhythm at 2- and 4-week follow-up visits post ablation and was asymptomatic from the standpoint of AF. The patient did not have any complications after the procedure. He received maintenance oral anticoagulation for the postablation blanking period, with plans to discontinue it afterward.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3296_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3296_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fdd1cad9dff902f07c3700dd7dc5775772113261
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3296_en.txt
@@ -0,0 +1,9 @@
+A 76-year-old Asian female presented with a 5-year history of a slowly enlarging lesion on her left breast and recently noted to have grown more rapidly. She reported no discomfort such as pain, pruritus, or systemic symptoms. Her medical history included hyperlipidemia but no hypertension, heart disease, diabetes, hepatitis, or tuberculosis. She had no personal or family history of skin or breast cancer, no significant sun or radiation exposure, and no history of immunosuppression or arsenic exposure.
+
+Physical examination revealed an elderly female in no apparent distress. Vital signs were stable. Examination of the left breast revealed a pigmented plaque with superficial erosion, measuring 10 mm × 8 mm. The surrounding skin was normal. The rest of the physical examination was unremarkable.
+
+Breast ultrasound scan, computed tomography (CT) scan of the chest, SPECT-CT, and axillary lymph node ultrasound scan identified no evidence of metastasis. Dermoscopic findings of the lesion showed multiple blue-gray globules, spoke-wheel areas, leaf-like areas, and erosions. And we did a pathological biopsy on the patient. The histopathological examination demonstrated nests of tumor cells arising from the surface epidermis. Each tumor nest had a palisading arrangement, and there was a small cleft around the tumor nests, proven to be pigmented superficial BCC.
+
+Considering that the patient was an elderly lady, and the examination results revealed no signs of metastasis, we decided to use standard surgical excision followed by intraoperative frozen pathologic evaluation of margins after a consultation with the patient and her family. The nipple and areola were surgically removed with 10 mm margin and primary closure. We did a postoperative pathologic evaluation as well. The surgical specimen was part of the breast skin, measuring 2.0 × 1.8 cm. The depth of excision was subcutaneous adipose tissue. The intraoperative and postoperative pathologic evaluation were both found to have negative margins.
+
+The patient was discharged on the second postoperative day. Following surgery, nonmedical treatment was employed as clear resection margins were confirmed microscopically. At the 3-month follow-up, the patient remained asymptomatic, with no clinical evidence of local recurrence or metastasis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_330_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_330_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a7ee15936ed920288e436925e5b58ad4db87150b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_330_en.txt
@@ -0,0 +1,11 @@
+A 46-year-old man, former professional athlete, presented with a hypertensive stroke secondary to use of intravenous (IV) drugs, including heroin and cocaine. While admitted to the hospital, it was discovered that he was human immunodeficiency virus (HIV) positive. The patient's stroke resulted in hypoxic-ischemic brain damage leading to severe spasticity. He developed 4/5 bilateral lower extremity spastic diplegia as per the Ashworth scale. Weakness of his right arm and face were additionally noted. The patient's speech was dysarthric but understandable.
+For 7 years poststroke, the patient underwent physical therapy, botulinum toxin injections, and took oral baclofen for his increased tone without relief. The patient was wheelchair bound due to the increased tightness and loss of strength in both of his legs. He was unable to stand up or mobilize independently, and needed assistance with daily activities such as bathing and dressing. The goals of his spasticity management included improvement in mobility and gait, as well as a better range of motion. Unable to achieve these goals with pharmacological treatment, his physiatrist administered an intrathecal test dose of baclofen through a lumbar puncture. A test dosage of 75 ug of ITB was administered. The patient responded positively and underwent surgical implantation of a 40 ml SynchroMed II pump with a T10 level catheter. Postoperatively, the patient did well and was transferred back to inpatient rehabilitation after 48 hours of flat bed rest and IV cefazolin.
+Two weeks postoperatively, the patient developed leakage of CSF from the lumbar incision and was subsequently transferred back to the neurosurgical service. The lumbar incision was oversewn and a lumbar puncture below the level of the catheter was done. A pressure of 24 cm H2O was documented. A computed tomography scan of the head showed mild to moderate ventricular enlargement. The next day, a right frontal Codman ventriculo-pleural shunt was placed. The patient's ventricular CSF did not initially show any bacteria. However, the following day the lumbar puncture CSF grew Staphylococcus epidermidis, sensitive to oxacillin. The patient was placed on IV antibiotics to prevent infection of the newly placed pump.
+After finishing 8 weeks of IV antibiotics, another area of the patient's incision site opened. Subsequently, the patient received a peripherally inserted central catheter line for another round of IV antibiotics. Due to these recurrent infections, it was decided to remove the patient's right-sided pump, and replace it with a new pump and spinal catheter on the left-side of his body. Postoperatively, the patient developed an infection at the abdominal incision site of the second pump, and the device was removed. At this time, the patient developed deep vein thrombosis and sepsis, and received 45 days of IV antibiotics through long-term IV access. Although the HIV was under control and the viral load was undetectable, it was believed that the patient's recurrent infections were due to his immunocompromised status. In addition, his urinary and fecal incontinence may have contributed to recurrent lower abdominal infections, secondary to contamination from his diaper.
+At this time, botulinum toxin injections were re-instituted as the primary treatment for the patient's spasticity: 600 units of botulinum toxin were administered in the adductors, plantar flexors, and hamstrings every 3 months. He reported improvement of his gait 2 weeks after each injection, and experienced maximum effect of the treatment 4 weeks postinjection. The patient was able to walk with a rolling walker; however, he noted difficulty with balance while standing. The effect of the botulinum toxin lasted approximately 2.5 months before wearing off. The patient became septic with a Staphylococcus infection secondary to multiple, recurrent intramuscular botulinum toxin injections.
+At this point, almost all options were exhausted, and the neurosurgeon proposed a SDR. The patient was explained the risks and unknown but potential benefits of SDR. The surgery would reduce the patient's tone, but could make it difficult for him to walk postprocedure if he was currently using his tone to ambulate. The risk of numbness in lower extremities, neurogenic bladder, and CSF leak were also discussed. The patient agreed to the procedure in an attempt to eliminate or decrease the frequency of the botulinum toxin injections.
+The patient underwent selective dorsal rhizotomies at levels L2-S1 bilaterally. Osteoplastic laminectomies were performed from L1 to L5. The dura was retracted laterally. The L2 nerve root on the left was dissected out and confirmed electrically. The nerve root was separated out into the ventral motor and the sensory dorsal portions. Each dorsal sensory nerve was isolated using intraoperative microscopic dissection, and the rootlets were separated into thirds or quarters. Each motor nerve was stimulated, and then each sensory rootlet was stimulated. Rootlets were sectioned if stimulation of the rootlet was associated with clonus and prolonged contraction of the involved muscle groups. This was repeated for L2 through S1 bilaterally based on electrophysiological stimulation and the observed and recorded results. Approximately 50–75% of each dorsal sensory nerve on each side was sectioned.
+Spinal nerve root function was tested in this procedure by recording spontaneous and electrically-triggered EMG activity from iliopsoas, adductor, quadriceps, tibialis anterior, gastrocnemius, biceps femoris, and external anal sphincter muscles innervated by these roots. Portions of these roots were selectively sectioned based on triggered EMG discharge patterns.
+At completion of the dorsal rhizotomy, the dura was sewn closed with a 6–0 Nurolon. The lamina of L1 through L5 was put back into position and laminar fusion was done using the Synthes laminar plating system. An epidural spinal catheter was placed for pain management control. There were no intraoperative complications.
+Postoperatively, the patient did well and was transferred back to inpatient rehabilitation. His spasticity was significantly reduced according to the Ashworth scale. Prior to his SDR, his lower extremity spasticity was 4/5. Postoperatively after SDR, this patient's Ashworth scale is consistently 1/5 bilaterally. The patient experienced no numbness or change in bowel and bladder control postsurgically.
+At the present time, 3 years postsurgery, the patient attends physical therapy twice a week. The patient has no spasticity. Although he still requires assistance to ambulate, he experiences increased comfort due to the reduction of his tone and associated pain. The patient continues to present with lower extremity weakness and cannot stand without support. His muscular strength is about 3/5 in both legs proximally and 2/5 distally. This weakness resulting from the stroke is permanent and cannot be improved via a dorsal rhizotomy, as most poststroke paresis is irreversible after 6 months. His hydrocephalus is well-controlled with his shunt set at 180 mm H2O. His HIV viral load is undetectable. The patient is extremely satisfied with the outcome of his dorsal rhizotomy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3312_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3312_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1d0b494b67a6f68009909cfe025a8a4320327ef6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3312_en.txt
@@ -0,0 +1,5 @@
+A 33-year-old male was referred to our Otolaryngology Department at Welcare Specialty Hospital with complaints of a foreign body sensation in the throat, progressive dysphonia, and choking for two months. The patient has no dysphagia or dyspnea. There is no history of previous intubation, gastroesophageal reflux disease, or other chronic illnesses. There is no history of voice overuse or abuse. He reported no history of smoking and does not consume alcohol.
+
+During the ENT examination, the larynx was examined using a 70-degree rigid laryngoscope, and a polypoid lesion measuring 25×8 mm was found on the posterior commissure of the right vocal cord. The epiglottis, arytenoid cartilage, and postcricoid area were normal. No palpable cervical lymph nodes were detected. No abnormalities were noted in the ear and nose examinations.
+
+The patient underwent surgery to remove the lesion using endoscopy while under general anesthesia. The histopathological examination revealed a polypoid tissue with proliferating blood vessels and inflammatory cells, diagnosed as lobular capillary hemangiomas. The patient returned for a follow-up three months post-operation and showed no signs of recurrence.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3327_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3327_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a237424864fda8f8f24bf788cbef8b5259776d07
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3327_en.txt
@@ -0,0 +1,3 @@
+Mr. RR, a 23-year-old male, presented at the emergency room reporting a week-long period of weakness that had worsened prior to admission, significantly impeding his daily activities. He described a four-month history of recurring, small fluid-filled sacs on the skin. These lesions evolved from reddish patches to rupturing and oozing, accompanied by itching but no pain or fever. He denied experiencing chest pain, shortness of breath, or vomiting but mentioned recent episodes of nausea. Upon examination, he appeared moderately unwell, with normal vital signs and pale conjunctiva. Physical assessment revealed palpable splenomegaly (Schuffner 6) but no lymph node enlargement or cardiac murmurs. Dermatologic examination revealed oedematous urticaria-like plaques, scaling, erosions, excoriations, and crusts all over the body, as well as a ruptured hemorrhagic bulla on the anterior body and left leg.
+
+Complete blood test showed that the White Blood Cell Count (WBC) was 23 × 109/l, the Absolute Neutrophil Count (ANC) was 644 cells/μl, the Hemoglobin (Hb) was 99 g/, and the Platelet Count (Plt) was 28 × 109/l. Bone marrow aspiration consistent with acute lymphoblastic leukemia-L1, led to the diagnosis of acute lymphoblastic leukemia in the patient. The decision for chemotherapy has not been approved by the patient, so patient only received corticosteroids and supportive therapy. At the onset of therapeutic intervention, the patient presented with erythematous patches accompanied by vesicular lesions spanning almost the entirety of his body. Subsequently, platelet concentrate transfusions were administered on the fourth and sixth days of treatment, with a total of eight bags administered on each occasion. On the eighth day of treatment, a histopathological exam showed that the patient had bullous pemphigoid because there was necrotic epithelium and chronic inflammatory cells. The decision to forgo direct immunofluorescent assay (DIF) was predicated upon the patient’s existing thrombocytopenia and heightened vulnerability to bleeding complications. Subsequently, on the twelfth day of treatment, the patient underwent a transfusion of one unit of packed red cells (PRC). Following this, on the thirteenth day of treatment, the patient received two units of PRC and eight units of platelet concentrates. On the fourteenth day of treatment, the patient experienced an abrupt loss of consciousness, preceded by a severe headache and anisocoric pupils. Laboratory findings revealed a post-transfusion platelet count of 7000/ul after eight bags of platelets were administered. Despite continued therapeutic interventions.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3330_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3330_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b545e12a0fbaa042a6cc35d0331cb6970c4db72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3330_en.txt
@@ -0,0 +1,3 @@
+The patient was a 95-year-old woman with a history of basal cell carcinoma in the right zygomatic region, which was surgically removed. She subsequently received radiotherapy for local recurrence. In addition, the patient was under palliative treatment and follow-up for an underlying chronic lymphoid leukemia. The patient presented to the emergency department of the José Carrasco Arteaga Hospital, Cuenca, Ecuador, for a history of increasing pain, pruritus and discharge in the right zygomatic region of a few days of evolution. On physical examination she was in regular general condition, conscious and oriented all three spheres; BP: 110/70, heart rate: 110 bpm, respiratory rate: 20 rpm, temperature: 38°C. A 5×5 cm cavitated lesion with necrotic margins surrounded by edematous hyperemic skin was observed in the right zygomatic-malar region with necrotic margins with foul-smelling purulent discharge and apparent bone involvement. Upon simple inspection, numerous fly larvae were observed embedded at the bottom of the skin cavity. The ipsilateral eye showed conjunctival injection and yellowish discharge.
+
+The patient was readmitted with the diagnosis of myiasis, facial cellulitis and conjunctivitis for administration of intravenous antibiotics and antiparasitic treatment with ivermectin. Surgical debridement was performed with removal of all larvae, whose macroscopic taxonomic characteristics matched those of Cochliomyia hominivorax. Improvement of the lesion under inpatient treatment was observed in the following days. Plastic surgical repair of the cavitated lesion was considered as most probably unsuccessful due to advanced age, increased surgical risk, history of basal cell carcinoma, underlying chronic leukemia and overall poor mid-term prognosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3334_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3334_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..92188d3e6378212d440bdcd4b7cee3ecb3edddb5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3334_en.txt
@@ -0,0 +1,5 @@
+Our patient is a 32-year-old G4P1021 (Gravida 4 Para 1,021–1 term delivery, 0 preterm deliveries, 2 abortions, 1 living offspring) with a body mass index of 37 who initially presented at 8 weeks of gestation for her dating ultrasound, which depicted a fetus in the right uterine horn and an empty left uterine horn. The patient had a known history of a didelphys uterus with two uteri and two cervices diagnosed several years prior on pelvic ultrasound. No additional imaging was obtained to evaluate for renal anomalies, which limited a complete antepartum evaluation, as renal tract malformations are highly associated with Müllarian anomalies. Her obstetrical history was significant for a prior low-transverse cesarean section at full term for arrest of dilation at 1.0 cm, a dilation and evacuation for a fetus with polycystic kidney disease and secondary anhydramnios, and a medical termination of pregnancy. All four of her pregnancies were located in the right uterine horn. Throughout her antepartum course, fetal growth was within normal limits with consistent cephalic presentation.
+
+At 39 weeks 3 days of gestation she presented in early labor at 1.0 cm dilated, 80 % effaced, at −2 station. She denied incisional pain. Her VBAC score was calculated as 35 %. She requested a TOLAC, was counseled appropriately regarding the risks and benefits, and was admitted for labor augmentation. The fetal heart rate tracing on admission was Category I with approximately three contractions in ten minutes on tocometer. She received an epidural and vaginal exam was repeated. A rudimentary cervix was palpated on the patient’s left with a slightly dilated cervix identified on the patient’s right, through which the cervical ripening balloon was placed. Both the uterine and vaginal balloons were inflated with 80 cc of normal saline. Pitocin was also started at that time.
+
+The balloon was in place for 11 h, at which time she was 4.0 cm dilated, 50 % effaced, at −2 station with the cervix still notably on the patient’s right. Her membranes were artificially ruptured at that time for clear fluid. She became fully dilated after 22 h on pitocin. She pushed for 90 min with a Category II tracing secondary to variable decelerations. Right mediolateral episiotomy was cut to expedite delivery of a viable female infant from LOA position with 1-and 5-min APGAR scores of 6 and 9, respectively. Birthweight was 3225 g (25.5th percentile). Retained placenta was manually extracted with a total estimated blood loss of 400 cc. The episiotomy was repaired with 2–0 vicryl in the standard fashion. The patient’s postpartum course was uncomplicated and she was discharged home on postpartum day 2.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3339_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3339_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e29c78fa241999cb94fc6cdf5f05add1e1c5a806
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3339_en.txt
@@ -0,0 +1 @@
+The case we present begins at 5 years of age in a boy who 'eats and sleeps a lot', initially attributed to a sedentary lifestyle. However, at 7 years of age he suffers two episodes of generalized tonic-clonic seizures with altered natremia, which raise the alarm. His first admission concludes a hypothalamic-pituitary axis dysfunction, with no significant findings in the complementary tests. In addition, his behavior, defiant and aggressive for his age, draws attention. After a polysomnography with multiple latency tests at the discharge of his first admission, he is diagnosed with narcolepsy type 1 (without cataplexy, but with low levels of hypocretin-1: 58.2 pg/mL). Thus, the hypersomnolence they attributed to being a 'sleepy boy' is now justified, although the rest of the symptoms of narcolepsy (cataplexy, sleep paralysis and hallucinations) were never present. During the following four years, symptoms and signs of a significant hypothalamic dysfunction are added, including altered thermoregulation (cold skin), hyperprolactinemia, hypothyroidism, stagnation of height and weight gain of 18 kilos in one year, which guide the definitive diagnosis of ROHHAD. The imaging studies with magnetic resonance ruled out structural lesions, as well as neural tumors, with the performance of a 123I-MIBG scintigraphy. Successive polysomnographies showed a deterioration of his quality of sleep, at the expense of hypoventilation during sleep, which could be documented by transcutaneous capnography, which showed a partial pressure of carbon dioxide (pCO2) > 50 mmHg during 72% of sleep and a mean pCO2 of 52.1 mmHg, with significant O2 desaturation in the absence of data of sleep apnoea. For all this, the patient received a multitude of treatments (topiramate, risperidone, levotiroxina, bi-level positive airway pressure at night and strict control of caloric and hydric intake). In addition, immunoglobulins, corticosteroids, rituximab, cyclophosphamide and etanercept were used. Nothing was effective to reverse, or at least stop, the progress of the disease, which in the last admissions associated significant malnutrition (obesity), dehydration, episodes of uncontrollable agitation with self and hetero aggressiveness, which required the use of parenteral nutrition and sedation. Finally, he died at 11 years of age, after six years from the onset of symptoms and four from the diagnosis of ROHHAD.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3347_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3347_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d3f91271b248aa2121ab8552dfc4eec14b655032
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3347_en.txt
@@ -0,0 +1 @@
+A 24-year-old male presented with recurrent pain and swelling in the right knee. He was initially diagnosed with tenosynovial giant cell tumor (TGCT), previously referred to as pigmented villonodular synovitis (PVNS), in 2019 and underwent an open posterior synovectomy at that time. A recurrence occurred in 2021, which was treated with arthroscopic synovectomy. By 2024, the patient reported persistent knee effusion and pain, limiting his daily activities despite prior interventions. On physical examination, there was mild swelling and tenderness over the suprapatellar region, with a restricted range of motion. Ligamentous stability and neurovascular status were intact. Magnetic resonance imaging (MRI) revealed diffuse synovial thickening with nodular features and characteristic low T2 signal intensity, consistent with diffuse TGCT. The imaging demonstrated a large multilobulated Baker’s cyst measuring 3.8 × 10 cm, located posteriorly, consistent with a synovial herniation cyst secondary to intra-articular TGCT. Additionally, MRI revealed synovial thickening adjacent to the medial femoral condyle, with no evidence of direct extra-articular tumor extension. Also, there were cartilage changes in the tibial plateau with minimal focal myxoid degeneration and evidence of small partial-thickness cartilage loss. Axial imaging confirmed the size and extent of the Baker’s cyst. The findings were significant for disease complexity, particularly involving the posterior compartment. The patient underwent arthroscopic-assisted synovectomy under spinal anesthesia. Diagnostic arthroscopy revealed inflamed synovium with cartilage changes in the patella, medial, and lateral compartments. Posteromedial and posterolateral portals were utilized to access the posterior compartment, allowing for thorough visualization and synovectomy. Synovectomy was performed in a systematic, stepwise manner, starting in safer peripheral regions and working toward critical areas to minimize the risk of iatrogenic injury, with careful protection of the neurovascular bundle. This was achieved by maintaining a clear surgical plane, using blunt-tipped instruments, and avoiding excessive dissection near neurovascular structures. The Baker’s cyst, identified as a secondary synovial herniation, was excised by removing its wall and contents to minimize recurrence risk. Postoperatively, the patient started physical therapy to regain knee range of motion. During the two-week follow-up, the patient reported mild residual effusion but was progressing well with rehabilitation. The surgical wound was healing satisfactorily, and there were no signs of infection or complications. Given the diffuse nature of TGCT and the high recurrence rates associated with the condition, the patient was referred to oncology for evaluation. The decision for adjuvant therapy, including radiotherapy or systemic treatment with Pexidartinib, was deferred to the oncology team in consultation with the patient. The options discussed included radiotherapy or systemic treatment with Pexidartinib, a colony-stimulating factor 1 receptor (CSF1R) inhibitor, both of which have shown efficacy in reducing recurrence risk. Ultimately, the choice of adjuvant treatment was left to be further evaluated by oncology during follow-up visits.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_336_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_336_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5c7c34d79fbc2d2d0a9ab7133bf5eef950684f57
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_336_en.txt
@@ -0,0 +1,3 @@
+In April 2006, a 75-year old man who had been successfully treated for colon cancer 13 years ago, thyroid cancer 12 years ago, and was receiving endocrine therapy for prostate cancer from last year was transferred to our hospital for a fracture of his left proximal femur. The chest radiograph showed a solid mass in the hilum of left lung, and the thallium scintigram demonstrated abnormal uptake at the left proximal thigh and the hilum of left lung. In addition, the screening of tumor markers revealed extremely high level of CEA (1250 ng/ml), slightly high level of NSE (16.6 ng/ml) and SCC (2.2 ng/ml), and low level of thyroglobulin (0.3 ng/ml) and PSA (0.009 ng/ml). Thus the fracture was considered to be a bone metastasis from his fourth primary pulmonary cancer. Physical examination showed no hyperpigmentation of his all body surface. Laboratory investigation revealed serum sodium of 134 mmol/l, potassium 4.7 mmol/l, and plasma glucose 110 mg/dl, with normal renal and liver function.
+He uneventfully underwent local excision and proximal femur replacement with a mega-prosthesis under general anesthesia. The bone tumor was pathologically diagnosed to be moderately differentiated adenocarcinoma. Later, the immunohistochemical examination revealed that cytokeratin 7 (CK7) and thyroid transcription factor 1 (TTF-1) were distinctly detected but cytokeratin 20 (CK20) never expressed. Recently, Chhieng et al. described that an adenocarcinoma was likely a primary lung tumor when it was of the CK7 positive/CK20 negative and TTF-1 positive phenotype . Thus, the bone tumor was finally diagnosed to be a metastatic lung cancer.
+The estimated intraoperative blood loss was 400 ml. The patient was extubated as usual, but the level of awakening was very poor. Postoperative laboratory examination demonstrated anemia and severe hyponatremia (126 mmol/l), but showed normokalemia (4.3 mmol/l) and normoglycemia (92 mg/dl). Despite the transfusion of blood and the administration of normal saline, the patient subsequently became hypotensive (SBP 60–70 mmHg), tachycardic, hypoxic, febrile (40.5°C) and confused. Re-intubation was required for respiratory distress. A chest radiograph showed diffuse pulmonary edema. We initially suspected this condition of acute pulmonary emboli. Immediately, the patient underwent CT examination from head to abdomen. Enhanced chest CT revealed a left hilar mass suggesting a primary lung cancer but no pulmonary embolus. A ventilation/perfusion scan performed on the next day showed no perfusion defect and confirmed definitely no evidence of pulmonary embolism. Concomitant brain and abdominal CT scan also demonstrated a low density area in the parietal lobe of the left brain and massively enlarged bilateral adrenal glands consistent with metastases . After the CT evaluation, we finally diagnosed adrenal crisis due to extensive destruction of adrenal tissue caused by metastases. Blood was drawn at 8:00 on the first postoperative day for serum cortisol levels that were found to be 2.0 μg/dl on the third postoperative day. Betamethasone (2 mg) was given to the patient at first, and switched to hydrocortisone, 100 mg administered intravenously every 8 hours. Dramatic improvement occurred in the subsequent hours following administration of hydrocortisone. The fever and hypotension promptly subsided and hyponatremia instantly disappeared. The patient recovered his consciousness and could be successfully extubated. On postoperative day 3, he was started on early remobilization by physical therapy. On postoperative day 7, the patient could sit down on the edge of a bed without assistance, followed by transfer exercise to a wheelchair. Although he could not undergo a CT-guided biopsy of the adrenal gland due to the flat refusal of his family, the following CT examination on postoperative day 35 demonstrated that bilateral adrenal glands neither decreased in size nor showed atrophic change, suggesting that adrenal enlargement was mainly caused by metastasis rather than hemorrhagic complication. The patient was transferred to the related hospital for further rehabilitation on postoperative day 39.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3371_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3371_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ba7509c7800ff43f86360eee980063240c9d9323
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3371_en.txt
@@ -0,0 +1,13 @@
+An 85-year-old menopausal woman was referred to our hospital for diagnostic evaluation of worsening dyspnea over 6 weeks. The patient had a history of chronic atrial fibrillation, hypertension, and chronic kidney disease (CKD) of uncertain etiology. She had a uterine fibroid diagnosed at 64 years of age. Pre-admission medication included amlodipine (10 mg/day), valsartan (40 mg/day), verapamil (120 mg/day), digoxin (0.125 mg/day), and rivaroxaban (10 mg/day).
+
+Her vital signs were as follows: blood pressure 146/97 mmHg, heart rate 90 beats/min and irregular, and respiratory rate 21 breaths/min. Physical examination revealed a third heart sound, diminished breath sounds from the right lower lungs, and notable bilateral leg edema, but no remarkable jugular vein distention (JVD) was observed. A hard mass was palpable in the lower abdomen. The electrocardiogram revealed atrial fibrillation. Chest radiography revealed cardiomegaly and right-sided PE. Laboratory testing revealed elevated levels of serum creatinine (1.36 mg/dL, reference, 0.65–1.07 mg/dL) and brain natriuretic peptide (BNP) (183 pg/mL, reference: < 18.4 pg/mL). Hepatic and thyroid function, C-reactive protein levels, and urinalysis were within normal ranges.
+
+Echocardiography demonstrated normal left ventricular (LV) cavity size and systolic function, with an ejection fraction of 54% and left atrial dilation (35 mL/m2). Doppler and tissue Doppler profiles for the assessment of LV diastolic function revealed a decreased septal e′ of 5.8 cm/sec and an elevated E/e′ of 17, indicating elevated LV filling pressure. In addition, continuous wave Doppler revealed a peak tricuspid regurgitation velocity of 2.6 m/s, consistent with a pressure gradient of 27 mmHg and an estimated right ventricular systolic pressure of approximately 35 mmHg. Echocardiographic evaluation of the right heart revealed almost normal systolic function; tissue Doppler of the free lateral wall (S′) = 9 cm/s (reference: ≥ 10 cm/s), tricuspid annular plane systolic excursion = 18 mm (reference: 16 ≥ mm), and fractional area change = 53% (reference: ≥ 35%), respectively.
+
+Thus, a tentative diagnosis of heart failure with preserved ejection fraction (HFpEF) was made. The patient was administered oxygen at 3 L/min and treated with intravenous loop diuretics (furosemide 40 mg daily). On day 6, although diuretic treatment improved leg edema, PE remained unchanged.
+
+A subsequent diagnostic workup of unexplained PE was performed. The patient underwent thoracentesis with drainage of 1240 mL of serosanguineous PE. PE analysis revealed lymphocyte-predominant exudates fulfilling Light’s criteria. Additionally, the serum-to-effusion albumin gradient was 0.3 g/dL (reference: ≤ 1.2 g/dL), further confirming the true exudative effusion. The adenosine deaminase activity in PE was 9.3 U/L. PE cytology, as well as the bacterial and mycobacterial cultures, were unremarkable.
+
+Chest computed tomography revealed an absence of lung tumors or inflammatory infiltration after the removal of PE. Abdominal/pelvic computed tomography scan revealed bilateral inhomogeneous ovarian masses. Magnetic resonance imaging further characterized the right substantial mass and detected a trivial ascites. Axial and sagittal T2-weighted images demonstrated the peripheral hypointense mass, which contained hyperintense and multilocular areas in the central portion, mimicking a malignant ovarian tumor with a central necrosis or a degenerated subserosal fibroid. Gadolinium-enhanced axial imaging showed inhomogeneous enhancement correspondently on the peripheral solid portion, suggesting malignancy. In addition, screening tests for tumor markers revealed elevated CA-125 levels (382 U/mL, reference: < 35 U/mL). Repeated serial thoracentesis was ineffective, and PE reaccumulated within a week. Thus, we highly suspected of ovarian cancer with pleural dissemination. Nevertheless, a repeated cytological examination of PE revealed no evidence of malignancy, which led us to consider the possibility of MS.
+
+On day 26, the patient underwent bilateral salpingo-oophorectomy. The resected masses exhibited yellow-to-tan fleshy cut surfaces, with hemorrhage and extensive hyaline degeneration. Histopathological examination revealed a mitotically active cellular fibroma (MACF) of the ovary. Spontaneous resolution of the right-sided PE was noted post-operatively after 7 days of follow-up, confirming a definitive diagnosis of MS. A follow-up echocardiography revealed no significant changes. The post-operative course was uneventful, and the patient made a full recovery and was discharged with no changes to her pre-admission medication regimen on day 33. She remained clinically stable upon subsequent follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3375_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3375_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..617c30f2f26808de09118dd546bc5d57125c1354
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3375_en.txt
@@ -0,0 +1,5 @@
+A 53-year-old man presenting with persistent pericardial effusion, a 3-month history of cough, and weight loss of 7.5 kg within 2 years was referred to our hospital. Ten months ago, he had visited a local hospital for periumbilical pain, nausea, and diarrhea, where abdominal computed tomography (CT) scan showed the existence of pericardial effusion. Because of no symptoms of dyspnea or chest pain, the patients did not receive any treatment for pericardial effusion. He coughed in his supine position for 3 months, and then came to our hospital. In addition to severe pericardial effusion, symmetric septal hypertrophy (thickness 18–28 mm), thickened and nonhomogeneous left ventricular walls with irregular echo-density of the myocardium were also detected by echocardiography in our hospital. There was no sign of systolic anterior motion. Heart failure with preserved ejection fraction was considered for the following reasons: Firstly, the symptom of heart failure was supine dyspnea presenting as cough; Secondly, serum level of N-terminal pro-brain natriuretic peptide elevated to 19,005 pg/ml at the admission to our hospital; Thirdly, although the left ventricular ejection fraction was 62%, the left ventricular hypertrophy and diastolic dysfunction, presenting as decreased mitral annular velocity (6 cm/s) in the interventricular septum and free wall, were found. Thus, furosemide and spironolactone were prescribed to him.
+
+Chest CT showed an irregularly shaped and internal necrotic mass (6.0 × 6.9 cm), and multiple enlarged lymph nodes in the anterior mediastinal region. The mass had invaded the pericardium, left ventricular walls, and homolateral superior pulmonary veins. Magnetic resonance imaging (MRI) revealed hypointense signals on T1-weighted sequences, non-homogeneous hyperintense signals on T2-weighted sequences, and late gadolinium enhancement around the mass that was indicative of metastatic disease. Moreover, 18F-Fluorodeoxyglucose positron emission tomography/CT (18F-FDG PET/CT) of the total body revealed increased FDG uptake in the anterior mediastinal mass, multiple lymph nodes, left ventricular walls, and left superior pulmonary veins. Above findings strongly suggested an aggressive and malignant neoplasm arising from the thymus invading into the ventricular, pericardium, left superior pulmonary veins, and multiple lymph nodes.
+
+Due to the superficial location of the thymic mass to the chest wall, CT-guided puncture was performed and specimen was taken for pathological biopsy. Hematoxylin eosin (HE) staining revealed the presence of a number of atypical, pleomorphic cells. Immunohistochemical staining showed the presence of the neuroendocrine markers synaptophysin (Syn), chromogranin A (CgA), the neuronal cell adhesion molecule CD56, and a proliferative index Ki-67 (5%). Thus, the neuroendocrine origin of the thymic carcinoid was confirmed. The patient finally decided to give up further treatment due to personal choice.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3381_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3381_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..87850faeb9846d73ac6b4eec52d49018fb9f1f33
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3381_en.txt
@@ -0,0 +1,5 @@
+A previously healthy 18-year-old girl student unintentionally ingested a large dose (60 mg) of metoclopramide (6 tablets of 10 mg), exceeding the typical therapeutic dosage, for the management of nausea and vomiting. Approximately 6 h after the ingestion of the medication, she experienced dizziness, blurred vision, neck dystonia, and upward deviation of the eyes. Seeing these symptoms and worrying about their child’s physical condition, the parents brought her to the medical center. Following an initial examination during which stable vital signs were observed, the patient was diagnosed with extrapyramidal syndrome and administered 5 mg of biperiden ampoules intramuscularly. However, due to a lack of improvement in the patient’s symptoms, she was subsequently referred to the emergency room of a medical center in northern Iran for additional assessment and treatment.
+
+Upon arrival at the emergency room, the patient exhibited a constellation of symptoms, including neck dystonia, upward eye deviation, abdominal and leg muscle spasms. These clinical signs prompted the initiation of treatment with an intravenous infusion of 5 mg midazolam ampoules over a 6-hour period, as well as intravenous administration of 5 mg biperiden ampoules. Based on these initial management measures, the patient was subsequently admitted to the poisoning ward for ongoing monitoring and care.
+
+After a period of 6 h, the patient’s symptoms improved completely, with vital signs remaining stable and all laboratory tests and electrocardiography yielding unremarkable results. To continue treatment and prevent symptom recurrence, 2 mg biperiden oral tablets were prescribed every 12 h. The patient was discharged from the hospital in a good general condition, with instructions to take 2 mg biperiden tablets twice daily for 3 days. One week after discharge, the patient’s follow-up visit revealed that her vital signs and general symptoms remained stable, with no new complaints or adverse events reported. Written informed consent was obtained from the patient for publication of this case report. This study was conducted according to the Declaration of Helsinki Principles. Also, CARE guidelines and methodology were followed in this study.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_338_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_338_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a824ac553067e05864a53f00dcc49775d46f099
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_338_en.txt
@@ -0,0 +1,47 @@
+A 60-year-old female patient, known case of type-2 diabetes mellitus, began to experience pain and irritation in the left eye after undergoing a left penetrating keratoplasty.
+On examination, the left lid was edematous, and the corneal graft showed edema with buried sutures. An infiltrate of 2 x 1.5 mm and an epithelial defect was observed temporally.
+The visual acuity was limited to finger counting close to the face. Direct microscopy of a corneal scraping revealed septate hyphae, and fungal culture grew A. nidulans.
+The patient was prescribed natamycin 5% and voriconazole eye drop 1% along with oral voriconazole 200 mg for 14 days. However, due to minimal resolution of infection,
+loose sutures were sent to the microbiology lab for a culture that again grew A. nidulans. The infection resolved after two months with an extended voriconazole treatment,
+and there have been no recurrences to date.
+A 65-year-old male farmer presented with diminution of vision and opacity in both eyes. He gave a history of redness and opacity in the right eye three years back and in the
+left eye one month back. The patient had been diagnosed with right anterior staphyloma and corneal melt in the left eye in a private hospital when he referred to our center.
+There was no history of ocular trauma, but a watery discharge and congestion were observed in both eyes. The visual acuity was limited to the perception of light in both eyes.
+The left eye examination revealed a 3x3 mm central corneal thinning. The case was diagnosed with left infective keratitis with corneal thinning and melts.
+The patient was empirically started on vancomycin 5%, tobramycin 1.3%, natamycin 5% eye drops, and oral ciprofloxacin for 14 days. On day 10 of presentation,
+the ulcer in the left eye had a 2.5 x 2.5 mm perforation, for which penetrating keratoplasty (PK) was performed, and an intraoperatively excised cornea was
+sent for microbiological workup. The direct microscopy did not demonstrate any bacterial and fungal etiology. Therefore, the patient was discharged with
+an empirical coverage of vancomycin 5%, natamycin 5%, tobramycin 1.3% eye drops, and oral ciprofloxacin for 7 days and a plan for weekly follow up visits.
+The fungal culture grew A. nidulans after 3 days. However, an oral antifungal could not be started as the patient did not visit the center again and was lost to follow-up.
+A 59-year-old male presented with sudden onset of vision diminution, pain, and redness in the left eye after undergoing cataract surgery five days earlier.
+The visual acuity for distant vision in the left eye was hand movement close to the face. Ophthalmic examination showed conjunctival congestion and the presence of AC cells,
+exudates, and flare in the anterior chamber. A diagnosis of acute post-cataract surgery endophthalmitis was made. Subsequently, an Endophthalmitis Pars Plana Vitrectomy (PPV)
+with intravitreal antibiotic instillation was performed. Vitreous biopsy was sent for microbiological workup, and the patient was discharged with
+an empirical coverage of vancomycin 5%, tobramycin eye drops 1.3% and oral ciprofloxacin for one week. Fungal culture grew A. nidulans.
+However, the patient did not refer for his first follow-up, and an antifungal could not be prescribed. The patient visited the center 18 days later due to the
+deterioration of his condition, and the examination revealed a membrane on the left pupil along with a nasally located fungal ball.
+The patient was operated for PPV with intraocular lens and bag explants, vitreous lavage, and intravitreal voriconazole (100μg /0.1ml) instillation along
+with natamycin eye-drops 5%, and oral voriconazole 200 mg for one month.
+The patient’s symptoms did not mitigate with the given treatment, and a diagnosis of recurrent endophthalmitis was made.
+The PPV was repeated with intraocular lens and bag explants, accompanied with intravitreal amphotericin B (10μg /0.1ml) and vancomycin (1mg /0.1ml) instillation.
+The patient could not visit the center for follow-up due to the COVID-19 pandemic. On teleconsultation, the patient reported left eye discharge, for which he was advised to follow up physically.
+Samples from all three cases were received in the ocular microbiology section. The samples included a corneal scraping and loose
+sutures (from case no. 1); cornea excised in PK procedure (from case no. 2); and two vitreous biopsies (from case no. 3).
+All samples were processed for gram stain, potassium hydroxide (KOH) wet mount, and culture. Sheep Blood agar (5%) and Sabouraud Dextrose Agar (SDA)
+(HiMedia, Mumbai, India) were incubated at 37°C for 18 to 24 h and at 25°C for a minimum of 14 days. Primary microscopy of cases no. 1 and 3 showed thin
+branching septate hyphae with few pus cells . Bacterial cultures were sterile in
+all three cases and SDA grew filamentous fungus between days 3 and 5. The isolation of fungi was considered significant if at least one
+of the following criteria was met: a) observation of fungal elements in primary microscopy and fungal growth in fungal culture medium (b)
+confluent fungal growth on the sample inoculation site . The fungal growth from all samples was initially white cottony and later appeared glabrous. It matured with tan and smoky green alternative rings
+on the obverse and dark brown pigment on the reverse . Lactophenol cotton blue staining showed septate
+hyaline hyphae with short to medium length brown-tinged conidiophores. These conidiophores produced biseriate, flask-shaped vesicles covered by metulae
+and phialides on the upper part bearing round, smooth, green conidia in chains .
+After 10-14 days, large round cleistothecia were observed encompassing asci producing red-brown lenticular ascospores .
+The cleistothecia were surrounded by numerous large, spherical, thick, double-walled hyaline ‘Hulle Cells’ .
+The morphological characteristics of the isolates were confirmed through slide cultures of all the isolates.
+The E-strip method (HiMedia, Mumbai, India) was employed to determine the antifungal susceptibility pattern of all the isolates . Minimum Inhibitory Concentration (MIC) was determined for amphotericin B, posaconazole, itraconazole, and voriconazole using E-test strip.
+All MIC values were recorded 24 and 48 h after the application of strips. The MIC was defined as the lowest concentration preventing
+any discernible growth. presents the results of the antifungal susceptibility test of the three isolates.
+Clinical breakpoints (CBP) were not determined by the Clinical and Laboratory Standard Institute (CLSI) for Aspergillus species.
+Therefore, the results of antifungal susceptibility testing of amphotericin B, posaconazole, itraconazole, and voriconazole were interpreted following
+the ‘modes’ (most frequent MIC) documented for Aspergillus spp. in the M38 document by CLSI .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3391_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3391_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..04deffa2f0c60f0a656b824de1ad7f09bf350fda
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3391_en.txt
@@ -0,0 +1,7 @@
+A 28 year-old male was found to have a slightly increased serum creatinine (1.7 mg/dl) during the admission to ER because of abdominal pain. Since both his past medical history and an abdominal ultrasound performed on admission were unremarkable he was discharged with the indication to see a Nephrologist. At the Nephrology outpatient clinic, because of the reduced eGFR and of the presence of proteinuria (300 mg/24 h), an hospitalization for further investigations was planned.
+
+While waiting for the admission, a couple of weeks later, the patient was admitted to the emergency room in another hospital for abdominal pain and dyspnea. On admittance the ECG tracing performed showed sinus rhythm with diffuse repolarization abnormalities. Further exams revealed an increase of troponin (54 ng/ml) and transaminases levels (GOT 50 U/L; GPT 125 U/L) and a cardiac ultrasound showed a severe left ventricular dysfunction with right heart failure. Patient was thus admitted to the coronary intensive care unit. During his hospital stay the possibility of acute myocarditis was excluded because of the absence of a recent viral syndrome and the negativity of IgM antibodies against the viruses most commonly affecting the cardiovascular system and because of the low inflammatory indexes. An abdominal ultrasound demonstrated abdominal and pleural effusions, regular size and morphology of spleen and liver, no pancreatic changes; both kidneys had normal size but showed irregular margins and a reduced thickness of the cortex, no hydronephrosis nor stones were observed. A magnetic resonance demonstrated an increased volume of the cardiac chambers with a severe reduction of the function of both ventricles (EF20%), however no signs of reduced myocardial perfusion, valvular defects or other tissue changes such as inflammation, fibrosis or edema could be demonstrated. A chest CT scan confirmed the presence of pleural effusion and showed parenchymal atelectasias mainly involving the lower lobes of the lungs. The patient was discharged after 11 days on diuretics (furosemide 100 mg/daily), B-blocker (carvedilol 37.5 mg/daily), acetyl salicylic acid (Aspirin 100 mg/day) and an Ace inhibitor (Ramipril 5 mg/day) with a diagnosis of dilated cardiomyopathy and severe left ventricular dysfunction complicated with cardiogenic shock and anasarca. Few days later an EKG ergometric test revealed no areas of inducible ischemia. A further admission to the Cardiology Unit to define the effect of treatment was performed a week later. Cardiac ultrasound confirmed the left ventricular dysfunction (EF 23%), a coronary angiography was negative and a right chamber catheterism and endomyocardic biopsy demonstrated no specific lesion nor inflammatory infiltrate. The patient was then admitted to our Nephrology Unit, as planned, to evaluate the cause of the chronic kidney disease. On admission the patient appeared healthy and well oriented, his blood pressure was 110/60 mmHg, heart rate 56 bpm, physical examination was unremarkable except for a 1/6 intensity systolic heart murmur better audible on mitral valve area. ECG tracing showed sinus bradycardia. Laboratory studies revealed an increased serum creatinine (1.87 mg/dl), eGFR 48 ml/min/1.73 m2, hypercalcemia (serum calcium 11.5 mg/dl), hemoglobin 15.1 g/dl, sodium 135 mEq/L, potassium 4.37 mEq/L, phosphate 3.1 mg/dl, serum albumin 4.07 g/dl. The patient denied use of vitamin D analogs thus in consideration of the unexplained hypercalcemia other exams were performed. Thyroid hormones, calcitonin, vitamin D, serum ACE, phosphate and calcium urinary excretion rate were all within the normal range. PTH was lower than 3 pg/ml. To rule out multiple myeloma serum protein electrophoresis, serum and urine immunofixation, and spine and skull x-ray were performed and did not show any pathological changes.
+
+Renal biopsy was finally performed without complications and the patient was discharged after 24 h. While waiting for the renal biopsy pathology report, medications were not modified, but for an increase of the dose of furosemide because of the hypercalcemia. The renal biopsy contained eight glomeruli none of which was globally or partially sclerotic and no pathological changes were observed at glomerular level, vessels were also unremarkable. Tubulointerstitium was the only affected compartment with a moderate to severe inflammatory infiltrate, some calcium crystals in the tubular lumen and two granulomas with multinucleated giant cells. No necrosis could be observed within the granulomas. A diagnosis of granulomatous interstitial nephritis due to sarcoidosis was made.
+
+When the patient was called to discuss his kidney biopsy, his serum creatinine had further increased (3.5 mg /dl), eGFR 22 ml/min/1.73 m2 and so had his serum calcium (13.3 mg/dl), serum albumin 4.06 g/dl. For this reason, he was hospitalized again and treated with pulse methylprednisolone (250 mg/day for three days) and then with maintenance dose prednisone (50 mg/day). Serum creatinine decreased in a few days and so did his serum calcium. Since the episode of acute kidney injury the patient has been followed at our unit and at the unit of Cardiology. Renal function returned to normal (serum creatinine 1.1 mg/dl, eGFR 91 ml/min/1.73 m2) and heart function markedly improved over the following two years (EF 49% vs 37% vs 32% vs 23%). The diuretic and cardiologic therapy was significantly reduced to only 25 mg of furosemide and a small dose of beta blocker. The steroid was gradually tapered to 5 mg/day of prednisone for one year and then stopped.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_364_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_364_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eb2b757da661d900da56f6ce4d8a97a2327398ff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_364_en.txt
@@ -0,0 +1,4 @@
+A 53-year-old man presented with increasing dyspnea and a weight loss of 3 kg over a 4-month period. Past medical history was significant for emphysema, seizure disorder and hepatitis C. Medications included albuterol and dilantin. The patient was unemployed and had a 35-pack/year history of smoking. He also reported intravenous heroin abuse 30 years previously (undertaken for a period of 10 years).
+Laboratory results including complete blood count, renal function and liver function tests were all within normal limits. Human immunodeficiency virus (HIV) serology was negative. A chest X-ray showed an ill-defined density close to the right heart border, and a computed tomography (CT) scan confirmed a 4.5 × 2.2 cm opacity in the medial aspect of the right middle lobe, with emphysematous changes and spiculated opacities in both lung fields suspicious for malignant spread. A CT scan of the abdomen and pelvis was unremarkable.
+The patient underwent autofluorescence bronchoscopy and the visualized portions of the upper and lower airways were widely patent with no abnormalities. Ultrasound of the mediastinum using ultrasonic bronchofibervideoscope located the echodensity inferior to the right hilum, and fine needle biopsy of this structure was obtained via endobronchial ultrasound-guided transbronchial needle aspiration. Biopsies were also obtained from four further echodense areas suggestive of malignant lesions involving both lungs.
+The biopsy returned negative for malignancy, and histology from the multiple sites showed bronchial epithelial cells with a marked foreign body giant cell reaction and associated polarizable birefringent foreign bodies . A diagnosis of talc granulomatosis secondary to previous intravenous drug abuse was made. The patient was discharged home and his dyspnea and weight loss were attributed to worsening emphysema in the setting of continued heavy smoking, superimposed on talc granulomatosis, causing deteriorating lung infection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_397_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_397_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5a90b95d641b45bb6bbf53f5ed00375c53274bd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_397_en.txt
@@ -0,0 +1,7 @@
+A 34-year-old Japanese man, with no significant previous medical history, presented to our hospital because of an incidentally detected renal tumor. The patient did not have a family history of RCC or any signs of hereditary RCC syndrome on examination. He did not have any physical and laboratory findings indicating RCC including microscopic hematuria. Contrast enhanced computed tomography (CT) confirmed a 2.5 cm left kidney tumor; it showed the early enhancement and washout typical of a clear cell RCC. Additionally, a retroperitoneal tumor with calcification was identified, the presence of lipid and soft tissue components was confirmed, and a presumptive diagnosis of retroperitoneal liposarcoma was made . Abdominal magnetic resonance imaging (MRI) showed a tumor located in the interaortocaval space with high signal intensity on the T2-weighted images. No apparent metastases were identified.Left partial nephrectomy and resection of the retroperitoneal tumor were performed in September 2003. The pathological diagnoses were clear cell renal carcinoma and retroperitoneal liposarcoma . The excised retroperitoneal tumor was a 6.8 × 4.8 cm well-circumscribed mass. Cut sections of the tumor had a lobulated yellowish appearance. Histological examination revealed the tumor to be composed of a mixture of fibrous tissue and mature-appearing adipose tissues , with the fibrous tissue separation the adipose tissue into regions of varied size. The adipose cells appeared almost mature, but the tumor contained atypical cells with varied size and shape, including a few mono- or mutli-vacuolated lipoblastic cells. The fibrous tissues contained muscle fibers. Few cells were positive for MIB-1 antibody (proliferating cells). The resected renal tumor was 1.6 × 1.6 cm in size, histopathology showed a clear cell RCC circumscribed by a fibrous capsule, classified as G1 pT1a (i.e. less than 4 cm in size and confined to the kidney). Surgical margins of both tumors were negative and no adjuvant treatment was performed. Ten years after the operation, the patient is doing well and has not experienced a recurrence.
+Young patient age can indicate a hereditary RCC syndrome. However, our patient had no family history and clinical signs of tuberous sclerosis, von Hippel-Lindau disease, and succinate dehydrogenase-associated familial cancer.
+We identified five reported cases of concurrent liposarcoma and RCC [–] . Patients age ranged from 58 to 79 years (median 71 years), slightly older than the average age for all RCC patients. The RCC histological subtype was clear cell in 1 case , papillary cell in 3 cases [, , ] and granular cell in 1 case (note: it has recently been shown that “granular cell” type RCC is not an independent histological type). The location of liposarcoma was perirenal [, ] in 2 cases, retroperitoneal [, ] in 2 cases, and cardiac in 1 case (found by autopsy). Although the number of reported cases is small, it is interesting to note that only one case represented the clear cell subtype whereas three cases were diagnosed as papillary cell RCC. In the present case retroperitoneal liposarcoma was located in interaortocaval space and RCC histology was clear cell. Our case and all of the previously reported cases were males, which fits with the male predisposition for RCC.
+In addition to the previously described cases, we found two published case reports regarding liposarcomatous differentiation in chromophobe RCCs [, ]. In contrast, the renal tumor in our case was a typical clear cell RCC, and the two tumors represented distinct entities.
+Over the last 15 years, 1123 patients with retroperitoneal soft tissue sarcoma have been reported in 25 series; these tumors had a mean diameter of 15.7 cm . Retroperitoneal soft tissue sarcomas represent 0.10 to 0.15% of all malignancies and 45% of all retroperitoneal tumors. Because of the localization, symptoms are nonspecific (e.g., abdominal discomfort and palpable mass) and caused by tumor growth, which is typically very large when detected. The only curative treatment modality is complete surgical resection; chemotherapy and radiation therapy show no survival benefit. It has been reported that 51.4% of these tumors can be completely excised and that 50.2% of these excisions include adjacent organs . The prognosis without complete excision is poor with reported 5- and 10-year survival rates of 16.7% and 8.0% respectively .
+Local recurrence represents the major type of progression for retroperitoneal liposarcomas. Yamamoto et al. described 45 patients with well-differentiated liposarcoma who underwent surgical treatment. Among 41 patients who underwent initial surgery, only one recurrence occurred, which was localized in the retroperitoneal space. For 4 patients who underwent a reoperation, the mean time between the initial surgery and the recurrence was 16.5 years. None of the 45 patients developed distant metastasis. In our case, during the 10 years of follow-up to date, no recurrence or metastasis has been detected. However, continued follow-up is necessary because late recurrences are common with liposarcoma.
+Previously reported liposarcomas have demonstrated heterogeneous signal intensity on MRI with great variation depending on the components and histological patterns of a particular tumor. Retroperitoneal liposarcomas have been classified into several clinico-pathological subtypes . Myxoid liposarcoma, consisting of a myxoid matrix and a small amount of mature fat, shows low signal intensity on T1 weighted image and high signal intensity on T2 weighted image . Well-differentiated liposarcoma presented high signal intensity on T1 weighted images, intermediate signal intensity on T2 weighted images, drop-out signal intensity on fat-suppressed MR images . Round-cell liposarcoma and pleomorphic liposarcoma exhibit the signal intensity of a soft-tissue tumor without a characteristic fat signal . Liposarcomas can present with intratumoral hemorrhage and may invade adjacent organs. In the present case, the tumor showed high signal intensity on the T2-weighted images, which is typical for myxoid liposarcoma and is inconsistent with well-differentiated liposarcoma which was diagnosed pathologically. Five-year and ten-year disease specific survival is the highest for well-differentiated liposarcoma (100% and 87%) followed by myxoid liposarcoma (88% and 76%), and is the lowest for pleomorphic liposarcoma (56% and 39%) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_421_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_421_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..afae130d978c602bd6b8832b066375e33d4248f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_421_en.txt
@@ -0,0 +1,2 @@
+A 60-year-old female patient was hospitalized for swelling and pain in the left lower extremity for 5 days. It was reported that, 5 days ago, the patient experienced swelling of thigh, which gradually spread to the lower leg, and increased local skin tension and temperature. The patient had no fever, shortness of breath, chest pain, cough, expectoration, hemoptysis, amaurosis, or syncope; no special relevant medical, family, psycho-social past histories, and no history of chronic lower limb symptoms, even during her previous pregnancy. Deep vein ultrasound of the lower extremity at local hospital reported thrombosis of left common femoral vein, superficial femoral vein, deep femoral vein, popliteal vein, anterior tibial vein, posterior tibial vein, and intermuscular vein for the first time. She had no history of surgery or catheterization. On physical examination, her heart rate was 88 bpm, and blood pressure was 130/74 mmHg. Examination of the left lower limb revealed swelling and edema with moderate tenderness and pain, while the right lower limb was normal. Blood tests revealed normal blood routine and normal liver and kidney functions. Computed tomography angiography (CTA) indicated compression of LCIV by RCIA, narrowed LCIV lumen, thrombi formed from the femoral vein to left external iliac vein, and collateral circulation formed between bilateral external iliac vein . She was diagnosed with DVT along with MTS.
+The patient underwent IVC angiography, filter placement, left iliac vein plasty, and stent implantation under local anesthesia. The right femoral vein was punctured successfully with Seldinger technique and then placed into the catheter sheath. Contrast agent was passed smoothly through IVC without filling defect . The sheath of the filter was transported, and a Cordis Optease filter was placed in the IVC at second lumbar vertebrae , followed by puncturing of the left femoral vein. The catheter sheath was then inserted; angiography revealed severe stenosis of the left external iliac vein and the common iliac vein, and the pelvic collateral compensation was seen through contralateral reflux . A 14 mm - 60 mm balloon was inserted into the IVC through a narrow segment of left external iliac vein and common iliac vein . Then, an E-lunimexx 14 mm - 60 mm self-expanding stent was inserted . The stent was in good position, and the expansion remained satisfactory . The contrast medium was passed through smoothly, and the original stenosis was relieved. At the end of the operation, the sheath of the bilateral inguinal area was removed, and the wound was dressed with a bandage. The patient returned to the ward safely and tolerated well, and was discharged 5 days after the surgery. The patient was prescribed with oral rivaroxaban and aspirin. After 28 days of the surgery, she came back to the hospital for the removal of IVC filter. This procedure was successful. The DVTs were ablated after 4 months of anticoagulation therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_432_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_432_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1bdf9d9283413fe67013028262e759e44edcac2d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_432_en.txt
@@ -0,0 +1,4 @@
+The patient was a 60-year-old male who regularly visited a general practitioner for type 2 diabetes, who performed routine examination to rule out malignant disease. As his serum carbohydrate antigen 19-9 (CA 19-9) level was slightly elevated, abdominal CT was performed, which revealed a unilocular cystic mass of 8.0 cm in diameter, located in the lower right retroperitoneum. He was, therefore, referred to our hospital for surgical treatment.
+The patient had no relevant family history or past history of malignant disease in the abdomen or retroperitoneum. He was asymptomatic and in good health, with the exception of severe obesity with a body mass index of 40. An abdominal examination revealed no tenderness or palpable mass. Laboratory findings showed a high hemoglobin A1c level (7%; normal range 0–6%). The increased serum CA 19-9 levels, which was 43.3 U/mL in the previous hospital, had normalized to 16.9 U/mL at the time of the examination at our hospital. Ultrasonography identified a uniform hypoechoic cystic mass without septum and calcification in the retroperitoneum adjacent to the end of the ileum and appendix, which indicated a hyperechoic region with a debris-like appearance and no obvious nodular lesions or blood flow in the cyst. On enhanced CT, the retroperitoneal cystic mass appeared to be close to the appendix on the ventral side and to the right gonadal vessel on the medial side . Non-enhanced CT was regularly performed by his general practitioner who was managing him or diabetes to rule out a pancreatic lesion, and we also observed the changes of this cystic lesion over the course of three and a half years . The first image showed that the lesion was a 5 cm cystic mass with a uniform high density, with a CT value of 101 Hounsfield Units (HU). The second image, obtained 3 years later, showed that the cystic lesion had grown to 8 cm and that the internal density had decreased, as CT value of 28 HU. Eventually, the cyst diameter increased further to reach 10 cm and the CT value decreased slightly to 20 HU. Based on these clinical findings and the location, retroperitoneal lymphangioma, dermoid cyst and mucinous cystadenoma of appendix were listed as differential diagnoses. After we informed the patient that it would be difficult to make an accurate diagnosis of the retroperitoneal lesion and that malignant transformation could not be denied as a reason for the enlargement, we planned surgical resection rather than careful follow-up.
+Laparoscopic surgery was performed under general anesthesia. The operative procedure began with the insertion of a 1.2 cm umbilical port using Hasson’s technique. Four additional ports were then inserted under direct visualization . The large cystic mass was identified in the retroperitoneal space below the right kidney and firmly adhered to the appendix and mesentery via the retroperitoneum . Due to strong adhesion, the appendix was dissected with a linear stapler and resected en bloc with the cystic lesion . After the lesion was mobilized from the retroperitoneal connective tissue, some feeding vessels from the right gonadal vessel were clipped and cut . The lesion was not associated with the colonic wall or ureter and could be completely dissected without injury to the surrounding organs. The lesion was placed in an entrapment endobag and removed from the abdomen via the umbilical port site. The total operative time was 157 min, and the estimated blood loss was small. Postoperatively, the patient made an uneventful recovery and was discharged home on postoperative day 4.
+The resected specimens consisted of a unilocular cystic tumor of 10 cm in maximum diameter with a smooth inner surface and the appendix . The cystic lesion included a large amount of yellow, turbid serous fluid . Microscopically, hematoxylin and eosin staining demonstrated the smooth muscular layers in the cystic wall, which was consistent with the muscularis mucosae, submucosa and muscularis propria of the gastrointestinal tract without communication with the appendix . Desmin staining confirmed the intestinal wall structure of the muscularis mucosae and the muscularis propria, which are needed to make histological diagnosis of EDC . The lining epithelial cells were positive for Mucin 2, indicating an intestinal-type glandular mucosa . The final pathological diagnosis was IEDC in the retroperitoneal space. There was no histological evidence of malignancy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_445_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_445_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fa82eaa75f779bc7d1a7b7aff12ba5aecf4c4478
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_445_en.txt
@@ -0,0 +1,8 @@
+On the 5th of August, 2020, a 58-year-old woman presented in our emergency department with seizures and hemiparesis. She had a prior fever, malaise, and dry cough a week before admission. She has had a history of hypertension since a year ago. The vital sign is within normal limit except the blood pressure is 170/110 mmHg.
+The results of the laboratory test were high blood glucose 254 mg/dL and HbA1C 6.5%. Leukocytosis with white blood cells (WBC) was 14/L and neutrophil-lymphocyte ratio (NLR) was 33. Increase level of erythrocyte sedimentation rate (ESR) 93 mm/h, D-dimer 21,176 ng/mL, and fibrinogen 446 mg/dL. The result of the reverse transcription-polymerase chain reaction (rt-PCR) test from the nasal swab was observed to be positive for SARS-CoV-2. The completed laboratory results are listed in Table
+Head contrast computed tomography (HCCT) showed cerebral edema at the right parietal lobe . There were hyperdense veins and sinuses at the right parietal lobe area, superior sagittal sinus (SSS), and bilateral transverse sinuses (TS), which suggested the presence of a cerebral sinus venous thrombosis (CSVT) , with a sign of venal hypertension. CT venography (CTV) was also confirmed CSVT at SSS, bilateral TS, and bilateral sigmoid sinus . Furthermore, the thorax CT scan showed ground-glass opacity and subpleural bilateral, with a fibrotic appearance in the left lung .
+During the patient’s treatment of COVID-19, 60 mg subcutaneous enoxaparin was administered twice daily, for 5 days. On the 5th day of treatment, D-dimer was decreased to 2092 ng/ml. The decision was made to continue with enoxaparin until the normal D-dimer or the patient’s negative status for the COVID-19 virus is attained. Other clinical manifestations also improved and the patient was discharged from the hospital on the 10th day.
+The second case, a 72-year-old male, was consulted from the intensive care unit (ICU) because of sudden decreases in consciousness. He had a history of high fever, dry cough, and shortness of breath a week before hospitalization. The patient was being treated as severe COVID-19 with ARDS for 10 days in ICU. He had no previous history of hypertension, diabetes mellitus, or cardiovascular disease. He already received heparin intravenously for 10 days and halted, due to good recovery of shortness of breath and hypoxemia. A day after heparin cessation, the patient suddenly unconscious and intubated due to severe hypoxia.
+Upon examination, his consciousness is coma with a slow response to the light of both eyes. He had hypothermia with a temperature of 35.4 °C, blood pressure of 140/69 mmHg on vasoconstrictor epinephrine support, and 90% oxygen saturation.
+Laboratory test showed, critical increase level of WBC (53.09 × 103/L) and NLR 58.1. We did not do a peripheral blood smear to examine any hematological disorder. Coagulation function tests were APTT 20.2 s, PT 11.9 s, INR 1.11, D-dimer 5.308 ng/mL (previous was > 50,000), and fibrinogen 525 mg/dL. The rt-PCR test from a nasopharyngeal swab sample was negative for SARS-CoV-2 on the 11th day. The laboratory results are listed in Table .
+Head non-contrast computed tomography (NCCT) showed hyperdense at superior sagittal sinus and right transverse sinuses, which suggested the manifestations of CSVT . Furthermore, there was associated cerebral edema at the left frontal, parietal lobe, and cerebellum . Thorax CT scan showed ground-glass opacity and subpleural bilateral with the fibrotic appearance in both lung and pulmonary angiography. Thrombosis at segments 8 and 9 of both lungs was also observed . The pulmonary CT-angiography (CTA) results were pulmonary embolism and thrombosis of both the left and right pulmonary arteries. Due to the massive thrombosis, a decision was made to administer streptokinase and heparin, to the patient intravenously. After 3 days of this treatment, the patient became desaturated (40% oxygen saturation) with spontaneous pneumothorax and passed away the next day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_44_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_44_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1a91d2b591771dfe07d8baca243511d09251bb1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_44_en.txt
@@ -0,0 +1,3 @@
+A 13-year old male presented to an ED with complaints of “frequent eye blinking” and reoccurring episodes of “stiffening and abnormal movements of the hands and neck” and “flickering of the upper lips” that began 24 hours prior to his arrival. About one week prior to presenting at the ED, the patient had been discharged from a psychiatric hospital, and his discharge medications for his mood disorder (Mood Disorder Not Otherwise Specified) included quetiapine 500 milligrams (mg) by mouth (PO) daily (qd) and valproic acid (VPA) 500 mg PO at bedtime (qhs). His dosing regimen of quetiapine for the three months before that hospitalization had been 100 mg qd, and he had not previously been prescribed VPA.
+The patient reported having insufflated two crushed tablets of quetaipine 500 mg on four separate occasions in the previous forty-eight hours. His desire to experience euphoria motivated him to abuse his prescription quetiapine. He reported having not taken his prescribed VPA in three days and also reported that he had not recently used any other medications, supplements, or illicit drugs. His symptoms began two hours after the last insufflation of quetiapine, the episodes of excessive eye-blinking and lip-flickering were intermittent, and the twitching of his eyelids was continuous.
+At the time of presentation, the patient was fully alert and had a Glascow Coma Scale of 15. He was afebrile, tachycardic (115 beats/minute), tachypnic (18 respirations/minute), and had normal oxygen saturation without supplemental oxygen. Physical exam abnormalities included only active twitching of both upper eyelids and bilateral dilated pupils (4/5). During observation in the emergency department, the patient had two myoclonic episodes of the extremities and intense flickering of the eyelids that the patient reported were associated with him turning his head to the right. The episodes lasted about two minutes, and the patient was alert and oriented during the episodes. The patient reported feeling restless and had a constant desire to walk. Results from a 10-panel urine toxicology screen performed at admission were negative for common drugs of abuse, and lorazepam 1.5 mg intravenous (IV) was given to relax the patient. His restlessness worsened, however, and he was admitted for observation and treatment of neuroleptic toxicity. Diphenhydramine 50 mg IV was administered, and he was in stable condition within 24 hours. Quetiapine was discontinued, and the patient was discharged and referred for substance abuse evaluation and treatment. His primary care provider and psychiatrist were notified regarding the medication abuse.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_455_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_455_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..49e35f3e8e53e02aea514a25d3ab59c152ce8011
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_455_en.txt
@@ -0,0 +1,6 @@
+An 11-year-old boy was referred to his dentist for gingival sinus on the buccal side of the right mandibular second premolar.
+The boy experienced intermittent spontaneous pain in the affected part for about 2 mo. His initial dentist referred the boy to our clinic for an incompletely formed root associated with a large radiolucency.
+Any trauma of the tooth was denied by his parents.
+His parents denied any personal and family history.
+The clinical signs were described as follows. Tooth # 45 was free of caries, but there was a sign of a fractured tubercle of DE on the occlusal surface. The tooth mobility was grade I, and there was a gingival fistula on the buccal side. The pyogenic fluids flowed out of the fistula under palpation . Tooth percussion was sensitive. The probing depths of the affected tooth were within a normal range.
+Initial panoramic radiography at his first visit showed that the root of tooth # 45 was fractured. A separated root apex was found apically under the main root and was almost completely formed. The main root remained immature with a thin root wall and was associated with a large radiolucency. However, the root of tooth # 35 was not erupted, and the second primary molar remained. The root development was graded as Nolla 8 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_45_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_45_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c9cc0a91e6558d1f50bd36d1d763647cfd0c6b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_45_en.txt
@@ -0,0 +1,4 @@
+A 63-year-old man was referred to Modarres Hospital, Tehran with gradual onset of obscure generalized abdominal pain six hours before admission. His pain was located in the epigastric and periumbilical region without subsequent radiation to anywhere else with one episode of vomiting.
+Other findings were moderate abdominal distension with periumbilical abdominal tenderness without guarding. Initial blood tests showed white cell count (WBC) of 21.7 × 109/L, neutrophils 84.2%, hemoglobin (Hb) 15.2 g/dL, C reactive protein +2 and amylase 63 U/L. abdominal x-ray and ultrasonography were normal.
+About five hours after resuscitation and appropriate fluid therapy, he has not felt better and blood tests were deranged with WBC of 18.4×109/L, neutrophils 76.5%, Hb 8.1 g/dL and abdominopelvic CT-scan showed evidence of hematoma near the head of pancreas and perihepatic and perisplenic fluid (, ). Because of clinical deterioration with a fall in BP to 95/55 mmHg and rise of pulse to 105/min despite appropriate resuscitation, he was transferred to operating room emergently.
+After midline laparotomy and evacuating massive intraperitoneal hematoma about 2.5 liters, right medial visceral rotation, the Cattell-Braasch maneuver, was performed and an active bleeding in the base of IPDA was detected. IPDA was suture ligated at the base with 4/0 nonabsorbable stitch to achieve hemostasis. The post-operative period was uneventful. Oral fluids were started the day after the surgery and patient was discharged from the hospital two days after the surgery. One week after discharge, he had a normal follow-up without any concerning problem.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_460_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_460_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..89ac9e862d08f48fe53169fce7a943e546e3b6ff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_460_en.txt
@@ -0,0 +1,4 @@
+A 42-year-old male was admitted to our observation with dyspnea, temperature, abdominal discomfort and weight loss. He had previously experienced tuberculosis infection, and his past surgical history was uneventful. The physical examination confirmed epigastric and mesogastric pain. The radiological images demonstrated right fluid pleurical collection with passive collapse of the lung inferior lobe, abnormal lymph nodes of the right internal mammary chain and anterior mediastinum . At the patient admission, we had drained the right symptomatic hemothorax and sent to our pathologists the pleurical fluid for cytology exam. The patient underwent an abdominal CT scan that demonstrated a 7 cm hypodense lesion between segment V and VIII of the liver with minute calcifications, inhomogeneously hypoattenuating relative to the surrounding liver parenchyma. This lesion was surrounded by a very thin capsule showing irregular limits in the cranial portion. The right hepatic lobe showed irregular profile with the presence of diffuse lesions of 0,5-3,5 cm in length, reported along right triangular ligament and subcapsular hepatic region, suspected for hematomas. Hemoperitoneum was also documented . According to the severe clinical condition and the hemodynamic instability, the patient underwent hepatic angiography with selective catheterization of the common hepatic artery, its branches and right diaphragmatic artery. The diagnostic phase of angiography did not document any active bleeding, as well as during the selective coaxial study of the intrahepatic arterial branches of right hemi-system and right diaphragmatic artery. An exploratory laparotomy was finally proposed. At surgery, the hepatic mass, the multiple subcapsular hematomas, and the hemoperitoneum were confirmed . The liver had no signs of cirrhosis. The extemporaneous biopsy showed signs of undifferentiated carcinoma. The surgical procedure consisted in omentectomy, toilette and hemostasis of the peritoneal cavity.
+The histological diagnosis of malignant PEComa is based on the published criteria by Folpe and co-workers. In our case, the tumor is characterized by the proliferation of epitheliod and spindle cells. The neoplastic cells are arranged in small-nests or sheet-like patterns, traversed by a delicate vasculature consisting of a rich network of sinusoid-type blood vessels. The tumor cells showed a round to oval nucleus, often with prominent nucleolus and exhibited high nuclear pleomorphism. The tumor is comprised of a population of large polyclonal cells with abundant cytoplasm. The mitotic index is elevated (> 40 figures per 50 high power fields, HPF) and the coagulative necrosis, a prominent feature, appeared as multiple foci of variable sizes. Microscopically the tumor border was infiltrative.
+For immunohistochemistry on formalin-fixed paraffin-embedded samples, sections were treated with H2O2/3% for 5 minutes to inhibit endogenous peroxidase and then washed in H2O. Antigen was unmasked by treatment with EDTA at pH 9, or with citrate buffer at pH 6 in a microwave oven (two 5-minutes courses). The slices were then held for 20 minutes at room temperature. After washing in PBS/Tween-20, sections were incubated for 30 minutes with the primary antibodies. Then, they were washed and stained with Bond™ Polymer Refine/HRP Detection Kit according to the manufacturer's protocol (Leica, Wetzlar, Germany) or Bond™ Polymer Refine Red Detection Kit (Leica) for HMB-45 an Melan-A. For negative controls, we substituted non-immune sera for the primary antibodies. The immunohistochemistry analysis demonstrated positive staining for Vimentin (Novocastra), Melan-A (Dako), HMB-45 (Dako), smooth muscle actin (SMA) (Dako), MIB-1(Novocastra), and CD31 (Novocastra). It was negative for S-100 protein (Dako), Cytokeratin-AE1/AE3 (CKAE1/AE3) (Novocastra), Cytokeratin-5 (CK5) (Novocastra), CD30 (Dako). Based on this specific immunophenotype profile, diagnosis of PEComa was made . The multiple lesions, suspected to be lymphatic metastasis in the thorax CT images, were not confirmed by a cytology exam of pleurical fluid. Infact, the cytology analysis has documented the presence of leucocytes, red globular cells and rare mesothelial cells, but not tumor cells. It was impossible in our case to confirm histologically the suspected metastatic lesions observed along lymphatic internal right mammary chain, anterior mediastinum, aorta-lung interface and of the lung.
+The immediate post-operative course was uneventful and the patient received supporting therapy with blood and plasma transfusions. PEComa was clinically malignant, leading to a fatal outcome in our experience.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_480_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_480_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f687e2adb35a7c4f8ca146b4bc95e0aaeacddce1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_480_en.txt
@@ -0,0 +1,9 @@
+A 33-year-old Caucasian female was subjected to elective LC for symptomatic uncomplicated GSD. A conventional antegrade cholecystectomy was performed, with no adverse events noted intraoperatively. The postoperative period, however, was protracted with persistent albeit mild-to-moderate abdominal pain and low-grade fever up to 38.3 °C. There was no secretion from the drain positioned in the gall bladder bed. On the 3rd postoperative day, the patient’s complaints resolved partially, and it was decided to discharge her for outpatient observation. Upon removal of the drainage tube, however, spontaneous evacuation of substantial amount of bilious fluid occurred. At this point, bile leakage from the cystic duct was suspected and the patient was referred to our institution for further evaluation.
+At admission, the patient’s general condition was preserved: blood pressure 110/60 mmHg, pulse rate 90/min, no fever. There was mild pain on palpation. Abdominal ultrasonography (US) was performed, which showed non-dilated bile ducts, fluid collection measuring 4/5 cm in the gall bladder bed, a small amount of fluid in the ileocecal region and above the urine bladder. Blood work established: leucocytes—13.3 × 109 (3.5–10.5 × 109/L), Hemoglobin (Hb)—152.0 g/L (120–140 g/L), thrombocytes—492 × 109 (150–450 × 109/L), Erythrocyte sedimentation rate (ESR)—22 mm/h (<15 mm/h), C-reactive protein (CRP)—17.5 mg/L (<5 mg/L), total bilirubin—59.12 µmol/L (7–22.2 µmol/L), conjugated bilirubin—33.2 µmol/L (1.2–7.2 µmol/L), alanine aminotransferase (ASAT)—82 U/L (<40 U/L), aspartate aminotransferase (ALAT)—160 U/L (<40 U/L), gamma-glutamyl transferase (GGT)—183.0 U/L (<52 U/L), alkaline phosphatase (AP)—325.0 U/L (<300 U/L). Urgent endoscopic retrograde cholangiopancreatography (ERCP) was scheduled the same day.
+ERCP was performed under intravenous anesthesia using a combination of fentanyl, midazolam, and propofol. Antibiotic treatment (ceftriaxone 2.0 g i.v.) was initiated. The patient was placed in a supine position. A therapeutic duodenoscope Olympus TJF-160VR (Olympus, Hamburg, Germany) was introduced and placed at the second portion of the duodenum “en face” with the major duodenal papilla. Deep biliary cannulation was achieved using the standard guidewire technique (sphincterotome—TrueTomeTM; Boston Scientific, Marlborough, MA, USA) and 0.035-inch guidewire (JagwireTM straight type, Boston Scientific, Marlborough, MA, USA). Cholangiography was obtained which showed non-dilated common bile duct with complete obstruction at the level of common hepatic duct (CHD) caused by a clip. Despite all efforts, advancement of the guidewire above the stenosis was impossible. It was concluded that the CHD was misidentified as the cystic duct (CD) and transection of the CHD above the clip was suspected (Strasberg type E4 BDI). Based on the ERCP, imaging, and clinical findings, biliary peritonitis following persistent bile leak was anticipated, so the patient was immediately transferred to the Surgical Department for further evaluation.
+Upon laparotomy, biliary peritonitis was established. Inspection of the liver hilum revealed massive injury (probably thermal) of the CHD involving the biliary confluence (confirmed Strasberg type E4 BDI). The clip was found at the distal end of the CHD. Taking into consideration the severe inflammation in this region, immediate repair of the defect and biliary reconstruction was deemed to be hazardous. Instead, two percutaneous biliary catheters (10 fr) were inserted in the left and right hepatic duct to ensure drainage, lavage of the peritoneal cavity was performed, and finally, three abdominal drainage tubes were positioned in the small pelvic area and at the subhepatic space. Since second revision of the abdominal cavity was anticipated, laparostomy was constructed and the patient was transferred to an Intensive Care Unit for supportive care. Re-exploration of the abdominal cavity was performed four days later and found resolved biliary peritonitis with adequate function of the biliary drainage tubes. The patient’s condition improved substantially and she was discharged 3 days later. Readmission was planned in 4 weeks for further assessment and subsequent biliary reconstructive surgery.
+Surgical intervention, however, was delayed by a COVID-19 infection, which was generally mild in nature and treated symptomatically in outpatient settings. Unfortunately, about a week prior to the planned surgery, displacement and spontaneous extraction of the positioned biliary drains occurred. Initially, spontaneous evacuation of bilious fluid through the already maturated external BF was noted. A few days later, though, bile flow seized and the patient noticed darkening of the urine, jaundice, and low-grade fever—37.6 °C. She was immediately admitted to the Department of surgery, where her lab tests showed elevation bilirubin to 82.5 µmol/L, ALAT—64 U/L, GGT—159 U/L, AP—358 U/L, CRP—242.9 mg/L, leucocyte—13.3 × 109/L. Computer tomography (CT) was performed showing dilated intrahepatic bile ducts. Benign strictures of right and left HD were suspected and she was scheduled for surgery. Surprisingly, in the course of hospital admission, jaundice resolved and the patient even noticed normal coloration of the stools, which were persistently pale since the LC. A lab test also showed substantial improvement—bilirubin—33.2 µmol/L, ALAT—34 U/L, GGT—88 U/L, AP—228 U/L, CRP—15.6 mg/L, leucocyte—10.1 × 109/L. At this point, the patient was again referred to Gastroenterology Department for evaluation.
+ERCP was performed in line with the described protocol. Upon transpapillary cannulation, no dynamic in the fluoroscopic finding was noted—non-dilated CBD, with proximal obstruction caused by a clip at the level of CHD. Careful withdrawal of the duodenoscope, however, revealed a fistulous opening at the level of bulbus duodeni with a flow of bile. Bilio-digestive fistula was naturally suspected. The fistulous opening was cannulated using a sphincterotome and a 0.025-inch straight guidewire . A short stricture was noted about 10 mm proximal to the fistulous opening, which was initially hard to negotiate through, but eventually, deep biliary cannulation was achieved. Fluoroscopy showed then a biliodigestive fistula formed between duodenum and the left hepatic duct (LHD), with a high-grade stenosis at the distal end of the duct. Further opacification of the biliary tree revealed an anatomical variation of the bile ducts with the right posterior duct draining into the left hepatic duct (Type 3A according to the intrahepatic duct anatomy classification; see ) . Considering this fact as well as the lack of clinical signs of cholangitis, it was decided that stenting of the left hepatic duct would ensure adequate biliary drainage and might preclude the need for surgery. The stricture was dilated to 8 mm using a biliary balloon dilation catheter (Hurricane Rx, Boston Scientific, Marlborough, MA, USA) and two straight plastic stents were inserted (Endoflex, Hamburg, Germany)—7 fr/6 cm in the 2nd segment branch and 10 fr/6 cm 3rd segment branch . There were no adverse events (AE) defined according to the European Society for Gastrointestinal Endoscopy (ESGE) and American Society for Gastrointestinal Endoscopy (ASGE) guidelines [,]. The patient was discharged 3 days later, with readmission for reevaluation planned six months later.
+At six months, the patient was readmitted and ERCP performed electively. Fluoroscopy revealed significant, though incomplete resolution of the stricture at the level of LHD. Further balloon dilation to 10 mm was performed, with subsequent insertion of 3 straight plastic stents—10 fr/6 cm in the 2nd segment branch, 10 fr/6 cm and 8.5 fr/6 cm in the 3rd segment branch. No ERCP-related adverse events were noted.
+The patient remained symptom-free for the next 12 months. At one year, elective ERCP was performed. Complete resolution of the stricture was found, with one of the stents proximally migrated in the HD (discussed as an AE in ASGE but not ESGE guidelines). All biliary prostheses were removed with a snare, with the migrated stent being extracted using a standard upper endoscope, which was easily introduced through the fistula.
+After one year of follow-up, the woman remains symptom free. Regular blood tests and abdominal US show no signs of biliary obstruction.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_481_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_481_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0125146cf07428829dd855040c162af10e4b597
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_481_en.txt
@@ -0,0 +1,4 @@
+Family screening in a 9-year-old boy by a local paediatric cardiologist suggested a possible diagnosis of familial HCM and he was referred to our paediatric cardiomyopathy clinic. His father suffered from HCM and died 6 years ago in his 3rd decade due to a stroke. The paternal grandfather of the proband and his sister were also diagnosed with HCM. Other affected family members included a paternal uncle and his son as well as a paternal aunt and her son. Genetic testing of the latter family members revealed a mutation in the MYL2 gene {MYL2, c.487G > A [p.(Glu163Lys)]}—. The mutation was classified as likely pathogenic after reviewing mutation type together with a search in scientific databases and literature. More detailed information was not available. A family pedigree is shown in .
+Clinically, he was well and asymptomatic with no signs of congestive heart failure and no history of syncope. His weight was 44.6 kg (93rd centile) and height was 150.5 cm (94th centile); heart rate was 60 b.p.m. and right arm blood pressure was 111/67 mmHg with a mean arterial pressure of 83 mmHg. On auscultation, a 2/6 systolic murmur in the 3rd intercostal space at the left sternal edge was audible. The ECG demonstrated discordant negative T-waves in Lead III and deep S-waves in the septal and anterior leads but based on these ECG findings solely and according to recent international recommendations in athletes, the patient would not have been considered for echocardiography. N-terminal prohormone of brain natriuretic peptide level was 434 ng/L (normal range <112 ng/L). The echocardiogram showed asymmetric septal hypertrophy (maximal wall thickness 18 mm) of the left ventricle (LV) with mild flow acceleration in the mid-LV cavity (peak systolic velocity 2.6 m/s) consistent with HOCM (, Movie clips ). There was no systolic anterior movement (SAM) and no mitral regurgitation. Cardiovascular magnetic resonance was performed and confirmed the diagnosis of HOCM with a maximum wall thickness of 19 mm at the midventricular inferoseptal and inferior level . Left ventricle systolic function was hyperdynamic with LVEF of 80%. Late gadolinium enhancement (LGE) imaging showed an area of patchy LGE at the level of the maximal LV wall thickness . The right ventricle was small for the patients’ age, functioning well, and not hypertrophied. Holter monitoring did not demonstrate significant arrhythmias. Cardiopulmonary exercise testing was carried out for functional and prognostic assessment and showed a reduced exercise capacity for his age with a peak oxygen uptake of 28 mL/kg/min (<3rd centile). Genetic counselling and testing were performed and showed that he carries the likely pathogenic familial variant in the MYL2 gene.
+Risk assessment for the primary prevention of sudden cardiac death was performed using the newly developed HCM Risk-Kids calculator. The estimated risk of sudden cardiac death at 5 years was 7.5%. A team discussion regarding the indication for implantation of an implantable cardioverter-defibrillator (ICD) took place considering genetic findings, family history, and results from the HCM Risk-Kids calculator. The decision was made to recommend ICD implantation and to discuss this with the patient and his mother. In addition, the patient was advised to avoid competitive sporting activities and to have a regular fluid intake. He was allowed to participate in low to moderate recreational activities. Beta-blockade with bisoprolol was started for treatment of the left ventricular outflow tract obstruction.
+The patient is under frequent follow-up in the paediatric cardiomyopathy clinic and is clinically well with no evidence for arrhythmias and no decrease in exercise capacity as shown by recent Holter monitoring and cardiopulmonary exercise testing.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_497_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_497_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c247deeaac32ce4ea2afeb7640b18b9feb6d4ce4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_497_en.txt
@@ -0,0 +1,3 @@
+A 48-year-old woman was admitted to the emergency department with sudden onset severe chest tightness whilst doing yoga. This was associated with pins and needles in both arms, nausea, and abdominal discomfort. It lasted for 1 hour before it self-resolved and was not related to exertion. She reported being under increased emotional stress in the preceding month prior to presentation. She had no significant past medical history and was not on any regular medications.
+She had a mother who died suddenly from an ascending aortic dissection in her 50s. Her mother was not hypertensive and suffered no symptoms or comorbidity suggestive of systemic illness.
+The patient was hypotensive with a blood pressure of 90/60 mmHg and a heart rate of 80 bpm with no respiratory compromise or fever. Her troponin I (high-sensitivity assay) was 54 ng/dl, 79 ng/dl, and 27 ng/dl, respectively. Her electrocardiogram (ECG) showed sinus bradycardia with no ischaemic changes. A CT pulmonary angiogram was performed and excluded pulmonary embolus and showed no other cause for chest pain. An echocardiogram showed preserved biventricular function with no significant valvulopathy and normal ascending aorta dimensions. A coronary angiogram performed on day 2 of admission showed type 1 distal left anterior descending (LAD) coronary artery dissection with thrombolysis in antiplatelets and myocardial infarction (TIMI) 3 flow . She was initially managed with fondaparinux (factor Xa inhibitor) and dual antiplatelets with low-dose beta blocker long term once spontaneous coronary artery dissection (SCAD) was confirmed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_509_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_509_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1d9a7fc97c0e1b9f5bfd431d4cf3bb93e73bfd45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_509_en.txt
@@ -0,0 +1,5 @@
+The patient is a 67-year-old male with a history of hypertension, hyperlipidemia, chronic hepatitis B, and chronic obstructive pulmonary disease secondary to remote smoking. After presenting to an outside hospital with conjunctivitis, elevated intraocular pressure, and hyperthyroidism, he was referred to our clinic and diagnosed with TED. His clinical activity score was 4 in the right eye and 5 in the left eye, with exophthalmometry of 19 OD and 21 OS (a). He was also diagnosed with anterior uveitis secondary to herpes simplex virus and noted to be hepatitis B positive.
+He initially received treatment for his uveitis and hepatitis B since his proptosis was not severe at this initial appointment. However, due to his persistent uveitis and gradually worsening proptosis, he developed a perforated corneal ulcer in the left eye requiring an urgent penetrating keratoplasty and, when deemed safe, an orbital decompression. The patient later developed a corneal ulcer in the right eye and was scheduled for an orbital decompression. However, with the onset of the COVID-19 pandemic, all non-elective cases were canceled, delaying his surgery. While waiting for surgery, he received multiple temporary tarsorrhaphy procedures and initiated teprotumumab. His BMI was low, approximately 16 kg/m2 at baseline. He was not suspected to be diabetic at that time, and because original guidelines did not recommend any labaratory tests except for pregnancy prior to teprotumumab initiation, none were performed. An HbA1c, measured 6 months prior during his initial admission at the outside hospital, was later found to be 6.3%.
+The patient received his first dose of teprotumumab partially alleviating his symptoms. Three weeks later, he received his scheduled 3-wall decompression in the right eye. One day after his surgery, a comprehensive metabolic panel reported a non-fasting blood sugar of 263 mg/dL. This was thought to be due to perioperative conditions, including perioperative steroids. He did not receive any follow-up treatment for his blood sugar elevation. A few days after his surgery, he received his second infusion and 3 weeks later, his third infusion.
+Soon after his third dose of teprotumumab, the patient experienced vomiting and low appetite for 1 week. In the ED, he was found to have a blood urea nitrogen of 70, creatinine of 2.4, and blood glucose level of 1,059 with no ketonuria. His HbA1c at the time of presentation was 11.7%. He was admitted to the hospital with a diagnosis of hyperosmolar hyperglycemic nonketotic syndrome and transferred to the ICU on an insulin drip at 4 units/h. Upon discharge, he was diagnosed with type 2 diabetes mellitus, started on glimepiride, insulin glargine 15 units, and set up with regular endocrine follow-up. His teprotumumab was discontinued.
+At his first follow-up appointment after hospitalization, glimepiride and insulin glargine were discontinued and insulin aspart mixed 70/30 with meals was started (20 units in the morning and 15 units in the afternoon) to improve blood glucose levels, which were in the 250s. Given his known autoimmune thyroid disease, workup was done to assess for autoimmune-mediated diabetes. The insulin autoantibody and anti-glutamic acid decarboxylase 65 antibody were negative, with detectable C-peptide of 3.1 ng/mL, suggesting medication-induced versus type 2 diabetes mellitus. Nine months after hospitalization, his insulin regimen was decreased to 15 units in the morning and 10 units in the afternoon with an A1c of 6.0%. He self-discontinued insulin approximately a year after hospitalization. An A1c performed on no insulin medication was 5.5%. At his latest follow-up, approximately two and a half years after his hospitalization, the patient had an A1c of 6.1% on no diabetes medication. The patient received a bilateral upper eyelid retraction repair and lower eyelid ectropion repair for his residual exposure keratopathy approximately 6 months after his hospitalization (b).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_516_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_516_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fe658b815c738316c183885fac04c4444fe6808d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_516_en.txt
@@ -0,0 +1,5 @@
+A 52 year-old male presented to our institution having undergone local excision of a left breast tumor one month previously. The tumor had measured 7 × 5 cm. The mass had been present for 10 years. At physical examination there was evidence of recent surgery and the patient had a 1 cm ipsilateral axillary lymph node. Serum tumor markers and other routine blood test were normal. The liver ultrasonography, chest X-ray and bone scan were negative for metastases.
+He underwent a modified radical mastectomy. Residual tumor measuring 2.8 cm × 2.6 cm was present. On macroscopic examination the tumor was firm and circumscribed . Microscopy showed the classical features of secretory carcinoma with a microcystic pattern with abundant intra and extracellular secretory material. No tumor was present at the surgical margins. Colloidal iron staining highlighted the secretory material . On immunohistochemistry, the tumor cells were positive for S-100 protein but negative for estrogen and progesterone receptor and HER2 (Dako, Carpinteria, CA). 2 of 24 resected lymph nodes were positive for metastatic carcinoma.
+The case was investigated for the t(12;15) ETV6-NTRK3 translocation using two complementary probe sets . A t(12;15) translocation fusion probe assay and a chromosome 15 NTRK3 gene split-apart assay were used to detect the t(12;15) translocation. All BAC clones used in this study were obtained from the BACPAC Resources Centre at the Children's Hospital Oakland Research Institute. All probes were labeled by nick translation with the use of the manufacturer's recommended protocol (Vysis, Downer's Grove, Illinois). BAC clones RP11-434C1 and RP11-407P10 telomeric to ETV6 on 12p were labeled with spectrum orange. On chromosome 15, RP11-114I9 and RP11-730G13, centromeric to NTRK3 on 15q were labeled with spectrum green and clone RP11-247E14, telomeric to NTRK3 was labeled with spectrum orange. Six-micrometer tissue sections were baked overnight at 60C and then subjected to FISH with a modified protocol (Vysis, Downers Grove, IL) . FISH signals were analyzed with a Zeiss Axioplan fluorescent microscope equipped with a COHU-CCD camera. Images were captures with Metasystems ISIS software (MetaSystems Group Inc., Belmont MA) with seven focal planes stacked for the analysis.
+In view of the nodal metastasis it was decided to treat the patient with six courses of adjuvant 5-fluorouracil, adriamycin and cyclophosphamide (FAC). The patient abandoned treatment after the second course. The patient returned to clinic eighteen months later with two hard nodules in the surgical resection area measuring 8 × 8 cm and 4 cm × 4 cm, (one ulcerated), and three left axillary subcutaneous nodules, two measuring 2 × 2 cm and one 3 × 3 cm .
+A chest CT scan identified pulmonary metastases with a right pleural effusion . The effusion was drained via percutaneous thoracentesis. He then began treatment with concurrent radiation (total dose of 60 Gy) and UFT (Tegafur-Uracil) to the chest followed by systemic UFT as a single agent for 3 months. Post-treatment, there was no change in the pulmonary disease and there was minor response of chest-wall and axillary disease .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_519_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_519_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..617d5d8a3986f9dca407855db7a552274f983be2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_519_en.txt
@@ -0,0 +1,3 @@
+A 67-year-old male patient consulted the emergency department for intermittent back pain and aggravation of exertional dyspnea since 4 months. Physical examination revealed an arterial pressure of 106/82 mmHg, heart rates of 94 beats per minute, and a bilateral lower limb edema. He weighted 79 kg and his height was 181 cm. A rumbling 3/6 heart murmur was heard at the 4th left intercostal space. The biological exams showed a five-fold elevation of high sensitive Troponin-I and a 700-fold elevation of NT-pro brain natriuretic peptide, a moderate renal insufficiency with creatinine clearance rates of 55ml/min.m², and signs of tissue hypoperfusion with lactate level of 2.1mmol/L. The electrocardiogram showed a sinus rhythm and an ST-elevation in the leads V2-V3. The transthoracic echocardiography showed a dilated left ventricle (left ventricular end diastolic diameter of 68 mm) and severely depressed ejection fraction of 29% with a large antero-apical aneurysm which was confirmed by Computerized Tomography Angiography ; a ventricular septal defect measured 8 mm was also visualized . Cardiac index was calculated to be 1.4 L/min/m². Mitral regurgitation was mild (grade I, Fig. A), and right ventricular dysfunction was severe with tricuspid annular plane systolic excursion (TAPSE) of 7 mm. Systolic pulmonary artery pressure was estimated to be 63mmHg. Cardiac magnetic resonance imaging (MRI) confirmed the ventricular septal defect with an estimated ratio pulmonary/systemic flow of 3.6. The extent of transmural infarction in the left ventricle was assessed to be 55%. Coronary angiography uncovered a sub-acute occlusion from the middle of the left anterior descending artery, a chronic occlusion of the ostium of the 3rd obtuse marginal artery as well as a significant stenosis of the right coronary artery. The EuroSCORE II was 30.8%.
+After panel discussion and medical preparation including Levosimendan infusion, a semi-urgent operation was scheduled which consisted of VSR closure, surgical ventricular restoration and right coronary artery bypass grafting. After harvesting of the great saphenous vein, full sternotmy and dividing the dense inter-pericardial adhesions, the heart was put onto cardiopulmonary bypass (CPB) with cannulation of the ascending aorta, and superior and inferior vena cava. The distal ascending aorta was then cross clamped, the right coronary artery bypass grafting was performed using great saphenous vein; left ventriculotomy was thereafter made through apical aneurysm, the demarcation between healthy myocardium and scarred tissue was obvious and there was no involvement of the mitral subvalvular apparatus; a muscular VSD sized 8 mm*10mm was then identified and repaired using bovine pericardial patch; finally, ventricular restoration was accomplished according to the Dor procedure. The first weaning cardiopulmonary bypass was uneventful; however, intraoperative transesophageal echocardiography (TOE) uncovered a severe type IIIb mitral regurgitation (MR, Fig. E) which did not exist preoperatively. A decision of re-clamping was soon made to perform mitral valve plasty using a downsized ring (Edwards Physio II, 28 mm). The subsequent TOE of control showed a trial residual MR with a mean transvalvular pressure gradient of 3mmHg. The second CPB was weaned with multiple inotropic supports but without mechanical circulatory assist. The total aortic cross clamping time and CPB time were 190 and 270 min, respectively.
+The postoperative course was complicated with, in particular, an hypoxemia necessitating a delayed extubation (Day 1) and high-flow oxygen therapy, an acute renal failure requiring continuous renal replacement therapy during 4 days, a sepsis complicating a bacteremia treated with antibiotics over 2 weeks, and a bilateral pleural effusion managed with pleurocentesis twice. Nevertheless, the patient did not present with severe low cardiac output syndrome and the catecholamines were progressively weaned on Day 11. After 30-day stay in intensive care unit and 6 days in the ward, the patient was finally discharged for rehabilitative training. At discharge, transthoracic echocardiography of control showed left ventricular dimension of normal range with an ejection fraction of 40% and cardiac index of 2.4 L/min.m², a good result of mitral plasty with a mean transvalvular pressure gradient of 2mmHg. The TAPSE was assessed to be 12 mm and systolic pulmonary pressure 23 mmHg. During eighteen months following this major operation, he was doing well, the computerized tomography angiography in follow up showed an almost-normal left ventricular morphology , and transthoracic echocardiography of control showed no signs of MR recurrence and a preserved left ventricular ejection of 50%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_520_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_520_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..70f3af4be44251a9ca04b49e3be4be08620ed349
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_520_en.txt
@@ -0,0 +1,2 @@
+A 56-year-old woman was referred to the emergency department due to a severe headache in the frontal area for 2 days before admission. The patient had nausea and vomiting in the morning but had no history of seizures or decreased consciousness. The examination of neurological symptoms was completely normal and showed no symptoms of meningeal irritation. The patient's vital signs were recorded as follows: blood pressure (BP)=130/85 mmHg, heart rate (HR)= 86/min, and temperature (T)=37.3 °C. In her past history, the patient had undergonetympano- mastoidectomy surgery and resection of the cholesteatoma 1 week earlier, and a canalwall down mastoidectomy (CWD) was performed due to right ear cholesteatoma. According to the information obtained from the previous surgeon, microtrauma was inflicted in the dural plate during surgery, but since no significant cerebrospinal fluid (CSF) leak occurred during the procedure, reconstruction was not necessary. After admission, examination and initial evaluation, the Mount Fuji sign was found on the brain CT scan of the patient, but no evidence of brain abscess or intracranial hemorrhage. The patient was immediately admitted to the intensive care unit (ICU).
+Initial treatments such as CBR, 30-degree head elevation, anti-fever therapy, analgesics and oxygen therapy, along with anti-compulsive drug (phenytoin), were prescribed. The patient did not undergo surgery due to a lack of neurological symptoms and a decreased level of consciousness or seizures. However, in the ICU, the patient was maintained under regular and continuous monitoring of vital and neurological signs and level of consciousness. The day after admission, the patient’s headache had completely resolved. The patient was admitted to the ICU for 5 days and was monitored for volume ofpneumocephalus every day with a CT scan. At the end of 5 days, the patient's pneumocephalus was resolved completely, and she was transferred to the ward. The patient was discharged after complete recovery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_521_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_521_en.txt
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index 0000000000000000000000000000000000000000..f133081f07cd5028f0acf7bb9d802fe5ba9a1e3e
--- /dev/null
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@@ -0,0 +1,4 @@
+A 4-month, 20-day-old girl was admitted to the University of Chinese Academy of Science-Shenzhen Hospital on February 8, 2021, with a cough that had lasted six days and a fever for three h. She was a full-term child whose parents were not close relatives. There was no history of radiation exposure, smoking, or drinking during pregnancy. Additionally, there was no history of cold, fever, medication, nontoxic substances, or radiation exposure during early pregnancy. The child was the fourth fetus and second birth in the family. She was delivered vaginally at a gestational age of 39 + 3 weeks with a birth weight of 2.7 kg. During delivery, there was no asphyxia, umbilical cord around the neck, or premature rupture of membranes; the amniotic fluid was clear, and the placenta was normal. Her Apgar scores 1 and 5 min after birth were both 10. She had six fingers on her right hand . Two days after birth, after feeding poorly, moaning for half a day, and developing a fever for 1 h, she was diagnosed with neonatal purulent meningitis, sepsis, pneumonia, and hyperbilirubinemia. Nineteen days after birth, a swollen, dark tumor developed on the child's right thumb. Due to evident ischemia and necrosis, a multi-finger resection was performed, and she was discharged from the hospital 22 days later. She was hospitalized 98 days after birth because she was not eating. Before admission, she ate 20–30 mL per meal, six times a day. On the day of admission, her total milk volume was 50 mL. She was eating 40 mL per meal every 3–4 h 12 days later and discharged.
+Before the present admission, she ate 50 mL per meal every 3–4 h. Physical examination indicated the following: head circumference 34 cm (unchanged from birth), body temperature 37.8 °C, pulse 146 per min, respirations 42 per min, blood oxygen saturation 95%, weight 4 kg (< 3rd percentile), and body length 53 cm (< 3rd percentile) . The fontanels were open. Her development was delayed (neck muscle weakness; could stand for 1 min, head height < 3rd percentile, could not support chest and abdomen for one minute on elbows). The pursuit of sounds and objects was normal. She was conscious, had an auricle deformity, warm limbs without cyanosis, and CRT 1.5 s. The patient has no cleft lip/ palate. Her sucking force was inferior, and muscle strength in both arms was slightly reduced, but both legs were normal and she could move her legs freely. The physiological reflexes were present, and no pathological reflexes were elicited. Brain magnetic resonance imaging (MRI) indicated an abnormal signal in the bilateral occipital subarachnoid space, suggestive of leptomeningitis or subarachnoid hemorrhage. Considering the possibility of an abscess, an enhanced MRI was performed. There were no apparent abnormalities in brain ultrasound or MRI of the head . Color Doppler echocardiography showed a continuous 2.7 mm interruption in the middle of the atrial septum . Re-examination was recommended after one year of age to rule out a patent foramen ovale. The systolic and diastolic functions of the heart were normal.
+Due to the postnatal growth and psychomotor retardation, auricle deformity, microcephaly, polydactyly, cardiac abnormality, and feeding difficulties, low-depth genome sequencing was performed at Shenzhen Huada Gene Research Institute with the consent of her family . This showed SEQ (grch37) del (8p21.2p11.22) chr8. A 12 MB pathogenic fragment, G.27228261–39230720del, was from an unknown source. The comprehensive ClinGen CNV score was ≥ 0.99, indicating a pathogenic lesion. The parents' and older brothers’ chromosomes were normal.
+As a result of the chromosomal disease, the patient's postnatal growth and development were delayed, and she had muscle weakness, insufficient food intake, and severe pneumonia. As she was weakly positive for Mycoplasma, she was given erythromycin and atomization treatment. Her cough improved with rehabilitation and physiotherapy. At discharge, she could hold her head up, remain upright for 2–3 min, and support her chest and abdomen on her elbows for a few minutes. She consumed 50 mL of milk every 3–4 h.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_525_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_525_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d0c6a3f48eede43e0ceca8414dd58af73a1c436
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_525_en.txt
@@ -0,0 +1,5 @@
+A 29-year-old female, gravida 3 para 2, was referred to our hospital at 13 weeks of gestation for suspected fetal abdominal wall anomaly. Ultrasound scanning revealed cauliflower-like intestinal loops floating freely in the amniotic fluid, suggesting gastroschisis. There was neither polyhydramnios nor bowel dilatation of the fetus. At 36 weeks’ gestation, a premature male baby weighing 1600 g was born by vaginal delivery with an Apgar score of 8 and 8 at 1 and 5 min, respectively. The baby was immediately referred to our neonatal intensive care unit due to evisceration of the stomach and small bowel through a paramedian full-thickness abdominal wall defect . As severe intestinal edema prohibited primary abdominal wall closure, the baby underwent a staged closure of the abdomen using a silo. Then, the Applied Alexis wound protector and retractor system (Applied Medical Resources Corp, USA) was used for wrapping and reducing the eviscerated bowel .
+On the 10th postnatal day, the silo was removed and definitive fascial closure was completed by suturing after placing the eviscerated organs into the abdominal cavity.
+After abdominal closure, mechanical ventilation was ceased the following day, and enteral feeding was started on the 7th postoperative day. The pace of enteral feeding increase appeared slow, and the baby showed frequent vomiting with increases in feeding dosage. Upper gastrointestinal series performed on day 51 revealed a sliding hiatal hernia, accompanied by marked GER , and hiatal sliding hernia was also confirmed by computed tomography . The baby was managed by gradual increase in oral intake and postcibal positional therapy, and anti-acid drugs. On the 81st postnatal day, the baby was discharged, with a weight of 3040 g, and the ability to tolerate an oral diet.
+In spite of continuous conservative management, he began to show frequent vomiting, a failure to thrive, and hematemesis at the age of 8 months. Esophageal pH monitoring of the distal esophagus revealed frequent GER. The percentage of total time with pH less than 4 was 58.2%. A laparoscopic fundoplication was done on the 290th postnatal day, when patient’s body weight was 6500 g.
+The first trocar was inserted in the left upper abdomen using Hasson’s method. A laparoscopic view showed a moderate space in the upper abdominal cavity with dozens of fibrous bands connecting the stomach, bowels, liver, and abdominal wall to each other . No adhesion was seen beneath the umbilicus. The second trocar was inserted at the umbilicus, and 3 other ports were added in the usual manner by dissecting several adhesive bands. The herniated upper portion of the stomach and abdominal esophagus could be easily reduced back into the abdomen using forceps with no remarkable tension. After the dissection of the moderately thickened phrenoesophageal ligament, the right and left crus of the diaphragm were cleared. The large hiatal opening, about 3 cm in diameter , was closed around the esophagus with 3 interrupted 3–0 braided polyester sutures . Thereafter, a short and floppy 360° fundic wrap was constructed . The wrap on the stomach was hitched to the bilateral cupolas of the diaphragm. The operation time was 308 min including umbilical reconstruction, and there was little blood loss. The patient’s postoperative recovery was uneventful, and he was discharged without incident on postoperative day 7. Postoperatively, vomiting ceased and an upper gatrointestinal examination revealed no signs of GER. He is now 8 years old and has remained asymptomatic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_529_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_529_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74d6753045f197d9817653373495cbf4da0d26e1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_529_en.txt
@@ -0,0 +1,6 @@
+A 48-year-old woman (III-8, a sister of the proband from this HLRCC family) underwent abdominal ultrasonography annually at a local clinic after 2007, and presented with a left renal mass detected by an ultrasonography and was introduced to our hospital in March 2013 (Additional file : Figure S1).
+She had undergone enucleation myomectomy for uterine leiomyomatosis at the age of 29 years at another hospital, while hysterectomy had been performed for recurrence large uterine leiomyomatosis at the age of 39 years at other hospital. In 2007 (when she was 40), her sister was diagnosed with HLRCC having a novel FH mutation at 241,671,938 bp (C574T) by direct sequencing of the FH gene from leukocyte DNA. Her sister subsequently died of HLRC-associated advanced renal cancer. In 2007, sequencing of DNA extracted from blood cells of this patient confirmed that she also had the same FH mutation as her sister . After 2007, we recommended that 13 members of this family with the FH mutation should receive active surveillance by annual imaging (abdominal plain computed tomography (CT) or ultrasonography) at a convenient clinic .
+Laboratory tests revealed moderate anemia (hemoglobin: 9.3 g/dl) and elevation of serum C-reactive protein (CRP: 3.19, normal < 0.3 mg/dl). Karnofsky performance status (KPS) was 100 %. Plain CT scans obtained at our hospital showed a left renal tumor with a diameter of 7 cm and involvement of multiple regional para-aortic lymph nodes, but no distant metastases (cT3aN1M0) . Positron emission tomography (PET) showed fluorine-18-deoxyglucose (FDG) accumulation in the renal tumor and the metastatic lymph node and the maximum standardized uptake value (SUVmax) was 15.3 and 7.5, respectively .
+Her risk classification for renal cancer was intermediate risk according to the Memorial Sloan-Kettering Cancer Center (MSKCC) criteria. However, the prognosis of patients with HLRCC-associated renal cancer, in particular those with extrarenal involvement, is extremely poor. Furthermore, her tumors showed a different imaging pattern from that of typical clear cell RCC (Additional file : Figure S1), and the histology of the renal cancers in her relatives was non-clear cell RCC (undifferentiated RCC in her mother, pRCC2 in both her sister and maternal cousin). Thus, the tumor of this patient seemed likely to be non-clear cell carcinoma, but we did not perform needle biopsy to avoid dissemination of cancer cells.
+In order to decrease the tumor burden and improve the feasibility of surgery, we selected preoperative treatment with a multi-targeted tyrosine kinase inhibitor (TKI). In comparison to first-generation TKIs targeting the VEGFR, axitinib is a potent second-generation inhibitor of VEGFRs with a higher affinity for tyrosine kinase and achieves stronger inhibition of kinase activity with fewer adverse effects such as thrombocytopenia. Additionally, first-generation inhibitors block other targets, such as PDGF receptors (PDGFR), KIT (cluster of differentiation 117: CD117), b-rapidly accelerated fibrosarcoma (RAF), and Fms-like tyrosine kinase 3 (FLT-3), which are not substantially inhibited by axitinib. These off-target activities might contribute to the adverse effects of the first-generation inhibitors, suggesting that more specific inhibitors of VEGFR such as axitinib might have an enhanced therapeutic window. We recently successfully treated a patient who had a large right RCC showing sarcomatoid differentiation that directly invaded the duodenum and inferior vena cava with regional lymph node involvement. In this patient, radical right nephrectomy, cavotomy with thrombectomy, and pancreatoduodenectomy were successfully performed after administration of axitinib as first-line neoadjuvant therapy without severe toxicity .
+We selected axitinib as preoperative molecular-targeting therapy to decrease the tumor size before surgery with good tolerability. Administration of axitinib starting at 5 mg/day was scheduled for four to six weeks before radical surgery involving left nephrectomy and extended retroperitoneal lymph node dissection (para-aortic and aorto-caval nodes). After 1 week, the dose of axitinib was increased to 14 mg/day. After four weeks of total dose of axitinib of 329 mg (5 mg/day for continuous 7 days and 14 mg/day for following continuous 21 days), there were no apparent adverse events of > grade 3, excluding headache and hypertension (systolic blood pressure > 200 mmHg). Tumor shrinkage and a decrease of SUVmax were observed . Subsequently, we successfully carried out radical left nephrectomy and extended retroperitoneal lymph node dissection (para-aortic and aorto-caval nodes). Macroscopically, the tumor was an invasive whitish-yellowish mass with partial necrosis. Pathological examination confirmed pRCC2 with Fuhrman grade 3 differentiation (pT3apN1M0). The pathological effect of axitinib was grade 2 (i.e., two-thirds necrosis of the tumor). The patient has been receiving axitinib at 5 mg/day in the manner of one cycle of one week (5 days on - 2 days off) as adjuvant therapy for 33 months, and remains well with no evidence of recurrence at 33 months after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_568_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_568_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f55fb82977c634b482a39ae08e7b2a55fc1d0606
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_568_en.txt
@@ -0,0 +1,5 @@
+A 27-year-old man presented with headache and diplopia for three days. The headache was a dull pain not accompanied by vomiting or dizziness. Fundoscopy showed left optic nerve atrophy and right papilledema, consistent with Foster-Kennedy syndrome. Neurological examinations were otherwise normal, and laboratory results were unremarkable.
+A left frontal irregular space-occupying lesion was seen on magnetic resonance imaging (MRI), and enhancement was shown on contrast-enhanced scan. The lesion appeared hyperintense on T1-weighted images. Hypointense signals were noted on T2-weighted images. The tumor was primarily located at the frontal lobe with ventricular compression and midline shift . Brain CT angiography (CTA) showed compression of the anterior and middle cerebral arteries. Small branches from the middle and anterior cerebral arteries supplied blood to the tumor . Meningioma was diagnosed prior to surgery.
+Surgery was performed via the left frontotemporoparietal approach and the tumor was removed four days after admission. The tumor was located at the anterior cranial fossa and adhered closely to the dura of the skull base. Only the infiltrated dura was not removed; the resection was Simpson’s grade II (that is, complete removal + coagulation of dural attachment). Grossly, the tumor was a soft, well-circumscribed pigmented lesion with a capsule, and proved to be meningeal melanocytoma on histopathological examination of resected tissues.
+Immunohistochemistry was positive for the melanocytic features human melanoma black (HMB)-45, vimentin and S-100 protein, while epithelial membrane antigen (EMA), creatine kinase (CK) and progesterone receptor (PR) were negative. Cellular proliferation was assessed via staining for Ki-67. Ki-67 was positive, but less than 1% . Based on the pathology results, the tumor was adjudged World Health Organization (WHO) grade I (low grade). After the diagnosis was established, a detailed physical examination was performed in which no skin melanoma was found. The patient denied a history of melanocytoma.
+The patient received one-time 30 Gray radiation therapy after surgery and the duration was one day. No tumor relapse was seen on follow-up MRI six months after surgery . At follow-up two and a half years after surgery, the patient was free of symptoms and no tumor recurrence was shown on the CT scan.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_573_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_573_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..700db52edc0a1376ff9b52e04081e93c5d1f606a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_573_en.txt
@@ -0,0 +1,3 @@
+A 73-year-old man was diagnosed with colon cancer and underwent right hemicolectomy at our hospital. The final diagnosis of colon cancer revealed adenocarcinoma, type 2, 70 × 40 mm, tub2 > tub1, T4a (SE), int, INFb, Ly1a, V1b, Pn0, N1a (1/30), p-stage IIIB (according to the ninth edition of TNM classification). Computed tomography (CT) before surgery for colon cancer revealed a solid nodule measuring 16 mm in diameter in the laterobasal segment (S9) of the right lung . Three months after the surgery for colon cancer, the size of the pulmonary nodule increased (diameter, 18 mm; Fig. b). The levels of tumor markers, including carcinoembryonic antigen (1.7 ng/mL), carbohydrate antigen 19-9 (5.2 U/mL), cytokeratin 19 fragment (2.2 ng/mL), and pro-gastrin-releasing peptide (66.9 pg/mL), were all within normal levels. The pulmonary tumor was highly suspected to be a metastasis from the colon cancer because of the tumor growth. No other metastases were observed on contrast-enhanced CT. We considered preoperative bronchoscopy. However, the patient preferred surgery for diagnostic and therapeutic purposes. Preoperative three-dimensional CT (3D-CT) angiography revealed that A7a branched from the right main PA, whereas A7b branched from the A8+9+10 as usual . The A7a and A7b were located on the ventral and dorsal sides of the basal vein, respectively.
+Right basal segmentectomy was performed via video-assisted thoracic surgery. The interlobar fissure between the middle and lower lobes was incomplete. Then, we dissected around the inferior pulmonary vein (IPV) to identify the border of the middle and lower lobes. Subsequently, during dissection of the cranial side of V6, we found the A7a that was close to V6 . The A7a branching from the right main PA was observed behind the V4+5 and middle lobe bronchus during surgery . The basal PA except for A7a was divided using a stapler, and A7a was ligated and divided . Then, the basal bronchus was divided using the stapler. After the vein of the basal segment (V7–10) was divided, the intersegmental plane was dissected using the stapler along the inflation and deflation lines. Intraoperative frozen section diagnosis revealed that the tumor was compatible with a metastasis from the colon cancer. The total operation time was 144 min, and the total blood loss volume was 30 mL.
+The postoperative course was uneventful. The tumor had reached a maximum diameter of 20 mm, and the final pathologic diagnosis was combined small cell carcinoma and adenocarcinoma as opposed to the frozen section diagnosis. The pathological staging of the tumor was p-T1cN0M0, p-stage IA3. Although we proposed completion right lower lobectomy with systemic mediastinal lymph node dissection, the patient did not agree. The patient received adjuvant chemotherapy (XELOX) for colon cancer after a discussion with the cancer board in our institution. There was no recurrence of lung and colon cancer at a 1-year follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_588_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_588_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e40428c075b6e631a093204b90b794535acdb127
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_588_en.txt
@@ -0,0 +1,5 @@
+A 47-year-old female patient presented with a palpable lesion protruding from the left areola. This lesion was first noted 10 years earlier and had not shown changes. However, recently it noticeably increased in size.
+She underwent breast augmentation surgery with silicone implants eight years ago.
+Physical examination revealed a soft, fluctuating, mobile, and non-tender mass measuring approximately 4 cm in size. Part of the overlying skin was slightly greenish in appearance with mild protrusion. However, there was no ulcer or other skin changes.
+Sonography showed a well circumscribed oval cystic lesion with internal hyperechoic debris and fluid-fluid level. There was no internal blood flow on color doppler study. The mass broadly contacted with dermis, compressing the breast parenchyma . Breast magnetic resonance imaging (MRI) was performed to check breast implants, on which the lesion could also be evaluated. MRI showed a well circumscribed oval mass of left subareolar area measuring 3.9 cm. The lesion attached to the cutaneous layer of the areola and compressed the breast parenchyma. Thin fatty layer was noted between the mass and the breast parenchyma, suggesting separated mass from the breast. The lesion showed T1 hyper-intensity compared to muscle and high T2 signal intensity. On post-contrast fat saturation T1-weighted image, the mass showed a well-circumscribed thin and even enhancing wall. There was a small enhancing mural component in the inner wall of the mass . It was not detected on ultrasound because internal debris filling the mass masked the mural component. In differentiation of the lesion, we overlooked the enhancing solid portion and considered the lesion as benign such as epidermal inclusion cyst.
+The tumor was resected due to its persistent and growing tendency. The mass was well demarcated with dense fibrous tissue. It was located between the breast parenchyma and the areola. The mass showed deep khaki color. It was filled with brownish and tan necrotic mucoid fluid. Microscopically, the lesion was predominantly cystic, measuring 3.5 cm × 2.5 cm × 2.4 cm with solid portion of 1 cm × 0.3 cm carcinoma and benign tissue of less than 0.1 cm. The carcinoma was composed of epithelial cells with clear or eosinophilic cytoplasm, prominent nucleoli, and frequent mitosis. Suspicious microinvasion to the fibrous cystic wall was noted . Resection margin was less than 1 mm and free of pathology. There was no lymphovascular invasion. Cytokeratin expression of the tumor showed positive for CK7 but negative for CK20. It was moderately positive for Ki-67, reflecting cell proliferation. Regarding other results in immunohistochemistry, it was positive for P63, C-erbB-2, and P53, but negative for estrogen and progesterone receptor.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_592_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_592_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..90edbf127dd19329fdbe21b9356f2a13eb9ad5c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_592_en.txt
@@ -0,0 +1 @@
+A 65-year-old non-smoking and non-drinking woman had split-graft deceased-donor LT for end-stage primary biliary cirrhosis (PBC) . No pre-LT induction immunosuppressant was given. Her post-LT immunosuppressants included oral tacrolimus (1 mg twice daily) and mycophenolate mofetil (180 mg twice daily). She also had prednisolone (10 mg twice daily) immediately after LT and gradually tapered to 5 mg daily. Prophylactic medication included fluconazole (200 mg daily), trimethoprim-sulfamethoxazole (TMP-SMX) (480 mg daily) and acyclovir (400 mg tds) were also given for 3 months. She developed biliary anastomotic stricture and bile leakage, which improved with repeated endoscopic retrograde cholangiopancreatography with balloon dilatation without stenting. The last endoscopic retrograde cholangiopancreatography was performed at 22 months after LT. At 25 months after LT, she was admitted because of a 2-day history of fever, dyspnea and dry coughing. At admission, her blood pressure was 132/80 mmHg, pulse 106 beat per minute, and SpO2 88% at ambient air. SpO2 improved to 95% with supplemental oxygen (2 L/min) via nasal cannula, but rapidly deteriorated requiring 100% oxygen via re-breathing mask to maintain SpO2 ≥ 92%. Chest X-ray and other investigations were performed . Pneumocystis jirovecii, CMV and RSV were detected in bronchoalveolar lavage by respective accredited in-house polymerase chain reaction. Her condition improved with intravenous TMP-SMX (trimethoprim component at 15 mg/kg/d divided in every 8 h), a tapering dose of corticosteroid for PCP and intravenous ganciclovir (5 mg/kg every 12 h as induction, followed by 5 mg/kg every 24 h as maintenance) for CMV. Her immunosuppressants were reduced and tapered during the PCP treatment. On day-10 TMP-SMX, her chest X-ray showed subcutaneous emphysema bilaterally and right pneumothorax suspected of pneumomediastinum . Computed tomography of the thorax confirmed the presence of right pneumothorax, pneumomediastinum and subcutaneous emphysema . She was managed with 7-day chest drain in situ with a standard Argyle-type chest tube of Fr-32 until her right lung re-expanded, in addition to 21-day TMP-SMX. She was not put on mechanical ventilation. She survived and was discharged on day 31 after admission. Chest X-ray on discharge showed resolution of the pneumothorax .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_617_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_617_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a053dd8d8ef7d22bd3ce320c76a07270c1c91f05
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_617_en.txt
@@ -0,0 +1,10 @@
+A 34-year-old man, a subsistence farmer, from southwestern Uganda with a history of multiple prior presentations with anemia, jaundice, and dark-colored urine requiring blood transfusions presented to us again in July 2018 with a week history of palpitations, dizziness, and dark-colored urine.
+His condition started in 2006 with an episode of palpitations, yellowing of eyes, and dark-colored urine where he was initially seen in different health facilities close to his home village and later admitted to Mbarara Regional Referral Hospital (MRRH). He recalled being transfused with >4 units of blood during that initial admission and was discharged when all his symptoms subsided.
+After discharge, he stayed fairly well for about 3 months before he developed another episode with similar symptoms. These symptoms continued to recur at an interval of 2–4 months, and each episode would require admission and blood transfusion.
+In 2012, he was referred to Mulago National Referral Hospital for diagnostics and management. Many investigations were done , and he was ultimately given a diagnosis of vitamin B12 deficiency. He was then treated for 1 year with vitamin B12 injections (no records of the doses available). Despite this treatment, he continued to have episodes of yellowing of eyes, palpitations, and dark-colored urine at approximately similar intervals (2–4 months).
+In 2013, investigations were repeated, and in addition, bone marrow aspiration was done. The serum B12 level was found to be high, and the vitamin B12 injections were stopped. However, similar symptoms continued to recur at similar intervals over the following 2 years.
+In 2015, he was restarted on B12 injections when found to have high serum levels of homocysteine despite a negative urine methylmalonic acid. The injections were stopped again a year later when found to have a very high serum B12 levels. Symptoms continued to recur at similar intervals till his recent admission in July 2018. Apart from B12 injections, the patient was given oral prednisolone on two occasions in the past but without significant improvement.
+On this admission, he presented with predominant symptoms of palpitations, dizziness, generalized body weakness, yellow eyes, and dark-colored urine for about 7 days. This time, he also reported a 5-month history of erectile dysfunction and intermittent mild to moderate abdominal pain without associated vomiting, diarrhea, or dark/bloody stools. Reviews of the other systems were uneventful. He has no other chronic diseases or history of allergies. He has not been on any chronic medications in the past, apart from the tablets of folic acid and ferrous sulfate and vitamin B12 injections. He reported no history of a similar condition in any of his family members or a history of hereditary anemias or hematological malignancies. He reported no history of radiation or toxin exposure and further denied any history of taking traditional remedies.
+His physical examination in the latest admission revealed severe pallor and jaundice of the mucous membranes. He had a displaced point of maximum cardiac impulse (6th left intercostal space and anterior axillary line) and grade-3 mitral and tricuspid murmurs of mitral and tricuspid regurgitation, respectively. He has no skin rashes, and the rest of his systemic examination was unremarkable. Many tests done during the course of his illness are displayed in .
+Due to the recurrence of the symptoms, DAT-negative hemolytic anemia, and new onset of erectile dysfunction, we did a flow cytometry including fluorescent aerolysin (FLAER) in which a large PNH clone was found. The details of the flow cytometry test are displayed in .
+In this admission, we transfused him with 4 units of blood and later discharged when his symptoms subsided.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_624_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_624_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..79b98a3a28a80df9cdd0de4dfec66785e1cf0d71
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_624_en.txt
@@ -0,0 +1,10 @@
+A 37-year-old woman presented to our hospital with complaints of blurred vision in the right eye for 10 months. She had no family history of hereditary ocular diseases and no previous history of eye surgery or ocular trauma. In addition, the patient had bilateral varus deformity of distal interphalangeal joints on the little fingers. Also, her sister was born with uterus didelphys.
+The best corrected visual acuity (BCVA) was hand motion in the right eye and 20/33 in the left eye. The refraction was + 4.25/− 0.50 × 90 in the left eye. Horizontal corneal diameters were apparently enlarged in both eyes (the right eye 14 mm/ the left eye 13.88 mm). Applanation intraocular pressure (IOP) were normal in both eyes. Main measures of the present case are summarized in Table .
+Anterior segment photography showed mild iridal atrophy of both eyes, which subsequently lead to insufficiently dilated pupils with diameters no more than 5 mm. White cataract was observed in the right eye . Inspection by anterior segment optical coherence tomography (AS-OCT) (Cornea/Anterior Segment OCT SS-1000, Tomey Corporation, Japan) indicated bilateral augmented anterior chambers with backward iridal concavity on horizontal orientation, although the backward concavity in the right eye was markedly reduced before the surgery because of the swelling cataractous lens; while on vertical orientation iris revealed rather flat . Ultrasound biomicroscopy (UBM) (MEDA MD-300 L) showed opacified lens with the apparently elongated suspensory ligaments in the right eye. Partially peripheral anterior synechiae and pectinate ligaments at anterior chamber angle were also observed in both eyes. Ciliary processes were small and scleral processes were not apparent under UBM inspection .
+On the basis of the above findings, the patient was diagnosed with bilateral anterior megalophthalmos complicating white cataract in the right eye.
+The operation was performed by an experienced surgeon (Y.L.). A 2.6 mm temporal clear corneal incision was made under topical anesthesia. Viscoelastic agent (DisCoVisc, Alcon, Fort Worth, TX, USA) was then instilled to maintain the anterior chamber with small pupil. Following a continuous curvilinear capsulorhexis of 5.5 mm in size, hydrodissection, chopping, nucleus rotation, and phacoemulsification (CENTURION Vision System, Alcon, Fort Worth, TX, USA) were then performed. A 1-piece foldable IOL (+ 20.5 D, Human Optics PC Acrylic IOL, MC X11 ASP) with four frame haptics to increase intracapsular stability, was inserted into the capsular bag. After aspiration of residual viscoelastic, the incision was hydrated with balanced salt solution and checked for water tightness. Gentle operation was emphasized intraoperatively considering zonular weakness and the deep anterior chamber as the infusion bottle height was set to 75 cm and the phacoemulsification was carried out in a slow-motion mode (vacuum: 300 mmHg; aspiration flow rate: 28 cc/min). Postoperatively, Cravit Eye Drops (Alcon Laboratories, Inc., Fort Worth, TX, USA), Pred Forte Eye Drops (Allergan Pharmaceuticals, Inc., Dublin, Ireland), and Diclofenac Sodium Eye Drops (Shenyang Xingqi Pharmaceutical Co. Ltd, Shenyang, China), all 3 times a day for 4 weeks, were given.
+One month after the surgery, the uncorrected visual acuity (UCVA) and BCVA of the right eye improved to 20/25 and 20/20. The actual postoperative refraction was + 1.50/− 0.50 × 115 in the right eye and the actual postoperative spherical equivalent (SE) was + 1.25 D. The IOP of the right eye was 18 mmHg. Postoperative inspection by AS-OCT indicated a low degree of IOL decentration and iridal backward concavity still remained on horizontal orientation with flat iris on vertical orientation . OPD-Scan III aberrometry (Nidek Co, Ltd, Gamagori, Japan) verified increased internal coma and tilt aberrations indicating slight dislocation of IOL after surgery . Three months after the surgery, the visual acuity and the refractive status of the operated eye were stable and the IOP remained within normal range (15.0 mmHg OD and 17.8 mmHg OS). The IOL also showed good centering and stability during the follow-up.
+The postoperative refractive error equals to the actual postoperative SE (+ 1.25 D) minus the predicted refraction calculated by IOL power calculation formulas as following:
+In this case, we originally used the SRK/T formula for IOL power calculation and the postoperative refractive error turned out to be + 1.44 D during the follow-up. To find the most accurate power calculation formula with lowest postoperative refractive error for the challenging anterior megalophthalmos cases, we further applied the Haigis and Holladay II formulas .
+The postoperative refractive error decreased to a rather low value as − 0.05 D after using the Haigis formula. As to the Holladay II formula, the postoperative refractive error was + 0.63 D. Therefore, compared to the SRK/T and the Holladay II formulas, the Haigis formula may be a more suitable choice according to our case, with higher accuracy and lower postoperative refractive error concerning to the IOL calculation in anterior megalophthalmos.
+For genetic analysis, we obtained the blood samples of the patient, her son and her parents for whole-exome sequencing based on family to identify any gene mutations directly related to anterior megalophthalmos. However, no known or newfound related gene mutations were found .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_626_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_626_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..564d97253215316cbe98504099d4ccf2dc101acd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_626_en.txt
@@ -0,0 +1,2 @@
+In December 2013, a 58-year-old man with a history of type-2 diabetes mellitus (DM2), systemic arterial hypertension (SAH) and dyslipidemia was referred to our centre, the Hospital de Clínicas de Sao Paulo, a large academic and public centre located in Sao Paulo, Brazil, from the primary care service to investigate uncontrolled blood pressure and blood glucose. At initial clinical examination, he presented facial phletora, hirsutism, violaceous striae and centripetal obesity, and a CS clinical diagnosis was suspected. Initial examinations identified hypercortisolism and elevation of ACTH . The ACTH increment in the corticotropin-releasing hormone (CRH) stimulation test was 14%, suggesting an ectopic ACTH-producing tumour. To confirm this hypothesis, the patient underwent an inferior petrosal sinus sampling with CRH stimulation. The central/peripheral ACTH gradient was less than 2 at 0, 3, 5 and 10 min after desmopressin injection, confirming the ectopic ACTH producing. Magnetic resonance image (MRI) of the abdomen showed an expansive lesion in the tail of the pancreas measuring 5.0 cm in the largest diameter, multiple small nodules in hepatic segment III and increased volume of both adrenals . In January 2014, he was referred to our institution, the Instituto do Cancer do Estado de Sao Paulo, where he underwent an R0 body-caudal pancreatectomy, splenectomy and removal of the segment III of the liver, which was compatible with PNET, infiltrating the liver tissue. The final diagnosis was of a well-differentiated PNET, with positive immunohistochemistry staining of synaptophysin and chromogranin A, three mitosis/10 high-power fields and Ki67 index of 6%. There was adequate clinical control of DM2 and SAH after resection. In July 2014, a Gallium-68-DOTATATE PET-CT was performed and did not show any measurable metastatic disease. However, in November 2014, he presented hyperglycaemia and high blood pressure again, associated with elevation of both serum cortisol and ACTH, which were resultant from hepatic recurrence with a new lesion of 1.2 cm in segment VI of the liver. Because the patient was quite sick to undergo new hepatic resection due to uncontrolled CS and also because of the short interval from last metastasectomy, new surgical resection was contraindicated. Octreotide LAR 20 mg IM once every 28 days was started but was unsuccessful in controlling symptoms. Subsequent hepatic embolisation did not improve his condition either. Due to uncontrolled CS in February 2015, bilateral adrenalectomy was performed and the CS finally resolved. The pathology report revealed a metastatic neuroendocrine tumour in the left adrenal, with immunohistochemistry staining positive for synaptophysin, chromogranin A positive and ACTH, negative staining for CD56, CDX2 and TTF1 negative and ki67 index of 30%.
+After symptom control, the patient was lost to follow up, returning six months with recurrent hyperglycaemia and skin hyperpigmentation; at that time, the elevation of plasma ACTH was identified. A new MRI of the abdomen showed a progression of hepatic metastases. Octreotide LAR was tried again, but there was disease progression after two doses. In October 2015, he received the combination of oxaliplatin 130 mg/m2 given on day one and capecitabine 1000 mg/m2 (CapOx) orally for 14 days, in a 21-days cycle. At this time, he presented diffuse exuberant hyperpigmented lesions of the skin, mainly in interphalangeal joints and tongue . After two cycles, there was significant improvement in cutaneous hyperpigmentation and the patient was restaged with new CT scans that showed stable disease. Despite good tolerance, the patient requested to stop chemotherapy and he went on chemoholiday. In March 2016, after three months without treatment, the hyperpigmented lesions of the skin worsened and imaging tests evidenced new progression of liver disease. Re-exposure to CapOx was indicated. He received three more cycles, when in in April/2016, CT scans demonstrated partial response in liver lesions. The patient chose to pause the chemotherapy once again. At the last image evaluation, in June 2017, the tumour has remained stabilised and three has been no further worsening of skin hyperpigmentation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_629_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_629_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1a21b9e01143c14c42722a9800eeb29f59142295
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_629_en.txt
@@ -0,0 +1,10 @@
+A 52-year-old man was admitted to our hospital in March 2020 because of continuous enlargement of the left eyelid mass with swelling and pain.
+The patient initially presented to our hospital with small hard bulges that emerged from both facial aspects after a frontofacial crash in June 2018. The rash tissue on the right side of the patient’s face was biopsied and confirmed to be MF by histopathology. The patient subsequently received twelve courses of COP (cyclophosphamide 400 mg day 1-5; prednisone 100 mg day 1-5; vincristine 2 mg day 1). Chidamide was suggested after rapid disease progression, but the patient refused it initially for economic reasons. In August 2019, the patient presented with swelling of the left orbital tissue and severe skin rashes on the forehead and cheeks. CVP (cyclophosphamide 1200 mg day 1; vincristine 2 mg day 1; prednisone 100 mg day 1-5), DHAX (oxaliplatin 250 mg day 1; cytarabine 3300 mg day 2; dexamethasone 40 mg day 1-4) and CHOPE (doxorubicin 80 mg day 1; vincristine 2 mg day 1; cyclophosphamide 1200 mg day 1; prednisone 100 mg day 1-5; etoposide 100 mg day 1-3) regimens were attempted continuously, but the eyelid mass and rashes were not significantly improved.
+The patient was diagnosed with syphilis two years prior and received treatment.
+There was no relevant personal or family history.
+Physical examination revealed that the skin was scattered with rashes, and a palpable mass approximately 2 cm × 2 cm in size with tenderness was detected in the right groin. There were multiple skin masses and plaque-like rashes on the frontal face; the largest was an approximately 3 cm × 4 cm mass on the left eyelid.
+During hospitalization, the patient’s leukocyte count was 13.5 × 109/L (reference range: 3.5-9.5 × 109/L), his lymphocyte ratio was 14.7% (reference range: 20%-50%), the monocyte ratio was 13.3% (reference range: 3%-10%), his red blood count was 3.18 × 1012/L (reference range: 4.3-5.8 × 1012/L), and high-the sensitivity C-reactive protein (hsCRP) level was 24.2 mg/L (reference range: 0-10 mg/L). Blood smear examination showed that the mature lymphocyte ratio was 15.0% (reference range: 20%-50%). The increased white blood cell count and hsCRP level were considered complications of infection caused by bone marrow suppression after chemotherapy.
+Abnormal fluorodeoxyglucose (FDG) uptake in multiple organs and lymph nodes throughout the body was identified with 18F-FDG positron-emission tomography (PET)-computed tomography (CT) .
+Orbital CT showed swelling of the facial, periorbital and intraorbital soft tissues on the left side with mass shadows and compression of the left eyeball and extraocular muscle .
+US images showed a mass 24.8 mm × 45.5 mm in size in the left upper eyelid. Colour Doppler flow imaging (CDFI) and contrast-enhanced ultrasound (CEUS) showed abundant blood flow signals in the mass .
+Pathological examination of the facial skin revealed a T cell proliferative disease. Immunohistochemical staining revealed that the tumour was positive for CD3, CD4, CD5, CD8, CD45RO, CD20, CD79a, Ki67 (+ = 40%) and EMA, but negative for CD56, CD30, GR-B, and EBEV .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_637_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_637_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4352367c4a6e7c416f4153a5dc677a471ce0b593
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_637_en.txt
@@ -0,0 +1,8 @@
+A 44-year-old Indonesian female patient presented to the Emergency Department of Sanglah General Hospital (Bali, Indonesia) with the chief complaint of blackish stool that had occurred 2 hours prior to admission and was accompanied by coffee ground vomitus and epigastric pain. Two weeks prior to admission, the patient had been admitted to the district hospital with complaint of blackish stool and received a blood transfusion. The blackish stool recurred 1 week later.
+The patient denied a history of abdominal trauma but reported a history of elective LC due to cholelithiasis 3 years prior to admission and was hospitalized for 5 days. History of abdominal pain or gastrointestinal bleeding afterwards was denied. History of alcoholism, hepatitis, or chronic liver diseases was denied.
+The patient’s vitals were within normal range; blood pressure was 110/70 mmHg, heart rate was 84 beats per minute, respiratory rate was 16 breaths per minute, and axillary temperature was 36.6°C. Pallor of the conjunctiva indicated anemia, and scleral icterus suggested slight jaundice. The patient expressed pain on palpation at the epigastric and right hypochondriac region.
+Blood analysis revealed low hemoglobin 9.88 g/dL (normal range: 12–15.5 g/dL) but normal platelet and white blood cell count. Liver function markers were abnormal, with aspartate transaminase of 354.9 U/L (11–33 U/L), alanine transaminase of 321.3 U/L (11–50 U/L), total bilirubin of 3.52 mg/dL (0.3–1.3 mg/dL), direct bilirubin of 2.95 mg/dL (0.0–0.3 mg/dL), alkaline phosphatase of 233 U/L (53–128 U/L), and gamma-glutamyl transferase of 301 U/L (70–140 U/L). Amylase, lipase, prothrombin, and partial thromboplastin times were normal.
+Results from abdominal ultrasonography were unremarkable; there were no signs of biliary obstruction or intraabdominal free fluid. Nonvariceal UGIB caused by peptic ulcer was suspected, and appropriate conservative treatment with lansoprazole bolus 60 mg intravenously followed by continuous drip 6 mg/hour intravenously was initiated, with esophagogastroduodenoscopy (EGD) ordered for further evaluation.
+The EGD revealed blood covering the gastric tissues up to the second part of the duodenum. After cleansing, the source of bleeding remained inapparent. However, a blood clot was found at the ampulla of Vater . The diagnosis of hemobilia was made, and computed tomography (CT) scan was planned
+While waiting for the abdominal CT scan, the patient experienced massive hematemesis and hematochezia. Emergent angiography was performed to determine the source of bleeding and address the patient’s hemodynamic instability. The imaging showed contrast extravasation from a gastroduodenal artery pseudoaneurysm distal to the common bile duct, with flow to the duodenum . The patient was diagnosed with hemobilia due to ruptured gastroduodenal artery pseudoaneurysm.
+The patient was treated with fluid resuscitation and packed red cell transfusion. Although transcatheter arterial embolization would have been the preferred procedure to stop the bleeding, it was unavailable in our center; therefore, laparotomy surgery was performed. The laparotomy confirmed the bleeding from gastroduodenal artery pseudoaneurysm, and ligation and excision of the pseudoaneurysm were performed . After surgery, the patient’s vital signs were stable, and no recurrent bleeding episode occurred. Unfortunately, the patient developed ventilator-associated pneumonia and passed away.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_652_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_652_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51feae147ef3648c54a4021e4ad9265332cec5d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_652_en.txt
@@ -0,0 +1 @@
+70 years old female was admitted to the hospital with epigastric pain, fevers and elevated white cell count. Abdominal CT scan demonstrated evidence of duodenal diverticulitis and she was started on broad-spectrum IV antibiotics . Overnight, her clinical condition had worsened with persistent tachycardia, increase in white count, fevers and signs of peritonitis on exam. Interval CT revealed significant amount of air and fluid in the abdomen concerning for free perforation. Patient was consented for exploration and possible pancreatoduodenectomy. During surgery, large perforation of the 4 cm juxtapapillary duodenal diverticulum originating from posterior-medial wall with peritonitis was found . Due to very medial location in close proximity to insertion of the ampulla, segmental resection was not possible and decision was made to proceed with pancreatoduodenectomy. Pathology confirmed perforation originating from duodenal diverticulum with no additional abnormal findings. Patient tolerated procedure without complications and was discharged home after 10-day hospital stay. She is doing well at 2 months follow up and has returned to work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_679_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_679_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c70160af8f8768290d351150cc6c377635b68734
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_679_en.txt
@@ -0,0 +1,2 @@
+A 48-year-old man had persistent severe right groin pain after activity for 9 months. He had played tennis and skied for over 20 years. Although he had full range of movement at the hip, he complained of pain on internal rotation. He experienced pain when undergoing both the flexion-adduction-internal rotation test and flexion-abduction-external rotation test. A radiograph of the hip showed acetabular dysplasia with a center-edge angle of 15 degrees . A cystic lesion was detected on magnetic resonance imaging (MRI) with T1- and T2-weighted images showing low and high signal intensity, respectively. Short inversion time inversion recovery images revealed an adjacent teardrop-shaped lesion (-). He underwent arthroscopic surgery under general anesthesia, during which he was placed in the supine position, and appropriate traction was applied on a traction table. A lateral portal was created over the tip of the greater trochanter and an anterolateral portal was placed between the lateral portal and the femoral artery and slightly distal to the transverse line. An anterior portal was established at the inguinal groove slightly lateral to the femoral artery. During arthroscopic evaluation of the central compartment, a cystic mass was identified between the transverse acetabular ligament (TAL) and ligamentum teres and in continuity with the TAL . When the cyst was punctured, a blood-streaked yellowish viscous liquid was expelled . The remaining cyst wall was resected in its entirety . Histological examination revealed a glassy fibrous tissue wall without lining cells, confirming a diagnosis of ganglion cyst .
+After surgery, weight-bearing was permitted as tolerated and the patient returned to recreational sports 6 months later. No recurrence was detected on MRI at the 6-year follow-up postoperatively ( and ), the patient had no complaints at that time.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_720_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_720_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..080d231ce70ef5a750769a282c16ee6f9ceed7d1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_720_en.txt
@@ -0,0 +1,9 @@
+A 37-year-old male patient was admitted to a local general hospital in October 2019 due to persistent fatigue for 1 year and repeated syncope for 1 month. Physical examination showed marked atrophy of the muscles of the extremities. The electrocardiogram (ECG) captured ventricular tachycardia (VT) with heart rate (HR) of 145 bpm . The blood tests revealed creatine kinase (CK) 1067 U/L (reference range: 20–174 U/L) and creatine kinase isoenzyme (CK-MB) 112 U/L (reference range: 0–18 U/L) respectively. Cardiac magnetic resonance (CMR) imaging revealed that a possibility of atypical myocarditis. Computed tomography angiography (CTA) showed that the coronary and intracranial arteries were normal. Echocardiography demonstrated enlargement of left and right chambers (LVDD 57 mm) with a reduced left ventricular ejection fraction (LVEF 42%). The above tests implied that the pathological VT was probably associated with neuromuscular or immune disease. Nonetheless, the patient rejected the further tests, and received implantable cardioverter-defibrillator (ICD) therapy. 5 mg of bisoprolol once daily was given for long-term use. The patient had a history of chronic hepatitis B and no other disease.
+In November 2019, the patient was hospitalized in the department of neurology of our hospital for aggravating muscle atrophy. Electromyogram (EMG) showed active myogenic damage. Muscle biopsy of the right biceps brachii demonstrated sporadic necrotic fibers with regeneration, but without obvious inflammatory cell infiltration. Autoimmune antibodies were measured and positive for anti-nuclear antibodies (ANA) and AMA. The muscular dystrophy was considered and coenzyme Q10 was prescribed in addition to the previous medications.
+In April 2020, the VT recurred and could terminate spontaneously . The patient was hospitalized again. He was administrated amiodarone (200 mg/day) and methylprednisolone (24 mg/day). The VT did not come out thereafter.
+Unfortunately, the patient suffered from repeated sustained VT in May 2020 . According to ICD programming, since the day before admission, the patient had 43 VT, with a HR of 180 ± 5 bpm, and received 37 ATP treatments and 1 discharge treatment . Meanwhile, he had new onset of blurred vision and diplopia.
+The vital signs: T: 36.2 °C , P: 70 beats/min, R: 18/min, BP: 97/60mmHg. The strength of proximal limb muscle was grade 3 out of 5, the distal limb muscle was grade 4 and the bilateral tendon reflex was active.
+Laboratory tests showed Troponin T 0.098 ug/L (reference range: 0.020–0.130 ug/L), CK 163 U/L, CK-MB 17 U/L, brain natriuretic peptide (BNP) 178 pg/mL (reference range: <100 pg/mL), glutamic-pyruvic transaminase 51.2 U/L (reference range: 0–40 U/L). The renal function and coagulation function were nearly normal. ECG showed VT with HR of 166 bpm . Echocardiography revealed that LVEF decreased to 28% and LVDD increased to 64 mm, Regional wall motion abnormality (RWMA) was not detected .
+Upon admission, esmolol, dexmedetomidine and amiodarone were administered to control the VT storm and under sedation. Besides, sacubitril/valsartan (50 mg/day), bisoprolol (7.5 mg/day), spironolactone (20 mg/day), and entecavir (0.5 mg/day) were also administered. However, these measurements did not work.
+In order to identify the aetiology, the previous histologic slice was overdyed. The results showed some muscle fibers atrophy and a few denatured and necrotic muscle fibers . Combined with negative genetic testing results and immunohistochemical stain, muscular dystrophy and mitochondrial encephalomyopathy can be ruled out . According to the advice of the rheumatologist, the patient was diagnosed as AMA-positive idiopathic inflammatory myopathy (IIM). Furthermore, Immune-mediated necrotizing myopathy (IMNM) could be confirmed according to 2017 EULAR-ACR classification criteria . Therefore, all the aforementioned symptoms and clinical signs were associated with the myositis.
+Thereafter, he received intravenous methylprednisolone 40–80 mg/day for 5 days, intravenous immunoglobulin 20 g/day for 5 days and mycophenolate mofetil (MMF) 0.75 g/day. Oral methylprednisolone was then started at a dose of 24 mg/day and the dose was subsequently reduced by 4 mg each week to 2 mg/day. The VT storm was controlled completely, and the echocardiography showed LVEF increased to 33% and LVDd decreased to 60 mm . After discharge, amiodarone was gradually discontinued, methylprednisolone was reduced to 2 mg/day, sacubitril/valsartan was increased to 75 mg/day, and the other drugs continued to use. During follow-up, the patient had no symptoms of heart failure, arrythmia, and diplopia. ICD programming showed the VT no longer recurred . Nine months after discharge, his last follow-up data showed remarkable recovery in LV systolic function (LVEF 52%) and normal CK level (38 U/L) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_739_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_739_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fab16552c3ce6b9a2ab9c2920c6ca15d43c90d9e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_739_en.txt
@@ -0,0 +1,8 @@
+A 54-year-old woman presented with intermittent left-sided chest discomfort over 2 years. She described this symptom as a “pressure” sensation in the anterior chest which was brought on by physical strain such as heavy lifting. She also reported that this discomfort was more noticeable and severe during air travel over recent years, with discomfort peaking during the middle of the flight and easing with descent. The most recent flight-related.
+Episode was particularly severe and this is what prompted her presentation. She had no dyspnoea or other symptoms of note.
+On further discussion, she revealed that she had been followed-up in the respiratory outpatient clinic of a different hospital some 10 years previous for an incidentally noted large bulla in her left lung. Following 5 years of annual surveillance imaging, she was discharged as she had remained asymptomatic and the bulla had not increased in size.
+She was a smoker in her youth, accumulating a 5-pack-year history and quitting before the age of 30. She had no medical history and no exposures of note. There was no family history of pneumothorax, lung or connective tissue disease.
+Examination revealed no hypoxia, digital clubbing or peripheral stigmata of respiratory disease. Auscultation revealed equal bilateral air entry with normal breath sounds.
+A chest X-ray was done which revealed a large bulla in the left upper zone. This was followed by a high-resolution CT of the thorax which demonstrated a large avascular, air-filled region occupying the upper half of the left hemithorax, consistent with a large bulla. A diagnosis of iGBE was made. There was compression of surrounding lung. There was no evidence of emphysematous lung disease (paraseptal or centrilobular) in the remainder of both lungs.
+Pulmonary function tests showed normal spirometry and diffusion capacity. Lung volumes were not performed. A connective tissue disease blood panel and α1 anti-trypsin level were unremarkable.
+She was referred for surgical assessment and a VATS Bullectomy was performed . This was a two-port procedure. The bulla was intentionally ruptured, creating space in the hemithorax. Adhesions within the surrounding structures were divided. The bulla was resected with a small rim of normal tissue. A 24 french drain was sited and the patient was then extubated. She tolerated this procedure well and without complication. At her recent 6-month follow-up, she was doing well and her previously described symptoms had completely resolved. Repeat spirometry is significantly improved and lung volumes are within normal limits .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_751_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_751_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5f4c1c5d533d86a78777173e193de5de27ed25e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_751_en.txt
@@ -0,0 +1,3 @@
+A 42-year-old man has no clear incentive to present an eating obstruction in July 2020. Symptoms worsen when hard and dry foods are consumed, accompanied by paroxysms of dull pain in the upper left abdomen, no chest tightness or pain, no nausea and vomiting, no hematemesis and melena, no fever and chills, and other discomfort. No history of autoimmune disease, no pneumonia, interstitial lung disease, no chronic obstructive pulmonary disease (COPD), denial of hepatitis B virus (HBV) or hepatitis C virus (HCV), human immunodeficiency virus (HIV) carrier, no recent vaccinations. He visited a local hospital on 13 August 2020. Gastroscopy revealed the lower esophagus, cardia and cardia by lumen narrowing, allowing endoscopy to pass through. There is a huge ulcer in the cardia. The nodules at the bottom are uneven and covered with dirt moss . Biopsy pathology: poorly differentiated adenocarcinoma . The patient came to our hospital for further diagnosis and treatment 17 August 2020. Contrast-enhanced Computed tomography (CT) of the cervicothoracic abdomen and pelvis demonstrated: cardiac cancer involving the esophagus and lesser curvature of stomach, with multiple lymph node metastasis; superior lobe metastasis of the left lung; hepatic metastasis . Eastern Oncology Collaborative Group (EOCG): 1, the patients had poor economic foundation, but as the breadwinner of the family, the patients and their families had a strong desire for therapy.
+After communication with the patient and comprehensive consideration, the patient requested to be enrolled in the “open-label study of AK104 (PD-1/CTLA-4 bispecific antibody)” . Patients with unknown HER-2 status or negative results could be included in the group. He did not undergo HER-2 and PD-L1 tests at enrollment. Six cycles of AK104 + mXELOX/q14d (AK104 6 mg/kg d1+ oxaliplatin 85 mg/m2 d1 + capecitabine 1,000 mg/m2 d1–10/Q14d) were initiated on 27 August 2020. A partial response (PR) was assessed by CT after three and six cycles of treatment (primary foci and hepatic and lung metastatic lesions were markedly decreased). After the sixth treatment cycle, the patient showed symptoms of fatigue, wheezing after activity, palpitation, cough, phlegm, dry mouth, and loss of appetite. On 15 November 2020, general bacterial sputum culture and identification were performed. No bacteria associated with inflammation were identified. Detection of 13 respiratory pathogens: hemophilus influenzae positive. PCT: 0.10 ng/ml. Chest CT: multiple floc and patchy high-density shadows in both lungs, appearance of interstitial pneumonia . He had not caught a cold recently and had no symptoms of fever. In addition, symptoms and additional examinations were combined to rule out the virus/bacterial pneumonia, considering the possibility of immune pneumonia. Antitumor therapy was interrupted, methylprednisolone sodium succinate (MPSS) 80 mg iv drip for 5 days, oral prednisone acetate tablets (taper off), and the patient’s symptoms were markedly improved. A CT scan performed on 28 December 2020 showed that the pneumonia was better than before, and the lung metastatic lesions continued PR .
+A cycle of oxaliplatin 85 mg/m2 d1 + capecitabine 1,000 mg/m2 d1–10/Q14d 1 cycle was initiated on 14 January 2021. AK104 6 mg/kg d1 + capecitabine 1,000 mg/m2 d1–10/Q14d regimen maintenance treatment commenced on 4 February 2021. During the CT evaluation, his condition was sustained at PR on 2 September 2021 monitoring of liver function: ALT 173.7 U/L and AST 148.4 U/L . We delivered liver preservation therapy and, on 3 September 2021, retest liver function: ALT 189.0 U/L and AST 114.8 U/L. At this time, oxaliplatin had been discontinued for 7 months, so it was considered that liver damage was likely to be related to immunity. We gave MPSS 1 mg/kg combined with liver protection and gallbladder therapy to improve the liver function test on 14 September 2021: ALT 69.4 U/L and AST 26.5 U/L. Then the patient was treated at home with oral prednisone, and liver function returned to normal after regular review. 5 October 2021: ALT 650.4 U/L, AST 499.6 U/L, TBil 35 umol/L, DBil 23.1 umol/L, I-Bil 11.9 umol/L. Incorporating the patient’s symptoms and hematologic findings, we diagnosed grade 3 immune-mediated hepatitis. MPSS 2 mg/kg combined with liver protection and gallbladder treatment was used to improve immune hepatitis. 14 October 2021: ALT 153.6 U/L, AST 35.2 U/L. 18 October 2021: ALT 171.3 U/L, AST 41.2 U/L. Considering corticosteroid resistance in patients, we treated them with the incorporation of mycophenolate mofetil. 25 October 2021: ALT 84.7 U/L↑, AST 18.2 U/L, TBil 17.3 umol/L↑, DBil 7.3 umol/L. The patient is getting better right now. Nevertheless, the patient was excluded from the clinical study due to the long-term absence of medication. Antitumor therapy was also discontinued in view of the adverse immune response of the patient. The patient did not receive subsequent immune antitumor therapy, and immune-related hepatitis still occurred intermittently, but the disease evaluation was maintained at PR. CR was confirmed by FDG-PET and the biopsy specimen from gastroscopy on 10 June 2020 . Next-generation sequencing (NGS)-Geneseeq PRIME (425-Cancer Gene Panel) of first biopsy tissue to guide subsequent therapy at a recent follow-up visit. The results indicated that TP53, JAK3, JARID2, CDKN2C, GREM1, EMSY, ERBB2 mutations; copy number 58.4934 (ERBB2), 15.158 (CCNE1); structural variation (ERBB2, CDK12); tumor mutational burden (TMB) = 3.1, microsatellite stability (MSS) (, ). Immunohistochemistry (IHC): EBV (−), PD-L1 CPS = 3, HER-2 (3+) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_783_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_783_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f4acdfc793fcd72aec260367c6f3b3740403eed6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_783_en.txt
@@ -0,0 +1,7 @@
+A 72-year-old Caucasian man presented to his local primary care physician with a one-year history of worsening dyspnea on exertion, along with edema of the legs. He reported recent paroxysmal nocturnal dyspnea and orthopnea, which required him to sleep in a reclining chair and an inability to walk more than a few steps without becoming considerably short of breath. He had no known history of coronary artery disease, and was not experiencing chest pain. Multiple tests for cardiac enzymes were negative. Echocardiograms performed eight months earlier showed mild dilation and hypokinesis of the right ventricle. Previous treatments for suspected obstructive lung disease and antibiotics for erythema and the leg edema had proved ineffective. The edema could not be attributed to deep vein thrombosis or to any marked obstructive pathology in the lungs, abdomen or pelvis.
+Our patient was referred to our institution for a second opinion. On physical examination at rest, his temperature was 37°C; blood pressure 126/75 mm Hg, heart rate 95 beats/minute, respiration rate 20 breaths/minute, and oxygen saturation 91% on room air. During a visit to our outpatient clinic, our patient appeared cyanotic, and was taken to the emergency department for evaluation of his hypoxia. With ambulation, his oxygen saturation dropped to 87%, and he was later admitted to hospital.
+Extensive examinations were performed. Electrocardiography showed left atrial enlargement and non-specific T-wave abnormalities. Computed tomography (CT) revealed nodular thickening of the pericardium and pleura bilateral . The echocardiographic findings were consistent with constricting pericarditis. The inferior vena cava (IVC) was severely dilated with a central venous pressure (CVP) of 30 mm Hg. Intrahepatic venous dilation was also indicative of constrictive pericarditis . There was marked septal shift with respiration and right ventricular compression . Transthoracic echocardiogram (TTE) also showed restrictive movement of lateral ventricular walls with septal bounce . Mitral flow was decreased during inspiration, due to a reduced pressure gradient between the pulmonary vein and left atrium, and reduced left atrial filling . As a result, the right atrium was significantly dilated.
+Based on the CT findings, extensive malignancy or infection was suspected, as well as constrictive pericarditis. Examination of bronchial lavage and interventional biopsies failed to provide a definitive diagnosis. Therefore, pleural and pericardial biopsies were obtained by video-assisted thoracoscopic surgery. Dense adhesions and aged hematoma were found, and histopathological examination showed acute and chronic inflammation and fibrous thickening, with no evidence of malignancy. Results of serology testing for fungi, smears for acid-fast bacilli, culture for mycobacteria, and Gram staining were all negative, and white blood cells were rare in the biopsied tissues. These findings were consistent with pericarditis that was unlikely to be caused by microbial infection or immune disorder.
+Selective cardiac catheterization, which revealed three-vessel coronary artery disease, was performed once extensive malignancy was excluded, and based on the results, we deemed a pericardiectomy was necessary. Our patient underwent emergency total pericardiectomy and triple coronary artery bypass. A standard median sternotomy was used for access and pericardiectomy performed off bypass. The pericardium was found to be grossly adherent, with thickening of up to 30 mm in some areas. Constricting layers of the epicardium were removed wherever possible. Evidence of an old hematoma was found throughout the diaphragmatic recess, and evidence of previous mediastinal haemorrhage was seen.
+After the pericardiectomy, our patient's transesophageal echocardiographic findings showed an immediate response towards normalization, with resolution of tamponade. At the inferior cardiac-diaphragmatic sulcus, a large (60 mm), well-organized hematoma was entered and debrided. Cultures and gross specimens were sent for examination, and found to be negative for any infectious or oncologic source, consistent with the earlier findings. Heparinization and cardiopulmonary bypass was then initiated for saphenous vein grafting of the three coronary arteries found to have significant obstruction on catheterization. Our patient was weaned from bypass without complication on dobutamine 3 mg. He was extubated and stable within 12 hours of surgery. His post-operative recovery was unremarkable.
+After recovery, our patient experienced improvement of all his previous symptoms. No further possible cause of his pericarditis was identified, except that on further conversation with our patient, he recalled falling and striking his anterior lower sternum and chest wall on the edge of a trailer hitch around 12-24 months previously. The accident had incapacitated him for several days, but he had not sought any medical therapy related to the trauma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_790_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_790_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..464e93e7c25550560d8f85f53372d6f20abafb21
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_790_en.txt
@@ -0,0 +1 @@
+A 73 year old male was admitted as an emergency in our department with symptoms and clinical signs suggesting SBO. The patient had undergone laparoscopic left colectomy for cancer of the descending colon, three years before. Abdominal imaging, including computed tomography with i.v. and per-os contrast, confirmed the diagnosis of obstruction of the mid-jejunum, without revealing any possible cause. After a 24-h period of clinical observation and conservative treatment, the patient underwent an exploratory laparatomy. The findings consisted of strangulated jejunal loops herniated through the mesocolic defect at the level of the colo-colonic anastomosis. Viability of the small bowel was ascertained and an intestinal resection was not considered necessary. An iatrogenic perforation of the colon at the level of the anastomosis during mobilization of the small bowel loops necessitated the exteriorization of the anastomosis in the form of a double barrel colostomy. The postoperative course was uneventful, and the patient was discharged on the 6th post-operative day .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_796_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_796_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d43a1f757ead5e8066f332127e7178105d2ce0db
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_796_en.txt
@@ -0,0 +1 @@
+When a 33-YEAR-OLD woman driving a car made a right turn at a crossroad, her car hit another car, causing her vehicle to tip onto its side. She had no remarkable medical history. The fire department dispatched an ambulance and requested the DH be dispatched after receiving an emergency call. After the DH equipped with the portable X-ray system landed at the rendezvous zone, the staff were sent by fire truck to the accident scene. When the staff of the DH checked the patient at the scene, her vital signs were as follows: Glasgow Coma Scale, E4V5M6; systolic blood pressure, 110/66 mmHg; pulse rate, 77 b.p.m.; percutaneous oxygen saturation, 100% under room air; respiratory rate, 20 breaths/min. She had mild posterior neck tenderness and pelvic tenderness with a seat belt mark. The findings of a focused assessment with sonography for trauma, chest X-ray, and pelvic X-ray in the ambulance, after the patient verbally confirmed that she was not pregnant, were all negative . She received a diagnosis of cervical sprain and pelvic contusion and was transferred to a local hospital by ambulance staffed only with emergency medical technicians.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_7_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_7_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c2a60107fd1cff7e7c95406922835e0d829801ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_7_en.txt
@@ -0,0 +1,5 @@
+In this report, we describe the case of 55-year-old lady of Central African origin with primary open-angle glaucoma (POAG) who underwent bilateral XEN gel surgery.
+The patient was initially referred by her general ophthalmologist to a tertiary glaucoma center with intraocular pressures (IOP) of 38 mm Hg and 22 mm Hg in the right and the left eyes, respectively. She had been diagnosed with POAG several years before and had been managed with two selective laser trabeculoplasties (SLT) and maximal medical therapy including oral acetazolamide (Vifor Pharma, Bern, Switzerland), despite mediocre self-reported compliance. She had a positive family history for open-angle glaucoma in her mother. At the time of presentation, her best-corrected visual acuity was 10/10 in both eyes on a decimal chart (6/6 Snellen) in slightly myopic eyes (−0.75 D and −1.25 D spherical equivalent in the right and the left eyes, respectively). Slit lamp examination revealed a deep and quiet AC and a clear crystalline lens. Cup/disk ratio was 0.8 in the right eye with an inferior notch and 0.7 in the left eye with a superior notch. Gonioscopy showed bilaterally open angles. Pachymetry was 580 μm and 585 μm in the right and the left eyes, respectively. Automated visual field examination (Octopus, Haag Streit, Koeniz, Switzerland) showed bilateral nasal quadrantanopsia. Optical coherence tomography imaging (Spectralis OCT, Heidelberg Engineering AG, Germany) of the retinal nerve fiber layer (RNFL) showed generally reduced RNFL thicknesses bilaterally, with complete atrophy of the RNFL inferiorly in the left eye. Brain MRI imaging was unremarkable.
+Bilateral mitomycin C-augmented XEN gel stent implantation was organized with a target IOP ≤18 mm Hg. Surgeries were performed following standard protocols described in the literature. No intraoperative complications were noted, and the patient received a standard postoperative treatment of topical combined tobramycin and dexamethasone (Novartis Pharma, Basel, Switzerland) in decreasing regime. The right eye recovered uneventfully, with IOP normalizing between 12 mm Hg and 16 mm Hg at 3 months, with no additional therapy. The left eye developed a 2-mm hyphema on the first day following surgery, associated with dense RBC in the AC and corneal edema. The initial intraocular pressure was 2 mm Hg, which gradually improved with scopolamine (OmniVision Pharma, Puchheim, Germany) to 9 mm Hg at day 3. After 8 days, the hyphema had completely resolved and IOP was stable at 12 mm Hg. After 1 month, the patient presented to her postoperative follow-up with an IOP of 50 mm Hg in the left eye. On examination, the filtration bleb was shallow but diffuse, the iridocorneal angle was open, the XEN gel stent was well-positioned, and no clear obstruction was visible on its intraocular tip.
+Intraocular pressure was reduced using topical and intravenous medications, and an emergency revision procedure was organized in theater. The absence of filtration through the stent was confirmed intraoperatively and the blocked tube was removed. It was sent for macroscopic analysis to confirm the cause of the obstruction and was replaced by a new XEN gel implant. The patient made good recovery without any postoperative complications, and at 1-month, her IOP was stable at 17 mm Hg.
+The macroscopic examination confirmed obstruction of the XEN gel stent on its AC extremity, with translucent cell fragments . No fibrin, blood clot, or other type of tissue could be identified within the obstructed tube.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_801_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_801_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..54b68592b1cbd61a2d86cb659dc601e742fa5479
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_801_en.txt
@@ -0,0 +1,6 @@
+The recipient of the blood transfusion was a 16-year-old Sri Lankan boy who has beta thalassaemia major with a co-morbidity of blood transfusion-induced cardiomyopathy. Thalassaemia is the commonest monogenic disease in Sri Lanka . The patient, who is from the Polonnaruwa district in the North Central Province of Sri Lanka gave no history of travel overseas. He had been splenectomized in 2010 and receives monthly blood transfusions. His last transfusion had been on the 21st of April 2021. He developed fever and headache 13 days following the transfusion on 4th May for which he sought treatment from a General Practitioner two days later. He was treated for a viral fever with anti-pyretics and malaria was not suspected nor tested for at this stage of the illness. As the fever did not respond to treatment he was admitted to the General Hospital, Polonnaruwa on the 9th of May 2021 for further investigation and treatment, 18 days after the blood transfusion. As a part of the routine fever surveillance activities carried out in hospitals by the Public Health Field Officer (PHFO) for the AMC, the patient was tested for malaria soon after admission, and was reported positive for P. falciparum by microscopy (parasite density of 51,315/μl with asexual parasites and gametocytes). The diagnosis was also confirmed by polymerase chain reaction testing.
+The day after admission, when the malaria diagnosis was confirmed the patient was febrile (37.8 °C), had a blood pressure of 90/60 Hgmm and a normal heart rate. Laboratory investigations revealed a haemoglobin (Hb) of 5.4 mg/dl, WBC count of 31,300/μl and a platelet count of 378,000/mm3. The patient was treated with artemisinin-based combination therapy (ACT), artemether-lumefantrine, the first-line treatment for P. falciparum malaria in Sri Lanka, for 3 days at the standard recommended dosage under supervision, based on national malaria treatment guidelines . Routine investigations on liver and other functions were performed.
+The patient’s clinical condition deteriorated over the first 3 days of treatment. The peripheral blood parasitaemia declined very slowly from a starting density of 51,015 parasites/μl on admission. After 72 h of commencement of anti-malarial treatment the parasitaemia was 7147 parasites/μl, blood pressure remained below normal at 90/50 mmHg, haemoglobin (Hb) level fell to 7.6 mg/dl and the WBC count was 47,430/mm3. He still had irregular spikes of fever. The liver enzymes increased (AST from 86.5 U/L to 250.8 U/L and to 458.9 U/L; and ALT from 62 U/L to 174.3 U/L and 314.9 U/L) over 3 days. Serum C-Reactive Protein was elevated above 100 mg/L. The patient was managed with intravenous inotropes (noradrenalin) because of the poor response of blood pressure to fluid therapy. With parasites persisting in peripheral blood on completion of the ACT course at 72 h, and deterioration of the patient’s clinical condition, further anti-malarial treatment options were considered. The second-line anti-malarial medicine in Sri Lanka, dihydroartemisinin-piperaquine (DHAPPQ) could not be used in this patient because it is contraindicated in cardiomyopathies which the patient suffered from. Treatment with the next option, intravenous artesunate 2.4 mg/kg was, therefore, commenced immediately (i.e. 72 h after starting anti-malarials) and given for a further 3 days while the patient was managed in the Coronary Care Unit of the hospital. Following the last dose of IV artesunate, he was started on a 3-day course of oral artemether-lumefantrine as the recommended practice after parenteral artesunate. By day seven of commencement of treatment, asexual malaria parasites were no longer seen in blood smears, but gametocytes (sexual stages) were present at a density of 270/μl. The patient had improved clinically by then and had a stable blood pressure after withdrawal of inotropes, and liver function test had returned to normal levels (AST- 48.7 U/L and ALT- 25.5 U/L). The gametocyte count decreased gradually to 152 parasites/µl on completion of oral ACT on day 9. A stat dose of primaquine (0.75 mg/ kg−3 tablets) was given on day 10 for its anti-gametocyte activity. The patient was completely cleared of parasites including gametocytes by day 15. Following the transfusion of three units of blood the patient was discharged from hospital on day seventeen (post transfusion Hb was 9.8 mg/dl (27th April 2021). Data on beta thalassaemia patient diagnosed with malaria is provided in Additional file : Table S1.
+Upon diagnosis of malaria in the recipient, information on the blood donor of the last transfusion given to the recipient on the 21st of April 2021 was traced, based on the records maintained by the National Blood Transfusion Service. The donor was a member of the armed forces who had returned to Sri Lanka on the 9th of December 2020 after spending 16 months in South Sudan on a United Nations peacekeeping mission. He was also traced in the AMC database as a person who was being kept under surveillance. While in South Sudan he had taken mefloquine and doxycycline as antimalarial prophylaxis, but reportedly, not on a regular basis. As per guidelines of the AMC, and through the close collaboration that exists with the armed forces, their members arriving from malaria endemic countries are screened for malaria by microscopy and Rapid Diagnostic Tests (RDT) at the airport, or, due to the current COVID-19 pandemic, at COVID quarantine centers where they are kept for 14 days. The first malaria screening of the group of 51 armed forces personnel of whom the blood donor was one, was performed at the airport on the 9th of December 2020 and he and the rest of the group were reported as negative for malaria by microscopy and RDT. He was asymptomatic on arrival and gave no history of malaria while in South Sudan. He had donated blood four months after his return, on the 9th of April 2021 and this blood donation was used on the beta thalassaemia patient. Prior to transfusion the blood product was screened for malaria by microscopy as a routine procedure but was reported as negative. However, when the stored blood smear was examined retrospectively after the incident of transfusion-malaria, it showed P. falciparum parasites (asexual parasites—112 parasites/μl, gametocytes—32 parasites/μl). On testing the asymptomatic donor for malaria on 10th May 2021, soon after the recipient was diagnosed, he was found to be positive for malaria by microscopy at a very low density of 32 parasites/ μl with ring and gametocyte stages of P. falciparum. On admission his Hb was 15.2 g/dl. He was admitted to the same hospital ward as the blood recipient a day later, and was treated with an oral ACT artemether-lumefantrine and a single dose of primaquine . His blood parasitaemia was completely cleared on day 3 of treatment and was discharged from hospital on the 4th day.
+Reactive parasitological and entomological surveillance activities commenced the same day as the diagnosis of malaria was made in the blood recipient and donor respectively in accordance with AMC’s prevention of re-establishment strategy. Primary and secondary case surveillance was carried out covering all residents of houses within a radius of 1 km of residencies of both the recipient and the donor . A total of two hundred persons were screened by microscopy and were found negative for malaria. The blood donor had 51 travel contacts in the armed forces group which had returned with him from South Sudan who were screened by microscopy, and they all reported negative for malaria.
+Entomological surveillance was conducted within a radius of 1 km of the residence of the blood recipient. With the reporting of larvae of Anopheles culicifacies, the primary vector of malaria in Sri Lanka, larval source management, space spraying and distribution of long-lasting insecticidal nets (LLINs) were carried out. Entomological surveillance was also carried out around all sites where, the blood donor had stayed night over the past 14 days from blood donation up to diagnosis, and larvae of primary vector was found in two locations. The same vector control methods mentioned above were applied at these sites as well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_806_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_806_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1acc62502e37c0f14a35566b6ec3e23bc0510dbc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_806_en.txt
@@ -0,0 +1,7 @@
+This is a 28-year-old African para1 housewife who presented with symptoms of irregular menses, vaginal bleeding, and lower abdominal pain of one-year duration. Seven years prior, she gave birth at home with the assistance of a traditional birth attendant who had difficulty delivering the placenta. After the delivery, both the mother and neonate were in good health and did not visit a hospital. Our patient had no previous history of gynecologic surgery, sexual disorders, pelvic inflammatory disease, or abortions. She received an HPV vaccination. There were no intermenstrual or postictal bleedings, and her menses, which last 3–5 days, occur every 28–30 days.
+She has had normal menses for the six years following the delivery, but she has not been able to conceive. She was examined for infertility at a private clinic, where she was informed of normal results from hormonal (LH, FSH) and abdominopelvic ultrasound studies. She experienced a mass-like sensation in the vagina, abdominal pain, and vaginal bleeding 2 months before presenting to our hospital. She was diagnosed with AUB (abnormal uterine bleeding) after being investigated with a CBC (complete blood count), which showed moderate anemia, at a local health center. Despite being given iron tablets and a combined oral contraceptive, her symptoms had not improved. In addition, she had no family history of bleeding diathesis, diabetes, heart disease, or any previous gynecological procedures.
+Upon admission, the patient appeared pale and acutely sick, with vital signs showing a pulse rate of 112 beats per min and a blood pressure (BP) of 90/60 mmHg. On physical examination, she had pale conjunctiva and a soft and non-tender abdomen. PV examination showed there was a rubbery mass protruding through the cervical OS, which made it difficult to pass the examining finger through the cervical rim.
+On investigation, her hemoglobin and hematocrit were 3.9 g/dl and 12%, respectively. Pelvic ultrasound revealed the uterine fundus to be on cervical OS, as depicted in Fig. , pointing towards the diagnosis of uterine inversion. There were no tumors or fibroids on the pelvic ultrasound.
+After transfusing 3 units of whole blood, the patient was prepared for surgery, and the first step was to try to manually return the fundus into the uterine cavity, which yielded no success. Under general anesthesia, the abdomen was opened by a Pfannenstiel incision, where a typical flower vase appearance with fundal cupping of the uterus and inward pulling of the tubes and ovaries was seen as in Fig. . Hence, confirming the diagnosis of uterine inversion. The uterus was held at the level of the bilateral round ligaments, and a vertical incision was made to the posterior wall at the point of the constrictor ring. Finally, the uterus was gently lifted upward and repositioned as depicted in Fig. , and the normal anatomy of the pelvic organs was restored by Haultain’s technique. Apart from the inversion, there were no masses or abnormal findings on the uterus.
+Our patient’s post-operative period was uneventful, with no complications and stable observations. Investigations (a renal function test and a liver function test) done after the surgery were within the normal range. Upon correction of the post-operative hemoglobin and hematocrit to 10 g/dl and 29%, respectively, she was discharged with iron tablets and advised on the next delivery. In addition to being given a subdermal implant, we stressed the need to deliver the next child by elective cesarean delivery. At her follow-up visit at 4 weeks, the patient was well, with normal vital signs and no bleeding. On a subsequent visit in the third month, the patient reported no new complaints, and menstrual flow was normalized.
+The patient returned 16 months after the procedure and informed us of her desire to conceive. Upon removal of the contraceptive, we advised her to adhere to strict follow-up. She conceived 4 months later, and her follow-up antenatal care was uneventful. At 37 weeks, the patient started to have labor pains and was unable to reach a hospital in time. By the time the ambulance arrived at her home, she was in the second stage of labor and had delivered via spontaneous vaginal delivery on the way to a health facility. The placenta was removed carefully by a midwife once she arrived at the hospital, and there was no excessive bleeding or derangement of the vital signs. Abdominal ultrasound, performed in the immediate postpartum period and on subsequent follow-up after 3 months, showed the uterus in its normal position.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_822_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_822_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e26afbb945b61eb7598a677aabb136c905c1326
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_822_en.txt
@@ -0,0 +1,3 @@
+A 69-year-old woman presented with pericardial discomfort and was subsequently diagnosed with advanced gastric cancer after upper gastrointestinal endoscopy. The patient underwent laparoscopic distal gastrectomy with D2 lymph node dissection, and the final pathological diagnosis was U, Less, Type 2, 46 × 38 mm, adenocarcinoma with enteroblastic differentiation, pT4a, INFa, Ly0, V0, pPM0, pDM0, pN2, and pStageIIIA (Japanese Classification of Gastric Carcinoma) . Human epidermal growth factor type 2 was negative, combined positive score of programmed cell death ligand 1 was 5 or higher and microsatellite instability was negative. The patient received oral S-1 (80 mg/m2 twice a day for 1–28 days) as postoperative adjuvant chemotherapy, but liver metastases were observed 8 months later in segments 4 (41 × 39 mm) and 8 (24 × 22 mm). The location and number of metastases were confirmed by contrast-enhanced computed tomography (CT), magnetic resonance imaging (MRI) and positron emission tomography (PET)–CT. There was no elevation observed in the tumor markers carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9). The patient was switched to weekly paclitaxel plus ramucirumab, but Grade 4 neutropenia was observed during the first cycle, and nivolumab monotherapy was initiated (3 mg/kg intravenously every 2 weeks) after consultation with the patient .
+After eight cycles, the target lesion of liver metastasis achieved a PR by Response Evaluation Criteria in Solid Tumors (RECIST), and nivolumab treatment was continued. After 18 cycles, liver metastases had shrunk to 24 × 22 mm in segment 4 and 11 × 9 mm in segment 8, and PET–CT showed no abnormal fluorodeoxyglucose (FDG) accumulation in liver metastases, and no new metastases appeared. CEA and CA19-9 did not show any significant changes within the normal range during the course of treatment. However, at this point, the patient developed a Grade 3 immune-related adverse event (irAE), a pemphigoid skin disorder, and the nivolumab treatment was discontinued.
+As the metastases were controllable with anticancer agents, no new lesions appeared, and the patient’s performance status was maintained, it was decided to resect the liver metastases. The patient underwent laparoscopic partial hepatectomy for segments 4 and 8, resulting in pathological CR . After a medication withdrawal period due to the surgery, the skin disorder had resolved, and postoperative chemotherapy with nivolumab was resumed. However, due to a recurrence of the skin disorder, the chemotherapy was immediately stopped. The patient was followed up without treatment, and no recurrence findings were observed for 25 months postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_824_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_824_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10f61102537e9600b4270847d24b4de097d8c50b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_824_en.txt
@@ -0,0 +1,5 @@
+A 26-year-old female patient came to our hospital with history of pain and black discoloration of index and little fingers of right hand for last 1 month with history of intermittent claudication of right arm for which she had difficulty in doing her household work. Patient was not a known diabetic or hypertensive. There was no history of fever, joint pain, oral ulcer, photosensitive rashes, Raynaud's phenomenon, chest pain, palpitation, trauma, pain abdomen, pedal swelling, headache, visual abnormalities, chronic drug intake, or addiction. Past and family history was noncontributory. Patient was unmarried.
+On examination, pulse rate was 88 beats/min, regular with brachial and radial pulse on right side found to be feeble compared to left side. Lower limb peripheral pulses were normal and equally palpable both side. Blood pressure was 94/68 mmHg in the right arm, 124/78 mmHg on left arm, and 138/84 and 144/80 mmHg in right and left leg, respectively. There was a bruit audible over infraclavicular region on the right side without any renal or abdominal bruit. Local examination of left hand showed, there was a dry gangrene with a clear cut line of demarcation between normal and gangrenous tissue . Other systemic examination was absolutely normal.
+Further investigational workup revealed patient's hemoglobin was 10.4 g/dL, total leukocyte count of 8,600/mm3 with normal differential count and platelet count. Erythrocyte sedimentation rate (ESR) was 104 mm/h withhigh sensitive C-reactive protein (hsCRP) was 8 mg/L. Patient had fasting and postprandial blood glucose of 98 and 116 mg/dL, respectively. Liver, renal function, and coagulation profile were normal with lipid profile study showed total cholesterol of 98 mg/dL, triglyceride of 123 mg/dL, and low density lipoprotein (LDL) of 45 mg/dL. Antinuclear antibody (ANA), perinuclear antineutrophil cytoplasmic antibody (p-ANCA), cytoplasmic antineutrophil cytoplasmic antibody (c-ANCA), anti-β2 GP1antibody, anticardiolipin antibody, lupus anticoagulant, hepatitis B surface antigen, hepatitis C virus, and human immunodeficiency virus (HIV) status were negative. Cardiac evaluation with electrocardiogram and two-dimesnional (2D) echocardiography was absolutely normal. Carotid Doppler study showed narrowing of lumen of bilateral internal carotid artery with normal carotid intima-media thickness (CIMT) without any evidence of plaque.
+Invasive peripheral conventional angiography revealed stenosis in the left subclavian artery proximal to the origin of the vertebral artery and right common carotid artery [Figure –]. According to angiographic classification, patient had type I TA. Bilateral renal, common iliac artery showed normal pattern [Figure and ].
+Patient was put on prednisolone 1mg/kg body weight and wound debridement done under surgical department. Patient discharged thereafter, and put on follow-up in outpatient door. Patient showed dramatic improvement in symptoms in late visit.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_850_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_850_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2811e4fc39762b85fc712458cee94ad1e2bbb2e6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_850_en.txt
@@ -0,0 +1,8 @@
+An 11-year-old boy who was diagnosed with MS was referred to our clinic with the complaint of reduced vision in his left eye. He had noticed a decreased vision in his left eye following a mild head trauma 2 weeks prior to our visit. He was found to have optic nerve swelling and was referred to a neurologist. Neurological examinations were normal. Brain magnetic resonance imaging (MRI) revealed high T2/FLAIR intensity lesions at juxta-cortical, subcortical, and periventricular white matter, as well as corpus callosum, calloso-septal interface and cervical and thoracic spinal cord without restricted-diffusion or enhancement (Supplementary Fig. 1). The diagnosis of pediatric-onset MS (POMS) was established by an MS specialist. Intravenous (IV) methylprednisolone (1g daily for 5 days) was administered, but his vision did not improve prompting referral to our center.
+In ophthalmologic examination in our clinic, the patient's visual acuity (VA) was 6/10 in the right and finger counting (FC) at 50 cm in the left eye. Anterior segment examination revealed bilateral mild injection of conjunctiva. There were no cells in the anterior chamber (AC). The intraocular pressure (IOP) measurements were within normal limits. A prominent relative afferent pupillary defect (RAPD) was present in the left eye. Vitreous organization, 2 + vitreous cells and haze, snowballs and snowbanks were observed in both eyes.
+In fundus examination, the left optic disc had blurred margins along with peripapillary hemorrhage. The right eye optic nerve examination was unremarkable . Perivascular sheathing in the peripheral retina could be appreciated in both eyes.
+Retinal nerve fiber layer (RNFL) optical coherence tomography (OCT) scans revealed remarkable increase in the left eye optic nerve head RNFL thickness . Macular spectral domain (SD)-OCT illustrated the posterior vitreous cells; Both eyes exhibited perifoveal non-cystic retinal thickening, which could potentially serve as an indicator of significant peripheral retinal vascular leakage, as suggested by a recent study . In fluorescein angiography, optic disc leakage, periphlebitis and vascular leakage in equator and more predominantly in the periphery of the retina were observed bilaterally; no macular leakage was evident..
+All laboratory testing including PPD, ACE, VDRL and RPR were reported within normal range or non-reactive.
+The patient was diagnosed with bilateral POMS associated intermediate uveitis. Considering active uveitis despite receiving high dose systemic corticosteroid, posterior sub-Tenon triamcinolone acetonide (20 mg/0.5 ml) was administered to each eye.
+At the same time, the patient was treated with another IV methylprednisolone (1 g daily for 3 days) and also plasmapheresis for five sessions in neurology ward; the treatment was continued with Rituximab (prescribed as 500 mg, IV infusion separated by two weeks and then every 6 months).
+After four months, the patient's vision improved to 10/10 and 9/10 in the right and left eye, respectively. The intensity of vitreous cells and haze decreased to 0.5 + in both eyes. At 4 months follow-up, fluorescein angiography demonstrated that optic disc and vascular leakage had subsided bilaterally .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_851_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_851_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c0f6f9645bf1543ebd73c9e8ed065b609f207fe4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_851_en.txt
@@ -0,0 +1,6 @@
+A 37-year-old man with a past medical history of AIDS-related lymphoma was admitted to Beijing Youan Hospital on 12 July 2016, for a relapse of diffuse large B cell lymphoma. The patient had been diagnosed with AIDS-related lymphoma 1 year earlier, and received eight courses of chemotherapy with rituximab, doxorubicin, vincristine, and etoposide (R-EPOCH). The patient recovered well and was discharged, with advice for regular follow-up. Three months ago, the results of a positron emission tomography-computed tomography scan suggested lymphoma recurrence, and the patient was transferred to our institution with an indwelling central venous catheter (CVC) catheter that had been inserted 3 months earlier for administration of chemotherapy. After 3 days of chemotherapy with etoposide, ifosfamide, and cisplatin, the results of clinical laboratory tests revealed myelosuppression, with white cell count of 0.11 × 109/L, hemoglobin of 4.0 g/dL, and platelet count of 8 × 109/L. His body temperature had been abnormal for 2 days, reaching 38.6 °C at the highest point, with procalcitonin of 0.96 μg/L, ESR of 56 mm/h, and CD4+ T-lymphocyte count of 52 × 106 cells/L. A physical examination revealed no specific signs of infections or skin manifestations. Two sets of blood cultures, one from a peripheral vein and the other through the CVC (each 10 ml in volume), were collected and sent to the laboratory for examination. The patient was started on empirical antimicrobial therapy with imipenem.
+The blood culture drawn through the CVC was first flagged as positive by a BACTEC™ FX instrument (Becton, Dickinson and Company, USA) after 38 h of incubation in an aerobic bottle. After 61 h of culture in an aerobic bottle, the peripheral blood culture also became positive. Direct microscopic examination based on Gram staining revealed the presence of nonsporulating beaded Gram-positive bacilli. Subcultured blood specimens were plated on sheep blood agar and MacConkey agar. On the sheep blood agar incubated at 35 °C in an aerobic environment with 5% CO2, small white colonies became evident within 24 h. After 3 days of incubation, the colonies became mucoid, and the colonies turned yellow-orange. The bacteria were positive for catalase, negative for cytochrome oxidase activity, nonmotile, and unable to grow anaerobically.
+Bacterial identification was performed by matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS) according to the manufacturer’s instructions, and the obtained protein profiles were processed and analyzed by MALDI Biotyper 3.0 software (Bruker Daltonics, Germany). However, the MALDI-TOF MS failed to confidently identify the isolate to the species level. Nevertheless, the isolate was identified as a Gordonia species, with a top match score of 1.764 (for Gordonia rubripertincta; scores of ≥2.0 and <2.0 to ≥1.7 represent identification to the species level and genus level, respectively), suggesting it did not resemble any known Gordonia species in the database.
+Thereafter, bacterial DNA extraction, PCR amplification, and DNA sequencing of the 16S rRNA with a universal primer pair were conducted to confirm the results. The obtained product sequence (1404 bp) was compared with published sequences in the GenBank database . The results showed that the isolate had 99% matches with the type strains of G. polyisoprenivorans (strains W8130 and VH2), Gordonia bronchialis (strain DSM 43247), and Gordonia terrae (strain EY-T12). Sequencing of the gyrB genes was then performed according to a previous report . The results showed that the gyrB gene of the isolate had 99.0% sequence identity with the gene sequence of the G. polyisoprenivorans strain, indicating that the isolate was G. polyisoprenivorans.
+The isolate was sensitive to amikacin, ampicillin, amoxicillin-clavulanate, cefotaxime, imipenem, meropenem, ciprofloxacin, minocycline, linezolid, and vancomycin, with intermediate sensitivity to trimethoprim-sulfamethoxazole.
+At 3 days after the start of imipenem therapy, there was a complete disappearance of fever and a remarkable improvement in the patient’s clinical status. From day 5 onward, the patient was switched to oral antibiotics. As there was no swelling or effusion around the CVC, the catheter was not removed. The patient was followed up for 3 months. There was no recurrence of the infection during the follow-up period. However, he died after 3 months apparently from progression of his hematological malignancies.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_878_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_878_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..741095a1c49c202adc6ea355cdb2864363a2ee16
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_878_en.txt
@@ -0,0 +1,4 @@
+A 73-year-old woman presented with dyspnea on exertion. Chest radiography showed an enlarged mediastinal silhouette. Preoperative computed tomography (CT) and echocardiography revealed a giant cyst (12 × 10 cm in diameter) occupying a large area around the left atrium and ventricle, and it was present behind the pulmonary artery. Based on the preoperative CT findings, a pericardial or an epicardial cyst was suspected. Additionally, attachment of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was suspected . Compression of the left atrium and ventricle was considered to be the cause of her symptoms. Her hemodynamic condition was stable. Percutaneous cystocentesis was performed, and 800 ml of serous liquid was aspirated. However, 1 week after cystocentesis, the cyst recurred, and its size was the same as that before the procedure. Therefore, resection was planned.
+If the cyst was an epicardial cyst, tight adhesion of the cyst to the left atrium, left ventricle, pulmonary artery, and pulmonary vein was considered possible. However, we believed that the cyst was more likely a pericardial cyst because a pericardial cyst is more common than an epicardial cyst. Therefore, resection involving video-assisted thoracoscopic surgery (VATS) was planned initially. However, the pericardium was intact and an epicardial cyst was diagnosed intraoperatively. As preoperative CT showed compression of the left atrium, ventricle, pulmonary artery, and pulmonary vein, adhesion was suspected. Additionally, the possibility of cardiopulmonary bypass (CPB) was considered. Therefore, open surgery through median sternotomy was performed. The cyst was found to be attached to the visceral pericardium involving the left atrium and pulmonary artery. Contrary to our expectation, the left ventricle was not involved. Additionally, coronary vessels were not involved. The cyst was most tightly attached to the main pulmonary artery. Thus, it was thought to have originated from the pulmonary artery . The content fluid was aspirated via direct puncture, and a heart positioner was used to provide sufficient traction to the right side, with several sutures placed on the cyst wall, so that the back of the heart and the pulmonary artery could be observed. The cyst wall was thick and hypervascular, and it was completely dissected with an ultrasonic scalpel. The surgery was successfully completed without CPB.
+The postoperative course was uneventful. CT confirmed absence of cyst recurrence or pericardial effusion. There has been no recurrence of the cyst since discharge (2 years).
+Histopathological examination revealed a single layer of mesothelial cells. In addition to blood and lymphatic vessels, calretinin-positive cells lining the cystic wall, alpha-smooth muscle actin-positive cells, smooth muscle negative for myoglobin, neuron-specific enolase positive cells, lymphocyte infiltration, and fibrosis were observed .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_916_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_916_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28ac9fbc292c998a8b6de3b30a0914a06776c7ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_916_en.txt
@@ -0,0 +1,5 @@
+We present a rare and interesting case of a 68-year-old White male with T4aN1bM0, stage III (AJCC 8th edition) squamous cell carcinoma of the thyroid. His past medical history included hypertension, prostate cancer treated with androgen deprivation therapy, external beam radiation therapy, and brachytherapy, and a benign parotid tumor status post-parotidectomy 20 years prior. He was retired from working in corporate management, and family history was significant for lung cancer in his father and breast cancer in a sister. Comorbid illnesses included gastrointestinal reflux disease, for which he took ranitidine 150 mg daily and omeprazole 20 mg daily; hypertension, for which he took lisinopril 12.5 mg daily; hyperlipidemia, for which he took atorvastatin 20 mg daily; and seasonal allergies and asthma, for which he took montelukast 150 mg daily and loratadine 10 mg daily. He was also using naproxen and cannabis for cancer-related pain at time of presentation. He was a lifelong non-smoker and did not drink alcohol to excess. He first noticed his right neck mass while shaving 3 months prior to presentation. He reported some mild pain with swallowing, weight loss of unknown amount, right neck sensitivity to light touch, increased hoarseness, and a raspy voice. He was initially diagnosed by his primary care physician as having lymphadenopathy secondary to a sinus infection and received two rounds of antibiotics. The mass failed to improve and, as a result, a fine needle aspiration of the lesion was performed. Evaluation of the biopsy material demonstrated dysmorphic cells containing cytoplasmic keratin, which stained positively for CK5/6, consistent with a squamous cell carcinoma. Monoclonal PAX-8 (Biocare Medical, BC12) staining was also focally positive . Subsequent laryngoscopy revealed no mucosal lesions, but right vocal cord paralysis was observed. A CT of the neck with contrast revealed a 4.8 cm peripherally enhancing hypodense mass with central necrosis lateral to the right hyoid bone, emanating from the thyroid gland . Multiple smaller nodular lesions within the prevertebral space, right paraesophageal region, and superior mediastinum were also identified. A staging PET scan showed a hypermetabolic right thyroid lobe with extensive conglomerate pathologic adenopathy at the right cervical lymph node chain, extending inferior to the right thoracic inlet, as well as a left retropharyngeal hypermetabolic lymph node, but no evidence of distant metastasis . On initial physical and neurologic examination, the oncology team noted a large, firm, fixed right medial neck mass without overlying skin changes, and a normal cranial nerve exam.
+The patient’s case was discussed at the head and neck multidisciplinary tumor board, with a consensus opinion that this squamous cell carcinoma was indeed of thyroid origin. Extensive surgical resection including a laryngectomy, thyroidectomy, and reconstruction followed by adjuvant chemoradiation as a potential curative course was recommended. However, due to the morbidity and lifestyle implications associated with surgery, the patient declined surgery and instead chose to pursue concurrent chemoradiation with weekly chemotherapy.
+Intensity modulated radiation therapy (IMRT) was used to treat the right thyroid mass to 70 Gy in 35 fractions at 200 cGy per fraction, as well as bilateral retropharyngeal nodes cervical neck nodal levels IB, II, III, IV, and V to 63 Gy in 35 fractions at 180 cGy per fraction . The patient completed radiation with weekly concurrent carboplatin-paclitaxel over 7 weeks. During treatment, he developed grade 2 fatigue, grade 2 mucositis, grade 2 dermatitis, grade 3 dysphagia, and grade 3 dry mouth with thickened secretions with excessive mucus. The skin desquamation was treated with silver sulfadiazine and mineral oil-hydrophil petrolat. A percutaneous endoscopic gastrostomy (PEG) tube was placed during the first week of treatment due to nutrition and oral intake difficulties at baseline, and the patient lost less than 15 lbs throughout the treatment. Long-term toxicity was significant for chronic xerostomia and dysphagia, requiring a permanent gastrostomy tube. He also developed treatment-related hypothyroidism and was started on levothyroxine approximately 3 months after completion of treatment, when his thyroid-stimulating hormone (TSH) was found to have gone up from 1.63 (baseline, normal) to 21 mIU/mL (elevated).
+After receiving concurrent chemoradiation, the patient underwent two additional cycles of high-dose carboplatin–paclitaxel every 3 weeks. Follow-up imaging after concurrent chemoradiation suggested a partial therapeutic response. PET (18-fluorodeoxyglucose/18-FDG)/CT of the neck demonstrated that the thyroid mass had decreased in size from 5.0 × 5.2 cm, with maximum standardized uptake values (SUV) of 35.3, to 3.8 × 2.1 cm, with maximum SUV of 19.4 . This was also apparent on physical examination, where the tumor was smaller, softer, and less tender to palpation. The right and left neck lymph nodes were also notably smaller and demonstrated less PET-avidity. Imaging of the chest, however, revealed pulmonary metastases up to 9 mm in size, as well as multiple bilateral hypermetabolic nodules .
+In light of the new pulmonary metastatic disease, additional systemic chemotherapy with carboplatin–paclitaxel was recommended to the patient. However, he opted for immunotherapy instead due to previous chemotherapy side effects and subsequently completed nine cycles of pembrolizumab. Imaging studies obtained after the third cycle of pembrolizumab demonstrated an interval decrease in the size of multiple pulmonary nodules bilaterally, suggesting a positive response to therapy . At the same time, however, a CT scan demonstrated an increase in the size of the thyroid mass . Additionally, new encasement of the distal common carotid artery, carotid bifurcation, and proximal internal carotid artery was present, and erosion of the thyroid cartilage was also identified. After the sixth cycle of pembrolizumab, imaging continued to demonstrate enlargement of the thyroid mass with increased extension to the tracheoesophageal groove, while the pulmonary nodules continued to get smaller . Following the ninth cycle of pembrolizumab, the thyroid mass had continued to enlarge, eroding the thyroid and cricoid cartilages, extending into the paraglottic space, and invading the cervical esophagus. No new or worsening pulmonary metastatic disease was identified at this time . The tenth cycle of pembrolizumab was halted due to leukocytosis (WBC 21.81 and ANC 19.05) and the patient’s desire to pursue supportive care. Fifteen months after his initial diagnosis, the patient was transitioned to comfort care and died 3 months later. Autopsy was not performed as the patient’s desire was to donate his body to science.
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index 0000000000000000000000000000000000000000..e7fc1e3326d1bb8553f0f418a96f48c8a6686058
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+A 43-year-old Chinese man, who complained of shortness of breath on exertion for 7 d and a 13-year history of peripheral blood eosinophilia, was admitted to our hospital.
+The patient was treated at a local hospital in August 2005 because routine blood examination showed a white blood cell count of 8.5 × 109/L, with 24.2% of eosinophils (2 × 109/L). In a bone marrow biopsy, eosinophils accounted for 13.5%, most with normally segmented rod nuclei. Once oral triamcinolone was initiated (4 mg, tid), the eosinophil counts rapidly normalized. After gradual dosage reduction in a span of 6 mo and eventual discontinuation, hyperplastic and nodular changes developed in both breasts, accompanied by abnormal lactation and bilateral axillary node enlargement. This condition was sufficiently burdensome to require surgery. Bilateral mastectomy was subsequently performed (January 2006) for chronic mastitis. Postoperative pathology examination disclosed male breast development and severe chronic inflammation (i.e., dilatation of mammary ducts with interstitial influx of eosinophils) .
+One month later, the patient presented with joint pain of the trunk and limbs, movement dysfunction, and an exacerbated skin rash. Dexamethasone and prednisone were prescribed. An herbal extract (Tripterygium wilfordii) was also used shortly and then abandoned due to severe treatment-related alopecia. Thereafter, the joint symptoms gradually relented, allowing the patient to resume work. In April 2017, however, bilateral lower extremity edema developed spontaneously (blood pressure, 150/100 mmHg; plasma albumin, 15.6 g/L; low-density lipoproteins, 6.87 mmol/L; and 24-h urinary protein, 14.78 g/d), prompting a clinical diagnosis of nephrotic syndrome. A kidney biopsy was performed, establishing a pathologic diagnosis of focal segmental glomerulosclerosis, non-specific type . A second bone marrow puncture again was indicative of eosinophilia, but qualitative polymerase chain reaction failed to detect the FIP1L1-PDGFRA fusion gene. The patient was given prednisone orally at an initial dose of 60 mg (12 tablets) per day. This was gradually reduced and discontinued in March 2018, at which time all parameters of nephrotic syndrome were stable.
+One month after medication withdrawal, hospital readmission was brought on by shortness of breath (April 2018).
+He initially presented in December 2004 with constipation, abdominal distension, and persistent vomiting. Gastroscopic inspection revealed superficial gastritis, duodenal bulbar inflammation, and gastric retention. Enteroscopy was then performed, showing rectosigmoid mucositis. Interstitial inflammatory infiltrates were prominent in gastric and colonic mucosal biopsies. After symptomatic treatment, the digestive symptoms gradually abated and disappeared. Several months later, the patient developed an erythematous papular skin rash and vitiligo. The rash coalesced in places but was largely confined to the dorsa of hands and limbs in a symmetric distribution, without itching. Vitiligo chiefly affected the face and trunk.
+Historically, the patient’s birth was premature (8 mo of gestation). There was one episode of pertussis during childhood and many instances of pneumonia. The patient’s father had succumbed to gastric cancer at the age of 50.
+Physical examination revealed alopecia, loss of facial and trunk pigmentation, and an erythematous rash on the dorsa of both hands and limbs . No dry or wet rales were detected in either lung.
+Pertinent laboratory results were as follows: Blood eosinophil count, 0.41 × 109/L; total IgE, 1491 IU/ml; PaO2, 53.6 mmHg; and SaO2, 91.2%. In bronchoscopic alveolar lavage fluid, eosinophils represented 30.0% of cells (CD4+/CD8+ = 0.15).
+Chest computed tomography (CT) showed interstitial pneumonia .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_960_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_960_en.txt
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index 0000000000000000000000000000000000000000..b4e66a8e97c4377b97fb3107f26f53c871015a17
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+A 40-year-old man with unstable Type I diabetes mellitus (with positive anti-insulin antibodies) was followed-up in the diabetology department of Strasbourg University Hospital. The duration of his diabetes was 35 years, during which he had normal renal function, no hematuria, stable microalbuminuria, and no other diabetic complications. Pre-transplant tests revealed neither HLA antibodies nor positive EBV serology, with negative CMV serology, normal cardiovascular exploration, and hepatic morphology. Since he did experience recurrent severe hypoglycemic episodes, the patient was included in the TRIMECO trial . In this trial, the patient received two pancreatic islet allografts using a percutaneous transhepatic portal approach over a 3-month period, without any immediate complications. Immunosuppressive induction for the first procedure included anti-thymocyte globulin (Thymoglobulin®, Sanofi Genzyme) at 0.5–1.5 mg/Kg/day for the first 3 days and anti-TNF-alpha etanercept (Enbrel®, AMGEN) on Day 0, which was decreased to 25 mg on Days 3, 7, and 10. Maintenance immunosuppression was conducted using 1000 mg of mycophenolate mofetil (Cellcept®, Genentech) twice a day and a CNI, tacrolimus (Prograf®, Astellas), twice a day, depending on the residual plasma levels (objectives: 9–13 μg/L for the first 3 months, then 6–9 μg/L thereafter). Induction for the second procedure consisted of 20 mg of the interleukin 2-receptor antagonist basiliximab (Simulect®, Novartis) on Days 0 and 4, along with etanercept. The total number of islets that were injected was 950,000 IEQ (islet equivalents to 150 pancreatic islet diameter). Two months after the second procedure, the patient became insulin-independent with a fasting C-peptide level of 2.3 μg/L (0.77 nmol/L), fasting glycemia of 5.7 mmol/L, and HbA1c of 5.1% (32 mmol/mol). This resulted in the disappearance of his hypoglycemic episodes. About 4 and 8 months after the second procedure, the patient was hospitalized due to recurrent watery diarrhea with Stage 1 acute kidney injury (AKI) , without any signs of hematological TMA. All microbiological explorations (bacterial, virologic, and parasitological in blood and feces) were negative, and kidney function returned to the normal range after intravenous hydration. This digestive episode was possibly linked to an undesirable effect of either mycophenolate mofetil or tacrolimus. However, these drugs were not discontinued.
+About 15 months after the second procedure, the patient was readmitted to hospital for Stage 3 AKI and high blood pressure (200/100 mmHg). All blood and urine analysis results are presented in Table . The renal ultrasonography was normal, and the association of mechanical hemolytic anemia–thrombocytopenia and acute renal failure led us to suspect aHUS . A hemodialysis session was initiated, along with plasma exchange (PEX; 60 mL/Kg) for 11 days. At this time, the first hypothesis established was direct endothelial toxicity due to overdosing of tacrolimus, in the context of dehydration from recurrent watery diarrhea, given that the trough tacrolimus level was at the upper limit of recommended targets. Since the suspicion was AKI/HUS induced by tacrolimus, the patient was first switched to ciclosporin (Neoral®, Novartis). He was subsequently switched to everolimus (Certican®, Novartis, anti m-TOR) after histological analysis of the renal biopsy results favored a typical TMA process . The poor response to PEX and low C3 level led us to suspect aHUS, so eculizumab (Soliris®, ALEXION) was initiated. Eculizumab was started 18 days after AKI was diagnosed, at a weekly dose of 900 mg for the first 4 weeks. Thereafter, therapy was maintained at 1200 mg per week for a further 2 months . At the same time, everolimus was similarly switched to cyclosporine. Although the thrombocytopenia resolved after 8 days of PEX, eculizumab administration was not followed by a recovery of renal function. During AKI, the islet graft remained functional. Despite the patient’s C-peptide level remaining uninterpretable in AKI, external insulin therapy was not deemed necessary to maintain normoglycemia.
+After receiving the patient’s written informed consent, blood samples were taken to screen for the six genes associated with aHUS. A rare nucleotide change (c.1775G > A) was detected in exon 14 of the C3 gene, resulting in an arginine-to-glutamine substitution in the C3 protein at position 570 (p.R592Q). This heterozygous variant, which has already been reported in patients diagnosed with aHUS , is an exposed amino acid located near the membrane cofactor protein (MCP) binding site. Functional analysis using a recombinant protein demonstrated decreased binding of the C3 variant with MCP, compared to the wild type, as well as a reduced rate of C3 cleavage by Factor I with MCP as the cofactor. This variant led to an indirect function gain, relative to complement activation, which explains the permanently low level of C3 in the patient’s plasma that was observed . Genetic evaluations that were conducted on two sisters revealed the same C3 gene mutation, which contraindicated a related living kidney donation.
+The 40-year-old male patient eventually spent 1 year on hemodialysis treatment before undergoing brain-dead-donor kidney transplantation. There was no evidence for HLA immunization prior to transplantation, and preoperative HLA scoring identified four mismatches in HLA Class I, with none in HLA Class II. Cold ischemia time was 16 h. Immunosuppressive induction included basiliximab (Simulect®, Novartis), and eculizumab was continued at a dosage of 900 mg on Days 0, 1, 8, and 15, and then every other week at a dosage of 1200 mg to prevent aHUS relapse. Evidence of hematological TMA was absent in the immediate kidney transplantation follow-up. After kidney transplantation, the immunosuppressive regimen was modified to cyclosporine and mycophenolic acid (Myfortic®, Novartis). Three months after kidney transplantation, renal and pancreatic islet functions were considered excellent, with plasma creatinine levels at 94 μmol/L (1.06 mg/dL) and an HbA1c level of 5.5% (36.5 mmol/mol), without insulin therapy. Kidney function remained satisfactory 12 months after renal transplantation, with a plasma creatinine level of 87 μmol/L (1.0 mg/dL) without TMA lesions at the per-protocol kidney biopsy. Four years after renal transplantation, the patient is still treated with eculizumab, his plasma creatinine is 99 μmol/L, his low C3 level persists, and his pancreatic islet function is satisfactory. He has been insulin free for 5 years. The laboratory results pertaining to the 4-year follow-up are detailed in Fig. .
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index 0000000000000000000000000000000000000000..b9fcff20e3e4584b70864a29ac21c58ecf18ee09
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+A 60-year-old woman was admitted with a mixed GGO in the upper lobe of her left lung that had been found a year earlier . Pre-operative enhanced chest computed tomography (CT) showed that the diameter of the GGO was 8 mm and also depicted the right aortic arch with right descending aorta and absence of the left pulmonary artery . The internal thoracic artery extended to the left lung , which meant that the left lung had a multifocal blood supply. The right lung showed compensatory inflation, and the volume of the left lung was reduced. The mediastinal and hilar lymph nodes were of normal size. Pulmonary function testing revealed increased respiratory resistance, with a forced expiratory volume in 1 s of 1.67 L (71.4%), a peak expiratory flow of 4.83 L/s (79.7%), and a maximum expiratory flow at 75% of forced vital capacity of 3.28 L/s (61.3%). The patient reported no symptoms of hypoxia.
+We performed pulmonary ventilation imaging and perfusion imaging. Pulmonary ventilation imaging showed reduced ventilation function in the upper lobe, the dorsal segment of the lower lobe, and the anterior inner basal segment of the left lung and in part of the apicoposterior segment of the right upper lobe. Pulmonary perfusion imaging showed no developing in the left lung.
+We then performed three-dimensional reconstruction of the bronchi, lungs, pulmonary vasculature, and mixed GGO. The reconstruction revealed that the aortic arch traversed over the right primary bronchus and that the left pulmonary artery was absent . The mixed GGO was in the apicoposterior segment of the left lung .
+During video-assisted thoracoscopic surgery, we observed pleural adhesion in the left side of the thorax and decreased compliance in the left lung. According to the three-dimensional reconstruction, the nodule was in the apicoposterior segment of the left lung, and wedge resection was performed to obtain the specimen for intra-operating pathological diagnosis. The specimen was fast-frozen, and pathological study revealed that it was adenocarcinoma in situ (AIS). On the basis of this pathological diagnosis, wedge resection was recommended. The final pathological examination revealed that the nodule was well-differentiated lung adenocarcinoma . The para-carcinoma tissue showed that there existed the dense tissue , which cause the decreased compliance in the left lung. Immunohistochemical staining showed that the tumor area was positive for c-MET, ROS1, P53, CD10, and CD31 .
+Although the pathological diagnosis was upgraded in this patient, wedge resection was adequate because of the GGO component, and a favorable outcome was expected. Chest CT performed a week after the operation revealed no hemorrhage or pneumothorax . The patient was discharged on postoperative day 7 and instructed to attend a follow-up check a month after discharge. To prevent relapse, regular follow-up was recommended.
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index 0000000000000000000000000000000000000000..6b083af3d0524d885736f126ec2201c95b71cc54
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+A 42-year-old female patient presented in June 2022 with a complaint of gradual progressive painless diminution of vision in the left eye that started 16 months earlier. Clinical history revealed an episode of sudden, profound, painless diminution of vision in the same eye that had occurred 18 months earlier in December 2020. At the time of that episode, visual acuity in the left eye was as low as hand motion, but gradually improved over a period of 4 months to reach 3/60. However, after that initial partial improvement, visual acuity in the left eye progressively deteriorated from 3/60 to become 1/60 at the time of presentation. Through medical history and earlier investigations i.e. FFA, SD-OCT macula , we concluded that the episode of acute drop of vision in the left eye was caused by left CRAO for which the patient had undergone an extensive systemic workup that established a diagnosis of SLE according to EULAR/ARC criteria with positive ANA, positive anti-Cardiolipin Ab, positive beta2 Glycoprotein Ab, fever, thrombocytopenia and non-cicatricial alopecia . The rheumatologist prescribed the patient HCQ at a dose of 400 mg/day which is equivalent to 5.3 mg/kg/day (slightly above the recommended daily dose of 5 mg/kg/day by the AAO revised guidelines 2016) and oral steroids with varying doses throughout the course of treatment ranging between 20 and 60 mg/day. At the time of presentation, ophthalmological examination revealed BCVA 6/6 OD and 1/60 OS, unremarkable anterior segment examination, right normal fundus, left bull's eye maculopathy and temporal optic disc pallor with attenuated retinal vessels .SD-OCT macula was performed which revealed foveal and parafoveal outer retinal defects involving the RPE, ELM, IS/OS as well as intraretinal degenerative cysts and generalized thinning and atrophy of the neurosensory retina in the left eye while the right eye was normal . Therefore, a diagnosis of left advanced HCQ maculopathy was made after exclusion of other possible causes of unilateral bull's eye maculopathy e.g. resolved unilateral acute idiopathic maculopathy (UAIM), subretinal fibrosis and uveitis syndrome (SFU), asymmetric cone or cone/rod dystrophy, benign concentric annular macular dystrophy, Stargardt's disease and traumatic maculopathy. These causes were excluded because none of them matches the clinical picture of our case for variable reasons e.g. the negative family history and the strictly unilateral involvement with completely normal right eye with BCVA 6/6 and intact color vision, excludes dystrophies. Moreover, the insidious rather than acute onset, the absence of signs of uveitis, the strict monofocal foveal and parafoveal involvement as opposed to multifocality, the regular oval edges of bull's eye rather than irregular pigmented edges, exclude UAIM and SFU as possible etiologies. Furthermore, the negative history of ocular or head trauma excludes traumatic maculopathy. Consequently, a recommendation to stop HCQ was conveyed to the rheumatologist who shifted the patient to Leflunomide.What is atypical about this case is the rather early onset maculopathy which manifested in the advanced form of bull's eye maculopathy after only 16 months of HCQ treatment compared to the reported incidence which is < 1% at 5 years. Another unusual aspect is the strictly unilateral involvement where the left eye shows advanced maculopathy while the right eye is normal. We assume that the early onset monocular HCQ maculopathy may be related to the CRAO that affected the same eye prior to HCQ treatment.
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index 0000000000000000000000000000000000000000..80bea60a2363e2160bfbe0c3a4322cab42cecff9
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+A 48-year-old caucasian male with an extensive psychiatric history of depression was admitted to the intensive care unit at a local hospital following intoxication of approximately 20 g venlafaxine, 450 mg zolpidem, and 250 mg propiomazine. His past history included intensive care hospitalization due to two suicidal attempts through pharmacological intoxication and self-harm with a knife. On admission, he was awake but drowsy and had a Glasgow Coma Scale (GCS) 13 of 15 (E3 + V4 + M6) but stable respiratory and circulatory status. His electrocardiography (ECG) was normal with a sinus rhythm of 57 beats per minute. Laboratory findings were within normal range . Admission occurred approximately 2 hours after intake of the pills. Activated charcoal suspension was administered via a nasogastric tube upon arrival at the intensive care unit.
+The patient was stable during the first 5 hours at the intensive care unit (ICU), but then 7 hours post-intoxication he experienced tonic–clonic seizures. This was successfully treated with diazepam 10 mg intravenously, and he was subsequently intubated and sedated with propofol and remifentanil. Vasopressor support with low-dose norepinephrine was also initiated.
+Nine hours after ingestion, his circulation began to slowly fail. Increased doses of norepinephrine were required, and the patient developed metabolic acidosis with lactate elevation. Fifteen hours after ingestion, the patient’s blood pressure fell rapidly despite high doses of norepinephrine. Prompt echocardiography revealed prominent hypokinesia with akinesia from the mid-left ventricle to the apex, as in TTC, with a left ventricle ejection fraction (EF) of 20%. The right ventricle was also affected with a tricuspid annular plane systolic excursion (TAPSE) measuring 10 mm. At this point, dobutamine was added to norepinephrine, but only a few micrograms were infused prior to cardiac arrest.
+Shortly after the addition of dobutamine, his circulatory status deteriorated further, and the patient suffered a cardiac arrest with an initial rhythm of asystole. Advanced cardiac life support was initiated according to national guidelines including manual CPR and intravenous epinephrine. The patient was given three doses of epinephrine 1 mg intravenously, and after 5 minutes without return of spontaneous circulation, the ECMO center at a tertiary hospital was contacted. Fifteen minutes post cardiac arrest, the patient regained circulation temporarily for approximately 10 minutes before relapsing into cardiac arrest. The patient’s circulatory status and blood pressure were, however, inadequate during these 10 minutes. High-dose epinephrine infusion (1.0 µg/kg/minute) was initiated and manual CPR continued for another 30 minutes. The patient was then transported by helicopter to a tertiary hospital using mechanical CPR (AutoPulse Resuscitation System) and ongoing epinephrine infusion. Transportation time was approximately 30 minutes. One hour 15 minutes after the cardiac arrest, the patient was delivered to the tertiary hospital for ECMO initiation.
+Upon arrival at the tertiary hospital and prior to initiation of ECMO, the patient had a sinus rhythm but very low cardiac output. Blood pressure was 55/45 mmHg without cardiac arrest, and external compression was continued whilst ECMO system treatment was established. Short pauses were taken during specifically vulnerable periods of the cannulation procedure. Lactate peaked at 4.6 mmol/L. Two hours after the cardiac arrest, the patient was on ECMO.
+After ECMO initiation treatment with sedation and circulatory drugs continued, continuous renal replacement therapy (CRRT) was initiated. CRRT was initiated due to anuria and creatinine level of 265 µmol/L. Sedation was reinitiated using midazolam and morphine instead of propofol and remifentanil. The amount of epinephrine was significantly decreased during the initial hours of ECMO treatment, and norepinephrine and milrinone were used instead. Multiple plasma and red cell concentrate (RCC) transfusion were also required due to significant bleeding from the femoral artery catheter. The patient was successfully weaned after 32 hours of ECMO. Epinephrine infusion was terminated the same day, while milrinone continued until the following day.
+The patient was transported back to the primary hospital with decreasing doses of norepinephrine the day after ECMO termination. Three days after the cardiac arrest, his cardiac function was echodynamically restored with an EF of above 55%. Values of the cardiac biomarker NT-proBNP decreased from 8360 ng/L the day after the cardiac arrest to 1190 ng/L 36 days after the intoxication. He was ventilated for 8 days and received CRRT for 3 weeks. Two days after extubation, the patient gradually regained consciousness. Thirty days after the intoxication, he had regained normal cardiac and cognitive function and left the hospital for further psychiatric treatment. The patient’s renal function was fully restored with normal creatinine level (82 µmol/L) 7 weeks after the intoxication. He was finally discharged in good health without his former prescribed psychiatric medications. Two years later, his cardiac and renal function were normal, although his psychiatric medication was reinstated.
+The serum venlafaxine concentration 24 hours after ingestion was 12.6 mg/L, but this laboratory result was not received until 1 week after ingestion.
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index 0000000000000000000000000000000000000000..7862dc00ad8b27ac291bfae2b5b27c65f5dbe37d
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+A 42-year-old Caucasian man presented to our hospital with acute onset of fatigue, nausea, vomiting, early satiety, diarrhea, and weight loss 3 months after LCH had been diagnosed on the basis of biopsy of an asymptomatic lesion on the left arm. His physical examination was pertinent for tender hepatosplenomegaly and multiple eczematous papular lesions on the trunk and extremities. His complete blood count (CBC) results and lactate dehydrogenase (LDH) level were normal. Esophagogastroduodenoscopy (EGD) demonstrated herpes esophagitis and Helicobacter pylori gastritis. Biopsies of the duodenum and esophagus showed involvement by LCH with features suggestive of LCS . The BRAF V600E mutation was not detected. Imaging did not demonstrate any suspicious bone or central nervous system (CNS) involvement. His bone marrow biopsy (BMBx) showed no LCH or acute myeloid leukemia (AML). He was started on intravenous cytarabine 100 mg/m2 daily for 5 days every 4 weeks, which led to improvement but no resolution of his skin lesions or gastrointestinal (GI) symptoms. After four cycles, his therapy was adjusted to every 2 weeks in view of kinetic failure. This adjustment led to clinical improvement, but his LDH level continued to rise, leading to repeat BMBx performed after cycle 8, which showed no evidence of AML.
+Three weeks later, he presented with acute left hemianopia resulting from an ischemic cerebrovascular accident. Workup demonstrated circulating blasts, spontaneous tumor lysis syndrome, and disseminated intravascular coagulation (DIC). BMBx confirmed acute monoblastic leukemia with a complex karyotype. Next-generation sequencing (NGS) showed no additional mutations. The patient was started on induction 7 + 3 (daunorubicin/cytarabine), which led to transient resolution of skin lesions that quickly worsened by day 15. The lesions appeared as multiple erythematous papules and nodules throughout the back. Histological sections showed heavily epidermotropic and bandlike dermal infiltrates of leukemic cells in the dermis with pseudo-blisters formed by tumor necrosis . A subset of tumor cells showed features of Langerhans cells, including reniform nuclei and atypical large and hyperchromic nuclei . Immunophenotyping revealed that the tumor cells were positive for langerin, S100, and CD1a with intratumoral heterogeneity and a Ki67 showing a nearly 80% cell proliferation rate . The tumor cells were also positive for CD56, CD117, and CD123 in a subset of cells. The immunophenotype supported both myelomonoblastic and Langerhans cell differentiation. Marrow cytogenetics detected t(13:14) in all tumor cells and additional structural abnormalities involving chromosomes 1, 8, 9, 10, and Y. In this particular context, the cutaneous lesions were best classified as cutaneous involvement of leukemia. Cytogenetic profiling with NGS showed nonsynonymous mutation p.E69K affecting the PTPN11 gene (SHP2), homozygous loss of CDKN2A at 9p21, and a tumor mutational burden of 26%.
+He was started on salvage therapy with CLAG-M (cladribine 5 g/m2, cytarabine 2 g/m2, granulocyte colony-stimulating factor (G-CSF), mitoxantrone 10 g/m2), and after the first dose of filgrastim (G-CSF), he developed acute diplopia with leptomeningeal involvement by AML as identified by brain magnetic resonance imaging and lumbar puncture . Intensive intrathecal therapy with methotrexate (MTX) was initiated twice per week for six cycles. The patient’s skin lesions and neurologic symptoms resolved with restaging consistent with complete remission. However, 1 week later, his skin lesions recurred, followed by recurrence of neurologic deficits that responded poorly to salvage therapy, including high-dose cytarabine, further intrathecal therapy, and CNS radiation. The patient died 1 year after diagnosis of LCH while undergoing treatment with MTX and cytarabine as a bridge to marrow transplant. Table summarizes the cardinal features associated with this case.
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+A 49-year-old man with a 2-year history of neck pain and weakness in both lower extremities was referred to our ward.
+The patient was treated conservatively at the outpatient clinic of Xiangya Hospital, Central South University, over the previous four months. After 4 mo of strict conservative treatment, including nutritional support, pain relief, and herbal medicine interventions, the patient's symptoms were not relieved, and the weakness in both lower limbs progressed even more.
+The patient had a history of pulmonary tuberculosis in both upper lungs for 4 years and was not on regular anti-tuberculosis medication.
+The patient had no specific personal or family history.
+The patient had decreased muscle strength (grade 3) in both lower extremities, significant sensory loss in the left thumb and index finger, active bilateral tendon reflexes, no Hoffmann's sign, and no significant abnormalities in the remaining extremities on physical examination.
+The tuberculosis infection T-cell spotting test was positive, but sputum smears on three consecutive days were negative for acid-fast bacilli. The erythrocyte sedimentation rate was increased, at 48 mm/h (normal range < 15 mm/h), and the results of other routine laboratory tests were normal.
+Plain X-ray radiography of the cervical spine showed destructive lesions in the appendage area of the C4-5 vertebrae . A computed tomography (CT) scan of the cervical spine showed bone destruction and a soft tissue mass in the appendage area of the C4-5 vertebrae . Spiral CT three-dimensional reconstruction showed the outline of bone destruction in the appendage area of C4-5 . The nature of the mass was to be determined, considering the possibility of a benign bone tumor. A contrast-enhanced magnetic resonance imaging (MRI) scan revealed a neoplastic lesion extending from the left epidural space to the paravertebral muscles at C4-5. The lesion was isointense on T1-weighted imaging (T1WI) and heterogeneously hypointense on T2-weighted imaging (T2WI) and showed heterogeneous enhancement . There were no obvious abnormalities in the signals of the remaining cervical vertebrae, and no obvious abnormally enhanced foci were observed after enhancement, suggesting that osteoblastoma was likely. A total bone single-photon emission computed tomography (SPECT) scan showed a slight increase in bone metabolism in the upper cervical vertebrae and the 9th thoracic vertebra, suggesting that positive changes were likely.
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+A 75-year-old woman received denosumab for the 1st time in October 2018 for severe postmenopausal osteoporosis. She had no history of other medication use for osteoporosis. Osteoporosis was diagnosed both clinically and radiographically . She had no nutritional deficiencies or family history of osteoporosis. She had undergone a hybrid THA because of developmental dysplasia of the right hip in 2006. At our hospital, she received denosumab 60 mg per dose, for a total of six doses. Meanwhile, colon cancer was detected in August 2019, and she underwent endoscopic surgery in September 2019. She also underwent positron emission tomography, which showed no metastasis, after which she underwent regular follow-ups without any anticancer drugs. No regular medications were prescribed for other diseases. She had been generally healthy otherwise. In May 2021, she experienced slight weight-bearing pain in the right hip with no antecedent trauma. Radiographs at the time of THA in 2006 and at the time of denosumab administration for the 1st time in 2018 showed no pathological changes in the femoral shaft around the stem ; however, there was an apparent transverse fracture line with lateral cortical thickening when she felt pain in the right thigh . Computed tomography revealed femoral cortical reactions more clearly . She had not received systemic glucocorticoids and proton-pump inhibitors, which had been listed as drugs that affect the bones in a previous study . A diagnosis of denosumab-associated atypical periprosthetic fracture was made. She underwent revision surgery for conversion to a longer cemented stem . 10 months later, the fracture site healed and she was possible to walk no cane at the latest visit in August 2022.
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