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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1005_en.txt

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+A 14-year-old boy with acute lymphocytic leukemia developed slight hematuria 4 days after HSCT at our hospital. Urine tests revealed significantly increased BK virus levels of 5.0 × 109 copies/mL, while adeno and JC virus levels were normal. No bacteriuria was observed. A Foley catheter was placed for the diagnosis of BKV-HC, and urological intervention was needed as bladder retention occurred on day 12 due to a blood clot. The purchase of Cidofovir (not approved in Japan), which was reported to be effective in several reports, was postponed due to financial issues. Frequent transfusions of RCC and PCy failed to improve Hb level and Plt count after HSCT .
+The BKV-HC with bladder clot retention persisted for 4 months with temporary improvement and recurrence; hence, frequent manual bladder washout and CBI were performed each time. TUE performed under general anesthesia on days 84 and 117 also failed to improve BKV-HC. The bladder wall was diffusely edematous and hemorrhagic . A bilateral 6 Fr single-J stent and 8 Fr Foley catheter were placed using a flexible cystoscope without manual bladder washout on day 120. As a result, the bladder clot gradually decreased, spontaneously drained from the catheter, and completely disappeared 27 days after stenting . The patient complained of slight pain in the external urethral meatus but not in the lower abdomen. No additional procedures, including manual bladder washout, were needed. Gross hematuria did not recur after the blood clot disappeared despite Hb level and Plt count remained low. The bilateral SJ stents were removed 97 days after being placed, followed by the removal of the Foley catheter . Urine tests showed decreased BK virus levels (1.0 × 108 copies/mL), at 8 months post-HSCT, BKV-HC has not recurred.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_100_en.txt

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+A 57-year-old female (body height 156 cm; body weight 64 kg) was referred to our hospital due to abdominal pain caused by a large uterine myoma. Nine years prior, she was diagnosed with polycythemia and an increased erythropoietin level , although she was asymptomatic. At that time, the erythropoietin level soon began decreasing slightly without medication, and thus, the follow-up was completed. However, at the time of admission to our hospital, the patient’s blood test results had worsened. Although she did not report any symptoms other than abdominal pain and her activity level was not impeded, blood tests showed a relatively high level of erythropoietin and a remarkably high level of hemoglobin. Levels of hemoglobin and erythropoietin were 21.9 g/dl (normal 11.5–15 g/dl) and 23.2 IU/ml (normal 4.2–23.7 IU/ml), respectively . Magnetic resonance imaging revealed a large uterine myoma measuring 25 cm in diameter. Therefore, she was suspected to have an erythropoietin-producing uterine myoma. There were no apparent symptoms of arterial or venous thrombosis or pulmonary embolism, which were ruled out by contrast computed tomography. Platelet count, coagulation test results, fibrinogen levels, and D-dimer levels were within normal ranges.
+Prior to abdominal total hysterectomy and bilateral salpingo-oophorectomy, phlebotomy was scheduled to treat polycythemia; this reduced the risk of arterial and venous thrombosis. The patient was phlebotomized, 300 ml once a week, for up to 3 weeks without any complications. Despite the phlebotomy, hemoglobin levels remained high ; thus, isovolemic hemodilution was planned to be performed immediately following anesthesia induction.
+Following placement of an epidural catheter into the epidural space at Th12/L1, general anesthesia was induced with 120 mg propofol, 0.1 mg fentanyl, and 50 mg rocuronium; it was maintained with 1.5% sevoflurane, 0.25 μg/kg/min remifentanil, and 10 mg rocuronium per 30 min. Electrocardiogram, bispectral index, end-tidal CO2, body temperature, and SpO2 were monitored during the surgery. Following induction of general anesthesia, an arterial 22 G catheter was placed in the radial artery, from which approximately 800 ml of blood was collected over 45 min while an equal amount of third-generation 6% hydroxyethyl starch (HES) 130/0.4/9 was infused from a peripheral venous 18 G catheter. As a result, the hemoglobin level dropped to 13.9 g/dl . The surgery was performed with a total blood loss of 285 ml. During surgery, the infusion mainly comprised acetic acid Ringer’s solution and HES 130/0.4/9; the total infusion volume was 3600 ml. Determination of the infusion volume was based on cardiac and stroke volume indexes, measured with a FloTrac™/Vigileo™ system (Edwards Lifesciences, Irvine, CA, USA; SVVFloTrac). The patient’s urine volume was 590 ml. At the end of the surgery, the hemoglobin level was within the normal range ; thus, transfusion of autologous blood was not needed. Shortly after the end of the surgery, the trachea was uneventfully extubated, and the patient was transferred to the high care unit.
+On postoperative day (POD) 2, following removal of the epidural catheter, a daily subcutaneous injection of fondaparinux 2.5 mg was initiated and continued for 5 days to prevent deep vein thrombosis and pulmonary embolism. The postoperative course was uneventful, and there were no symptoms of thrombosis or bleeding. Continuous epidural analgesia with 0.25% levobupivacaine at a rate of 5 ml/h was performed postoperatively, and the patient did not report severe pain. Hemoglobin levels remained within the normal range, and the erythropoietin level dropped dramatically . Pathological examination confirmed the production of erythropoietin from the tumor cell as well as the diagnosis of erythropoietin-producing uterine myoma .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1011_en.txt

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+A 63-year-old man was hospitalized with COVID-19 in the emergency department. CT examination showed a 2-cm renal mass in the right kidney. He had no palpable lymphadenopathy, and blood tests showed low lymphocytes and hemoglobin and a normal LDH (white blood cell count 6.8 × 103/μL, 70.2% neutrophils, 11.5% lymphocytes, hemoglobin 12.0 g/dL, LDH 219 U/L). Anti-HTLV-1 antibodies in the serum were negative. Abdominal enhanced CT examination was performed that showed good enhancement of the noted mass in the corticomedullary phase and washout in the nephrographic phase . He was diagnosed as having cT1aN0M0 renal cell carcinoma, and RAPN using a retroperitoneal approach was carried out. The resected specimen was a tumor with a dark red cross-section and indistinct borders. HE staining of the tumor showed diffuse infiltration of intermediate-sized atypical lymphocytes. With further immunohistochemical staining, it was found that the lymphocytes were CD3(+) and CD20(−) , indicating that the neoplastic lymphoid cells were considered to be of T-cell origin. Immunostained lymphocytes were CD4(−), CD8(+), TIA-1(+), and EBER(−) . We diagnosed the patient as having PTCL-NOS. Postoperative FDG-PET did not show metastasis. From the above, the disease was considered to be in the IE stage of the Lugano classification. The patient has been followed for 20 months after RAPN without additional treatment and recurrence.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1014_en.txt

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+The patient was a 53-year-old woman with no relevant medical history. She experienced discomfort and pain in the anal region, and a colonoscopy detected a tumor in the colon. On the basis of imaging and endometrial sampling cytology with conventional biopsy findings, she was diagnosed with International Federation of Gynecology and Obstetrics stage IVB endometrial cancer (endometrioid adenocarcinoma Grade 1) with colon metastasis and lymphadenopathy in the bilateral obturator lymph nodes and sacrum. She received neoadjuvant chemotherapy (four cycles of paclitaxel 175 mg/m2 and carboplatin area under curve 6). Two months later, Hartmann surgery was performed to prevent the tumor from occluding the colon. Pathological evaluation of the tumor specimen confirmed endometrial cancer, surgical stage IVB. MSI testing revealed the tumor was MSI-H.
+After the surgery, computed tomography (CT) showed an enlarged recurrent tumor in the colon, with peritoneal dissemination and multiple metastases in the paraaortic lymph nodes. Hence, she was started on a combination of lenvatinib (20 mg, administered orally once daily) and pembrolizumab (200 mg, administered intravenously as a 30-minute infusion every 3 weeks). On day 11 after the LEAP therapy, she received 4 units of red blood cells due to a fall in her hemoglobin level to 7.3 g/dL. She was discharged on day 12. On day 15, she developed a gait disorder and tremors. Hypothyroidism (thyroid stimulating hormone [TSH] level: 5.350 ng/mL, free thyroxine 4 [FT4] level: 0.99 pg/mL, free thyroxine 3 [FT3] level: 2.08 pg/mL) was also detected on the same day on consultation with endocrinologists.
+On day 18, she was referred to the emergency room for an altered sensorium. On arrival, her Glasgow Coma Scale score was E3V4M6. Her blood pressure showed a continued increase . There was no electrolyte imbalance or renal or liver failure . An emergency CT scan found no brain metastasis or intracranial hemorrhage . Magnetic resonance imaging (MRI) showed a slightly high signal intensity in the left occipital lobe, with no apparent cerebral infarction . LEAP therapy was discontinued. Although there were no visual complaints or findings given the location of the MRI abnormalities and electroencephalogram was normal, her consciousness level gradually worsened, resulting in convulsions, which were suppressed by an intravenous injection of diazepam (5 mg). She was started on levetiracetam (200 mg) to prevent convulsions. For further investigation, additional blood tests and multiple lumbar taps were performed. While serum vitamin B1, TSH, FT4, and FT3 levels were normal, a slight increase was seen in the anti-thyroid peroxidase antibody levels . The blood glucose level was 110 mg/dL. Analysis of the cerebrospinal fluid found cells (5/µL), protein (154 mg/dL), and glucose (50 mg/dL) , suggesting that meningitis was unlikely. The disturbance in consciousness gradually improved with time, indicating the low probability of Hashimoto encephalopathy.
+Previous clinical trials have revealed that the incidence of adverse effects of lenvatinib and pembrolizumab on the central nervous system was 0.4% and less than 0.1% , respectively, and could have caused PRES and encephalitis, respectively. The absence of markers of inflammation in the cerebrospinal fluid and a high signal intensity in the left occipital lobe on MRI suggested PRES, rather than encephalitis. Therefore, it was concluded that these symptoms were caused by lenvatinib, not pembrolizumab. She was resumed on treatment with pembrolizumab. Although no long-term sequalae of PRES were observed, unfortunately, CT showed multiple lymph node metastases after four cycles of pembrolizumab monotherapy, indicative of further disease progression. Pembrolizumab was discontinued, and she is now enrolled in another clinical trial in Japan.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1031_en.txt

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+XS, a 51-year-old gentleman, came to our attention complaining of several weeks of worsening angina now occurring upon minimal exertion. Hypertension was his only cardiovascular risk factor actively treated with an angiotensin converting enzyme (ACE) inhibitor. No other relevant past medical history was noted. Physical examination was unremarkable highlighting clear heart sounds with no added murmurs and normal lung sounds. His blood pressure was 140/85 mmHg whilst his electrocardiogram (ECG), upon presentation, showed normal sinus rhythm (98 b.p.m.) with widespread ST segment depression consistent with diffuse subendocardial ischaemia and a first troponin sample was below the limit of significance. Given the presentation with progressively worsening angina (unstable angina) and the ECG which suggested a large area of myocardium at jeopardy the patient was loaded with aspirin 300 mg and ticagrelor 180 mg and, following a new anginal episode at rest, a decision was made to undergo urgent invasive coronary angiography. The investigation highlighted a left dominant circulation with a severe mid-left anterior descending narrowing with reduced distal coronaryflow [thrombolysis in myocardial infarction (TIMI) 1] and a severe, large, first obtuse marginal (OM1) stenosis which were both treated with drug-eluting stents implantation with excellent angiographic result, no complications and resolution of ECG anomalies . A statin (atorvastatin 40 mg) was started as part of standard ACS therapy on top of dual antiplatelet therapy (DAPT) and ramipril, of interest no beta-blocker or other rate limiting drugs were commenced. The first 24 h a free of complications, no arrhythmic episode was registered by telemetry monitoring, a routine echocardiogram was unremarkable showing normal ejection fraction in the absence of regional wall motion abnormalities or major valvular dysfunctions, and the patient received two standard doses of ticagrelor (8 a.m. and 6 p.m.). On the second night of hospital stay, whilst lying in bed, the patient complained of the sudden feeling of lightheadness and profound sweating and called out for medical assistance. Upon medical review the patient denied any other symptoms, in particular any pain or angina, no ischaemic changes were noted on the ECG whilst telemetry monitoring review highlighted a 16 s long asystolic pause . The episode was self-limited with return of sinus rhythm thereafter. Electrolytes were checked and found to be within normal limits. Hence, new medications were investigated looking for a possible explanation to the unexpected asystole given also the patient had no history of syncope. Ticagrelor, due to its brady-arrhythmic effect was suspected to be involved and was therefore halted shifting the patient to prasugrel following the administration of a 60 mg loading dose. A temporary pacing line (TPL) was inserted fearing possible further episodes. However, no new brady-arrhythmic episodes were noted on telemetry monitoring and the unused TPL was removed 24 h later. After 2 further days of monitoring, the patient was discharged home on Day 5 post-PCI in excellent general conditions.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1046_en.txt

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+The patient, an 11-year-old female, has been suffering of short stature for 6 years before being admitted to the hospital. The girl was the fifth child born to a nonconsanguineous couple. She was born naturally at full term, with a low birth weight and height, and was breastfed. After the age of 5, the patient’s height is lower than that of children of the same age. After admission to our hospital, Blood tests showed the decreased levels of phosphorus to 0.80 mmol/L (normal range: 0.96–1.62 mmol/L), 1,25-(OH)2-D to 11.39 pg/ml (normal range: 20–100 pg/ml), tubular reabsorption of phosphate (TRP) to 83.7% (normal range: 84 to 96%) and increased levels of alkaline phosphatase to 1427.40 U/L (normal range: 45–125 U/L). The other electrolytes, thyroid hormone, 24-hour urine calcium levels and ratio of maximum rate of renal tubular reabsorption of phosphate to glomerular filtration rate (TMP/GFR) were unremarkable. The patient’s siblings and parents blood phosphorus results revealed that one of the patient’s sisters had low blood phosphorus, and bowed legs were the only clinical manifestation. Here are the patient’s laboratory test results along with their corresponding normal reference ranges.
+Table Phosphate clearance test results: after consuming 300 ml of distilled water on an empty stomach, the following measurements were taken 2 hours later; TRP: tubular reabsorption of phosphate; TMP/GFR: ratio of maximum rate of renal tubular reabsorption of phosphate to glomerular filtration rate.
+Hand X-ray showed left distal ulnar radius consistent with rickets in active phase , radiographs of growth plates demonstrate metaphyseal widening, cupping, lucency and flaring, possible old fracture of the distal radius on the left side, and bone age comparable to the girl’s standard of 9 years; renal scan suggested a strong echogenic cluster of about 6 mm in the right renal pelvis and calyces ; the chest radiograph showed reduced bone density in the bones within the scan area ; previous bone X-rays of both hands suggested that the hands and wrist joints were dysplastic and rickets was considered; radiographs of both lower limbs suggested that rickets was present in both lower limbs with bowed legs. Pure tone audiometry: the average hearing threshold at speech frequencies of 20 dB in both ears. The conductance map shows a binaural (type A) curve, no otoacoustic emissions elicited in either ear. Auditory brainstem: binaural hearing thresholds of 25dBnHL, suggestive of normal hearing.
+A case is reported in this paper. The proband’s parents are not consanguineous. With the informed consent of the patients and family members, whole exome sequencing analysis was performed and showed that the proband harbored the c.1402C > T; p.R468W in theSLC34A3gene , this variant has been described by Bergwitz et al. 2006 . Sanger sequencing was performed to verify this variant in other family members. The proband’s mother and father carry a heterozygous variant of the gene, and the proband’s sister had a homozygous variant. The proband also harbored a c.3917C > T (p.A1306V) homozygous variant in theLRP5gene . The proband’s mother and father carried a heterozygous variant in the gene, but the proband’s sister was normal.
+Therefore, combined with the clinical manifestations of the patient, the genetic testing results and family analysis can be used to diagnose hereditary hypophosphatemic rickets with hypercalciuria. The relevant manifestations of the patient and her relatives are as follows .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_106_en.txt

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+A 46-year-old man presented with chest pain and acute paraplegia with acute type A aortic dissection,3 h prior admission. He had no known relevant medical history. Transthoracic echocardiography revealed normal left ventricular function and mild aortic regurgitation. Motor and sensory grades of both lower extremities were zero and pulses of both femoral arteries were absent. Figure shows preoperative aorta computed tomographic angiography (CTA).
+We decided to perform surgery as soon as possible. Figure shows the cardiopulmonary bypass (CPB) circuit. Partial CPB was established (blood flow 1000 cc/min) after insertion of two 14-Fr DLP® arterial cannulas (Medtronic Inc., Minneapolis,MN) via both common femoral arteries for antegrade distal perfusion of both lower extremities as well as 24-Fr venous cannula (Edwards Lifescience LLC, Irvine, CA) via the right common femoral vein. The left axillary artery was used for arterial cannulation using the side graft technique with a 10-mm Dacron graft (Atrium Medical Corporation,Hudson, NH) because of dissection of the innominate artery. Total arch replacement was performed by establishing routine CPB with systemic circulatory arrest (rectal temperature 26 °C) and bilateral antegrade selective cerebral perfusion. During systemic circulatory arrest, perfusion of both lower extremities was maintained.
+Maintaining partial CPB for right lower extremity perfusion (blood flow 500 cc/min), left- sided axillo-femoral bypass with an 8 mm Dacron graft (Atrium) was performed. The times for total CPB, aortic cross clamp and systemic circulatory arrest were 320 min, 175 min and 40 min, respectively. In turn, terminating the CPB, femoro-femoral bypass with an 8 mm Dacron graft (Atrium) was performed. At the time of discharge, motor and sensory grades of both lower extremities were 2 and 3, respectively. Figure shows the follow- up aorticCTA.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1088_en.txt

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+A 31-year-old Asian man who was a schoolmaster presented with lower abdominal pain and was diagnosed with an acute perforation of the sigmoid colon by computed tomography (CT) at an outside hospital . He has neither past medical history nor family history. He was morbidly obese, weighing 150 kg (BMI 50 kg/m2), and laboratory data showed acute renal failure (creatinine 2.59 mg/dL, blood urea nitrogen 26.8 mg/dL) and uncontrolled diabetes (DM) (blood glucose level 345 mg/dL). After initial outside admission into the intensive care unit (ICU), he was transferred to our hospital and consented to undergo emergency surgery.
+The patient was placed in the supine position and was induced under general anesthesia . A 12-mm trocar for a 10-mm flexible laparoscope was inserted through the umbilicus using an open technique. Pneumoperitoneum was maintained at 12 mmHg with carbon dioxide. Next, one 12-mm and three 5-mm long trocars were placed under laparoscopic visualization, and the abdominal cavity was explored. We performed LLD and diverting ileostomy as the first-stage surgery. After adhesions of the peritoneum and greater omentum were dissected from the pelvis, purulence was drained from the rectovesical pouch . A large amount of purulence was also drained from the mesentery after exposure of an abscess cavity . After peritoneal lavage using 36 L of saline, no gross fecal contamination was noted. After placement of drainage tubes into the abscess cavity, the right and left subphrenic spaces, the right pararectal fossa, and the rectovesical pouch, we created a diverting loop ileostomy. The operation time was 372 min and blood loss was 240 mL without any major complications during the first operation. He started oral intake from post-operation day (POD) 3. He was transferred to another hospital to receive medical treatment with drainage tube and wound in POD17. The drainage tube was removed in POD33. There were no complications after surgery in all hospitalizations.
+One year later, the patient was seen in follow-up after losing approximately 70 kg. He safely and successfully lost his weight by the educational admission to the diabetic tract medicine. Barium enema examination revealed numerous diverticulum of the sigmoid colon. We performed laparoscopic sigmoidectomy in the lithotomy position as the second-stage surgery. After inserting six trocars, the abdominal cavity was explored. The sigmoid colon was densely adherent to the pelvic cavity, and an incisional hernia around the ileostomy was detected without surrounding adhesions. After displacing the small intestine towards the right upper quadrant of the abdomen, a medial to lateral approach for the mesenteric dissection was undertaken. The specimen was extracted from the abdomen through the umbilical incision. An intra-corporeal double stapling technique was used to complete the anastomosis. At the end of the operation, a drain was inserted behind the colonic anastomosis. Pathological examination revealed diverticula with panniculitis of the sigmoid colon . He was discharged 7 days postoperatively after an uneventful hospital course.
+Five months after the second-stage surgery, we performed ileostomy closure and incisional hernia repair as the third-stage surgery. He suffered a postoperative ileus, which resolved with conservative treatment. No other postoperative complications occurred.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_109_en.txt

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+On the 24th April 2006 a 9 month old girl was brought to the Emergency Department of a hospital which routinely refers patients to us. She had sustained a dog bite to her face 30 minutes previously. She was seen by the emergency physicians and was found to have received multiple lacerations to her face over the right zygoma, right paranasal area, right cheek, left eye lid, left paranasal area, left lower cheek and over her left body of her mandible. She was fully examined and found to have no wounds elsewhere however due to the circumstances of patient and parental distress, intra-oral examination was not possible. The initial work up did not include radiographic investigations as it was felt by the emergency physicians that only a soft tissue injury was sustained. On the advice of the on-call maxillofacial team she had her facial wounds cleaned with aqueous iodine solution and she was started on an oral course of Co-Amoxiclav and paracetamol. An examination by the ophthalmologist revealed no ocular injury.
+She was transferred to our unit the following day, fasted in preparation for an examination under general anaesthesia and primary closure of her facial lacerations. During the procedure it was found that she had sustained an open fracture of her left mandible consistent with a dog bite. . This was treated via a trans-oral approach with a five hole 1.2 mm titanium plate and four 3 mm screws. . She had her facial laceration copiously irrigated with normal saline and chlorhexidine and primarily closed in with a fine nylon suture. She was discharged home the next day. Seven days later she attended for removal of sutures under a general anaesthetic and examination of her jaw. The facial wounds were healing well and there was no movement at the fracture site. Ten weeks after the first operation she was admitted for removal of her mandibular plate under general anaesthetic. There was good bony union and the plate was removed with no complications . She will continue to be reviewed in clinic to monitor dentoalveolar development and mandibular growth.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1100_en.txt

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+The proband was a preterm newborn boy, the first child of non-consanguineous parents, born at 31 weeks gestation to a 44-year old father and a 43-year old mother by cesarean section. At birth, the child weighed 1,480 g, measured 44 cm in crown-to-heel length, and exhibited multiple congenital anomalies. The newborn was transferred to the Intensive Care Units (ICU) immediately after birth. His general health condition deteriorated progressively, leading to his death at 105th days after birth. The newborn had brain malformation, including ventriculomegaly and corpus callosum dysgenesis, cleft lip and palate, retrognathism, hypertelorism, clenched hands with overlapping fingers, and hypotonia. Additionally, he revealed mild heart septal hypertrophy, ambiguous genitalia, enlarged kidneys without corticomedullary differentiation, and gallbladder with tiny cystic formations . His mother had three miscarriages from previous marriages and one miscarriage with her current husband. The remaining of his family history was otherwise unremarkable.
+Both parents signed a written informed consent and the mother signed as the legal representative for the child. Peripheral blood was obtained to isolate genomic DNA for CMA using Qiagen QIAamp® DNA Mini kit (Hilden, Germany). Karyotyping was performed in a private laboratory through conventional cell culture, harvesting, and GTG banding with a > 550 bands resolution following standard procedures . Chromosome analyses were done using Zeiss Axio Scope (Jena, Germany) and the software IKAROS® (Metasystems Corporation, Altlussheim, Germany). All laboratory procedures were carried out following international standardized protocols and consensual criteria of quality.
+The CMA was carried out on proband and his biological parents using the GeneChip® CytoScanHD™ (Affymetrix, Santa Clara, USA) following the manufacturer’s recommendations without modifications. Chromosomal analyses were done using the Chromosome Analysis Suite (ChAS®) software (Affymetrix, Santa Clara, USA) and the CNVs found in the patient were analyzed in comparison with public databases, including Database of Genomic Variants (DGV), Database of Chromosomal Imbalance and Phenotype in Humans using Ensemble Resources (DECIPHER), and CytoScanHD™ Array Database. Furthermore, CNVs were classified according to their nature, based on [, ].
+The proband showed a male karyotype with a large submetacentric SMC in 90% of the analyzed metaphases after counting 50 metaphase spreads. His karyotype was 47,XY,+mar[45]/46,XY[5], suggesting 10% mosaicism. The parental karyotypes and CMA results had no visible numerical or structural alterations. The proband’s CMA revealed the marker chromosome corresponded to a de novo 70.77 Mb gain at arr[GRCh37] 9p24.3q21.11(203,861_70,974,662)× 4[0.3] dn with 30% mosaicism, encompassing 286 genes, including 152 OMIM morbid genes .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1115_en.txt

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+A 61-year-old woman was admitted to a hospital due to obstructive jaundice. Extensive EC was found by diagnostic imaging, and she was subsequently scheduled for brachytherapy since the tumor was found to be unresectable. Seven years prior at the same hospital, she underwent multi-organ en bloc resection for advanced gall bladder (GB) carcinoma involving the distal stomach and right side transverse colon . Extended cholecystectomy, distal gastrectomy, and right hemi-colectomy with loco-regional lymphadenectomy were also performed. Despite not receiving adjuvant chemotherapy, she had remained without tumor relapse. She was referred to our institute for a second opinion.
+Obstructive jaundice was resolved by percutaneous transhepatic biliary drainage (PTBD) via the left lateral sector of the liver at the previous hospital. Enhanced abdominal computed tomography (CT) and PTBD cholangiography showed wide stenosis of the intra- and extra-hepatic bile duct (a and b). Cholangioscopy and intraductal ultrasonography (IDUS) showed a papillary tumor with wall thickness and stenosis with no involvement of the adjacent right hepatic artery (RHA) (a and b). Endoscopic biopsy performed at the stenotic lesion and non-stenotic bile duct at the confluence of the anterior and posterior sectional branches was negative. Although invasive adenocarcinoma was diagnosed, cancer infiltration was not observed at the non-stenotic bile duct epithelium. Since neither distant nor node metastasis was observed and liver function reserve was sufficient for hemi-hepatectomy, we planned for HPD despite the possibility of tumor recurrence from GB cancer.
+There was no peritoneal dissemination, liver metastasis, or distant node metastasis by laparotomy. Although there was a postoperative adhesion in the upper abdomen, the front of a superior mesenteric vein (SMV) was found and pancreaticoduodenectomy (PD) was performed (a and b). During exfoliation of the hilar bile duct, adhesion to the surrounding main vessels became severe, particularly in the neighboring RHA (a); however, this was considered non-tumor invasion by macroscopic findings. The anterior sectorial arterial branch was partially injured and was repaired with 8-0 polypropylene sutures (b). After anastomosis, arterial flow increased compared with dissection. Left hepatectomy with transection of the right hepatic duct was also performed at the lesion. Thus, R0 resection was performed without tumor exposure at the dissected plane . Pancreatojejunostomy, hepaticojejunostomy, and jejuno-jejunostomy were also performed. The total operating time was 685 min (including 45 min for arterial repair), and blood loss was 1200 mL, which did not require blood transfusion.
+Microscopic findings showed papillary adenocarcinoma with stromal and pancreatic invasions that did not extend to the dissected surface. Lymph node metastasis was found on the pancreatic surface. R0 resection was also histologically confirmed. The postoperative course was uneventful without severe damage to the liver, and the patient was discharged at day 14. Four months after HPD, she remains without tumor recurrence or complications.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_111_en.txt

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+A 25 year old lady presented in a state of shock with massive haematuria. Patient gave a previous history of lower segment caesarean section 2 month ago following which she was doing well for one month. On 30th post-operative day of caesarean, she started passing blood and blood clots (long cylinder) in urine. There was no history of bleeding from per vaginum and other site. There was no history of dysuria or trauma and also no significant history of drugs or allergy found. She was evaluated outside and a CT was done which suggested a uterine/internal iliac artery pseudoaneurysm along with bladder clots. A cystoscopy was done outside 4 days before presentation which showed a defect of size 2.2 cm on dome of bladder. Intrabladder blood clot was evacuated. She was then referred to our center. On arrival she was haemodynamically unstable and her pulse rate, blood pressure, haemoglobin, blood urea, and serum creatinine were 154/min, 62/40 mm Hg, 4.8 g/dl, 10.8 mg/dl, and 0.44 mg/dl respectively. She was aggressively resuscitated with crystalloids and later 4 PRBC and 4 FFP was transfused. She was started on inotropic support and shifted to ICU for stabilisation. She responded to fluid resuscitation and her BP and pulse normalised. She developed blockage of the Foley catheter with clot retention in bladder. Foley catheter was removed and a tri-way Foley catheter with bladder irrigation was started. Later urine got cleared after irrigation. After 20 h when the patient stabilised, a CT angiography was done to localise the source of bleeding. CT angiogram was suggestive of left uterine pseudoaneurysm. She was taken to DSA after stabilisation which showed a pseudoaneurysm in the pelvis on the left side between the bladder and the lower uterus, possibly from the anterior uterine wall, with surrounding haematoma. There was clot and air within the urinary bladder; however no direct vesico-vaginal or vesico-uterine fistula was evident (A and B).The patient was urgently taken up for digital subtraction angiography and subsequent embolization. It revealed a hypertrophied and tortuous left uterine artery with a large pseudoaneurysm distally. Then after super selective microcatheterisation using 2.7 F microcatheter of left uterine artery, successful glue embolization was performed using 20% n-butyl cyanoacrylate and lipiodol mixture (C). Post procedure control angiogram showed complete devascularisation of pseudoaneurysm (D). This intervention was done by an additional professor with 12 years of experience in Level-1 trauma center. She was remaining haemodynamically stable throughout the procedure. In the post angio period she was kept in the ICU for 2 days where her condition remains stable. Haematuria persisted for 2 days and then it gradually cleared. She was later shifted to general wards from where she was discharged. She was doing well at 6 months of follow up.

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+A 35-year-old Chinese female was referred to complete root canal treatment of the maxillary right molars using a DOM. She had repeated episodes of swelling in the upper right posterior maxilla for the past three months. The basis for the referral was the presence of a second root canal in the mesiobuccal root (MB2), as stated by the general dentist was suspected but not found. The pulp of 3 main root canals for the upper right first permanent molar (#16, Fédération Dentaire Internationale notation) and upper right second permanent molar (#17, Fédération Dentaire Internationale notation) were removed by the dentist. The medical history was non-contributory. The intraoral examination revealed profound disto-occlusal destruction in #16 and mesio-occlusal destruction in #17 . Teeth #16 and #17 were sensitive to palpation and percussion but were negative for thermal testing.
+Based on the preoperative radiographs of teeth #16 and #17, the pulp chamber was noted to be extended, the pulp floors exhibited apical displacement, and the roots were short. In addition, teeth #16 and #17 had periapical translucency .
+According to the radiographic images, teeth #16 and #17 were diagnosed as symptomatic apical periodontitis and mesotaurodonts.
+The clinical condition was explained to the patient, and root canal therapy was proposed and conducted. After proper disinfection and rubber dam isolation, all the subsequent procedures were performed using a DOM (Leica, Germany). The residual decay was excavated, and the access opening was prepared. The pulp chamber was identified with three orifice openings (MB, DB, and P), and the dentist utilized the ProTaper F2 after discussion. A complex pattern of the dentinal map in teeth #16 and #17 was demonstrated. After removing the dentinal lips around the orifice of the three prepared canals with a DG-16 endodontic explorer, the second canals (MB2, DB2, and P2) of the tooth #16 were identified. In contrast, the extra root canal orifice was concealed approximately 2–3 mm under the prepared canal orifice of MB and P in the tooth #17.
+Two experienced operators (He Wang and Na Cao) analyzed the data taken by CBCT using a Scanora ® 3D unit (SoredexOy, Tuusula, Finland). In this device, the mandible is stabilized with a cheek rest while the patient is seated, and two vertical plastic rods (one on each side) are used to support the head position. The settings (FOV and voxel resolution) were chosen for each patient based on the area to be examined and the diagnostic task in question. Considering the small FOV (6 × 6 cm, resolution 0.13-mm), the scan time was 23 s.
+The results were further evaluated and verified by the CBCT . Together with the DOM, the ultrasonic tips maintained good visibility of the operative field. The ultrasonic tips were used for the removal of gross tissue and calculus. We prepared six canals in the tooth #16 with two canals in the mesiobuccl root (MB1 and MB2 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals) . Also, we prepared seven canals in the tooth #17 with three in the mesiobuccal root (MB1, MB2, and MB3 canals), two in the distobuccal root (DB1 and DB2 canals), and two in the palatal root (P1 and P2 canals) . All of the extra canals were prepared using a stainless steel hand files (ISO size 8). During the root canal preparation, it was apparent that MB2 and MB3 in the tooth #17 were joined together in the apical third of the mesiobuccal root, but P1 and P2 in the same molar were separated in the middle third of the palatal root and joined together in the third apical. The working length was determined by both radiographs and an electronic apex locator (Raypex5; VDW, Germany). The instrumentation was completed using ProTaper sequence S1, S2, F1, and F2 rotary files (ProTaper Universal; Dentsply Maillefer, Switzerland) as per instructions from the manufacturer. Sodium hypochlorite (2.5%) was used as intracanal irrigat, and calcium hydroxide was used as a disinfectant. The access cavity was sealed with a temporary filling (IRM; Dentsply).
+One week later, the two teeth were not associated with symptoms, and root canals were obturated using a continuous-wave condensation technique with thermoplasticized gutta-percha (E&Q Plus system; Meta, Korea) and AH Plus (Dentsply) as sealer cement . The access cavity was temporarily restored, and the patient was sent for coronal rehabilitation.

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+A 43-year-old male was implanted with a dual-chamber implantable cardioverter-defibrillator (ICD) for primary prevention. The patient presented with dyspnoea and had a family history of sudden cardiac death (SCD), hypertrophic cardiomyopathy, and mild LV systolic impairment (Class IIB recommendation for an ICD with a 5% risk of SCD at 5 years). No other abnormalities were detected. The underlying rhythm was sinus with first-degree AV Block (PR interval 340 ms) and a QRS duration of 90 ms. The ICD (AUTOGEN EL, Boston Scientific) was programmed to DDDR mode with rates of 70–120 b.p.m., and sensed and paced AV delays of 80 ms and 110 ms, respectively. Subsequent device follow-ups demonstrated normal device function and measurements, >95% atrial and ventricular pacing, and patient was symptomatically improving.
+Seven years after the initial presentation, patient presented with symptoms of progressive dyspnoea and a follow-up echocardiogram demonstrated moderate LV systolic impairment . As a result, RYTHMIQ™ and AV Search+ device features were enabled to minimize RV pacing. A device check 7 months later verified normal device and lead parameters . Atrial and ventricular pacing were 100% and 1%, respectively. As patient’s symptoms were improving, no changes to the device settings were made. The following day, the patient experienced a single episode of appropriate device (shock) therapy for ventricular fibrillation. Interrogation of device electrograms demonstrated initiation of ventricular arrhythmia due to R on T pacing.
+The alert demonstrated an episode of shock delivered for ventricular arrhythmia. The trace begins with atrial pacing and ventricular sensing (VS) at the sensor indicated rate (SIR) (120 ppm) (1,2). As the RYTHMIQ™’s criteria were met (VS within A-A + 150 ms), the device remained in AAIR mode. In the presence of AV block and subsequent ventricular beats falling in the atrial blanking period , the device failed to detect the intrinsic ventricular events: [VS] (3). This initiated mode switch to backup VVI pacing [lower rate limit (LRL) set at 70 ppm, therefore, VVI backup is 55 ppm (1090 ms)], with ventricular paced beats on the 3rd, 6th, and 9th beats (4). We believe the closely coupled V-V timing resulted in R on T pacing (5), initiating ventricular fibrillation.

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+A 26-day-old boy was referred from a peripheral hospital with a right-sided incarcerated congenital inguinal hernia. The referring pediatrician told his father that he has a palpable testis in his right inguinal canal but no palpable testis on the left side. Apart from a clinically evident right irreducible hernia and empty both hemiscrota, the rest of the examination was unremarkable. After initial resuscitation with intravenous fluids and antibiotics, an urgent operation was undertaken. On inguinal exploration, the hernia sac was found to contain a viable cecum and small bowel loops. After reduction of the contents to the peritoneal cavity, the right testis was found in the inguinal canal. However, a second testis was unexpectedly delivered through the deep inguinal ring. Both testes have independent spermatic cords, i.e. two separate sets of vas deferens and testicular vessels on either side of a T- shaped structure resembling an infantile uterus and fallopian tube . Because of the shortness of the spermatic cord and the vague nature of this anomaly for the operating surgeon, only a biopsy was taken from both testes and all the structures were returned back to the peritoneal cavity followed by herniotomy.
+Postoperative pathology showed normal testicular tissue bilaterally with absent ovarian structures. Karyotyping was done for the patient and revealed a normal 46XY male karyotype. Diagnostic laparoscopy was performed at the age of 6 months, which showed a closed left internal ring on the left side and a widely open internal ring on the right side. In addition, the left sided testis and spermatic cord were found joining their counterparts on the right side through the rudimentary uterus close to the right internal ring. The rudimentary uterus as well as the fallopian tubes were partially excised. Peritoneal dissection was made to gain extra length for both spermatic cords. Orchiopexy was done, with each testis fixed into its corresponding hemiscrotum. The patient had an uneventful recovery. Throughout the 6-month follow-up period, the size and the blood flow of both testes were normal as evaluated by Doppler ultrasound.

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+The patient was a 29-year-old nulliparous woman (height, 158 cm; weight, 58 kg; BMI, 20.4 kg/m2) who had received oral thyroid hormone replacement due to previous subtotal thyroidectomy for Graves’ disease. No abnormalities in platelet count or coagulation had been noted. She was initially referred to our institution due to suspected placenta previa. At 31 weeks of gestation, the placental position was confirmed within the normal range, and the placenta previa was denied. No additional concerns were described during the remainder of her pregnancy. At 41 weeks of pregnancy, vaginal delivery was induced by oxytocin administration. The patient did not ask for epidural analgesia for her childbirth. The malpresentation or malrotation of the fetal head was not confirmed, which would compress the nerve root and induce severe radiating pain. The obstetrician expected uterine hypertonus when her fetus developed non-reassuring fetal status. The patient was advised of emergent cesarean delivery because the discontinuation of oxytocin did not improve the fetal status.
+After careful disinfection with 10% povidone-iodine, waiting for the disinfectant to dry, spinal anesthesia was performed with the patient’s left lateral position. The L2/3 interspace was identified by palpating the posterior superior iliac spine to confirm the L5 and S1 vertebrae. A 25-gauge Quincke needle was used to puncture the L2/3 interspace via median approach.
+The first puncture obtained clear cerebrospinal fluid reflux. A mixture of anesthetics containing 12 mg of 0.5% hyperbaric bupivacaine, 0.1 mg of morphine hydrochloride, and 10 mcg of fentanyl citrate was administered. There were no concerns, such as bleeding or radiating pain, during the puncture or infusion of the anesthetics. The level of the blockade successfully covered the sixth thoracic vertebral dermatome level.
+The delivery was uneventful for both the patient and infant, and the estimated blood loss was 500 mL. The patient noticed discomfort and numbness in the left lower extremity 7 h after the spinal procedure, but she did not tell the finding to her obstetrician. On a postoperative day 1, she complained of sensory numbness on the lateral side of the left lower leg and difficulty with dorsiflexion and plantar flexion of the left foot. A neurologist was consulted by her obstetrician and assessed the manual muscle strength test and found that her left tibialis anterior and gastrocnemius muscles had weakened by 3/5. The neurologist also noted sensory loss on the lateral side of the left lower leg. Collectively, the injury to the L5 and S1 nerve root was suspected. On postoperative day 3, the patient underwent MRI to rule out the possibility of such complications as epidural hematoma formation. The image showed a T2W1 low signal in the left side of the spinal canal at the L5/S1 level due to adhesive arachnoiditis . No abnormal signal was observed in the spinal cord. She could walk unaided within a few days; however, the dullness and paralysis persisted at discharge on the sixth postoperative day. The symptoms gradually improved and entirely disappeared within 2 months.

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+A 24-year-old male was complained of intermediate dry cough for 1 month. He denied any history of fever, weight loss, chest pain. Chest CT showed a tumor located on the posterior 6th left rib, which measured about 20 mm × 18 mm. An area of local bony destruction with conserved cortex was noted, and the margins were delineated with some ossifying matrix. Enhanced CT revealed non-uniform enhancement. There was no evidence of extension to the adjacent soft tissue. The imaging first diagnosis was LCH, a giant cell tumor, or other type of neoplasm .
+His family medical history was negative for any type of malignancy. Physical examination, the tumor wasn’t palpable and no pain by pressing on the chest wall. The overlying skin was normal, and no sensory deficit. Laboratory testing results, including tumor markers, complete blood cell count and erythrocyte sedimentation rate (ESR) were within the normal value. The derivation purified protein skin test and tuberculosis test were negative too.
+The patient was anesthetized with double-lumen endotracheal intubation and lied on the right side. The endoscopic incision about 1 cm length was the 8th intercostal space of the left posterior axillary line, and another operating incision about 3 cm length is the 4th intercostal anterior axillary line. The right lung was ventilated and the left lung was collapsed. It was observed to be present on the posterior side of the 6th left rib, the margins were well-defined, and no sign of adjacent soft tissue invasion was noted. The electrocoagulation hook kept about 0.5 cm away from the tumor border and completely resected the tumor. Frozen section pathological examination demonstrated a benign or a low-grade malignant bone tumor. The more surrounding tissues and partial intercostal muscle were removed further. The straight pliers were used to guide the ribs to separate the ribs, and the wire saws cut off the broken ribs, including a margin of at least 1 cm of normal rib. No reconstruction was required for the rib deficit .
+Pathological examination of hematoxylin and eosin (H-E) stained revealed typical polygonal-shaped chondroblasts and osteoclast-like giant cells. The chondroblasts were large and closely packed with a central, characteristically translucent cytoplasm and grooved nucleus .
+IHC examination made a diagnosis of chondroblastoma .
+There were no intraoperative or postoperative complications, and the patient was discharged after 5 days. Patient described only minimal pain, and had only 2 small incisions on the chest wall. There was little impact on lung function, and a shorten chest drainage tube time and hospital stay .
+Radical resection and no adjuvant therapy were given postoperative. The patient was followed every 3 months with chest CT or chest radiograph and blood tests within the first year and every 4 months within the second year. The patient has no chest pain, chest tightness, no abnormal breathing on the chest wall and the lung function is normal . About 23 months follow-up there was no evidences of recurrence or metastasis.
+A timeline showed the whole medical procedure of this case.

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+A 10-year-old HIV-infected girl who presented to Mulago National Referral Hospital in Kampala, Uganda with a new-onset, generalized tonic-clonic seizure, which resolved with rectal diazepam given in the hospital. The seizure was preceded by a severe frontal headache and subjective fevers for 3 days. Otherwise, she did not have rash, vomiting, diarrhea, night sweats, or weight loss at presentation. There were no known contacts with tuberculosis. On initial exam, she was well appearing, with no abnormalities in vital signs or neurologic examination.
+Cerebrospinal fluid (CSF) results showed WBC of 0–1 per high powered field (hpf), red blood cells (RBC) 1–2/hpf, protein 43 mg/dL, glucose 2.5 mmol/L (normal 3.3–4.4). Rapid cryptococcal antigen in CSF and blood were positive. An acid-fast stain and Indian ink stain were positive (++) for yeast cells. An opening pressure was not obtained due to lack of supplies. Two days later, the CSF culture returned positive (++) for Cryptococcus neoformans, and she was diagnosed with cryptococcal meningitis. Bacterial meningitis and HIV encephalopathy were the other considerations. CD4 count at the time of presentation was 445 cells/milliliter.
+She was diagnosed with HIV at 6 years of age. Since starting ART, she reported poor adherence, leading to treatment failure and switch to second-line therapy (ABC-3TC-EFV➔AZT-3TC-LPV/r) 8 weeks prior to the onset of her current symptoms; viral load at that time was 224,000 copies/milliliter. Her mother reported excellent adherence, with no missed doses, since starting second-line line ART. Her most recent CD4 count was from 3 years prior at 366 cells/milliliter. There were no recorded cryptococcal antigen tests from the previous year.
+On admission, she was started on amphotericin B deoxycholate (0.8 mg/kg/day) and high dose oral fluconazole (12 mg/kg/day), as flucytosine is not readily available. Given ongoing neurologic symptoms (headache, vomiting), several therapeutic lumbar punctures were performed throughout admission (day 2 of hospitalization 8 mL was drained, day 6, 10 mL, day 10, 15 mL and day 18, 12 mL) with transient improvement in symptoms. Despite this, on day 16 of hospitalization she developed bilateral cranial nerve VI palsy (see Fig. ). CSF analysis showed a negative India ink stain and culture; CSF cell counts were not obtained due to a shortage of reagents. A CT head with/without contrast from day 17 showed mild parenchymal edema of left parietal lobe, otherwise normal. HIV viral load obtained at that time was 262 copies/milliliter. Given persistent symptoms, her induction therapy of amphotericin B and high dose fluconazole was increased from 14 to 21 days. She did not receive other adjuvant therapy such as glucocorticoids.
+At discharge on day 21, she remained with bilateral cranial nerve VI palsy, but otherwise asymptomatic and seizure-free. Her cranial nerve defects resolved within 10 weeks of discharge and she has remained on oral fluconazole. Six months after discharge, she remains without seizures, cranial nerve palsies, or other sequala of CCM.
+This case report received IRB approval. We have obtained written consent from the primary caregiver of the child (the mother) and written assent from the child to publish the case report and associated images.

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+An unrelated natural couple brought an 11-month-old female with delayed development to the outpatient department for genetic counselling . There were no obvious abnormalities detected during the foetal period for this patient. After birth, the baby was found to have jaundice (lasting for 1 month), difficulties falling asleep and a small head circumference. At the age of 7 months, physical examination showed muscular hypertonia, hands often clenched, and global growth regression. The electroencephalogram showed bounded linearity. Cranial MRI showed that the volume of the bilateral cerebellar hemispheres was significantly decreased, especially in the lower part of cerebellar hemisphere, the cerebellar sulcus was widened and deepened, and the occipital cistern was widened (suspected cerebellar hemisphere dysplasia). Additionally, the signal of the bilateral globus pallidus changed slightly, the sulci of the bilateral cerebral hemispheres was slightly widened and deepened, the bilateral frontotemporal extracerebral space was slightly widened, and the bilateral lateral ventricles were slightly widened. At 11 months of age, the head circumference was 40 cm (< − 3 SD) (reference value: 41.9–47.3 cm) . The clinical diagnosis was primary microcephaly. There was no genetic history in the family, and the parents were not close relatives . We initially diagnosed the patient with intellectual developmental and microcephaly with pontine and cerebellar hypoplasia (MICPCH) based on the specific clinical characteristics. There were no phenotypic abnormalities observed in the parents of the patient.
+We extracted DNA from the patient’s peripheral blood sample and performed WES. The results showed that the CASK gene had a heterozygous missense variant, specifically CASK: NM_003688.3: exon 7: c.638T>G: p.L213R. .
+According to the bioinformatics analysis, this variant was not previous reported and was not found in most databases, including the ExAC browser, 1000 Genomes Project, and In-house Chinese-Control. The latest gnomAD database indicates that the frequency of this variant is 0.000005520 . In addition, this variant site is highly conserved in many species according to mutation taster . PhastCons and PhyloP were used to evaluate the scores of amino acid sequence conservation. The scores indicated that this variant site is highly conserved . Moreover, this mutation was predicted to be deleterious by the following bioinformatic tools: SIFT , PolyPhen-2 , and M-CAP . The above results indicate that this variant site is pathogenic and well conserved.
+To further confirm the negative effect of this variant on CASK expression, wild-type and mutant plasmids were constructed and transfected into HEK-293T cells. We determined the mRNA and protein expression of both the wild type and the mutant and found that there was no significant difference in mRNA expression between the wild type and the mutant. However, compared with the wild type, the protein expression of the mutant was downregulated.
+Finally, we predicted the structural pattern of the protein after the amino acid arginine (R) was substituted for leucine (L) by PSIPRED [–]. Importantly, the mutant protein showed decreased protein stability, which is represented by the increased Gibbs free energy (ΔΔGpred = 1.857). The results of the protein structure prediction showed that the nuclear charge of the protein increased (ΔCharge = 1) and the stability of the protein decreased (ΔΔGpred = 1.857) after the variant. Moreover, a random coil in the secondary structure is changed to a β-sheet, which also affects its spatial structure . Therefore, the decreased protein stability and the changed protein structure might contribute to the downregulation of CASK protein expression, further causing the loss of protein function.

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+An 80-year-old Asian woman with Alzheimer dementia was found lying unconscious at her house, which had no air conditioner and the windows were kept closed; the highest outside temperature was 36.1 °C. There was no history of seizure, previous use of medication, diabetes mellitus, hypertension, alcohol abuse, smoking, or cardiac disease. During transportation, a physician began to assist her ventilation, and she was intubated because her SpO2 level was 78% under room air. She was brought by the ambulance with a physician onboard to our hospital unconscious. Her Glasgow Coma Scale score was 6 (eye, 1; verbal, 1; motor, 4), with a high bladder temperature (42.5 °C). On arrival, her blood pressure was 104/79 mmHg and pulse rate was abnormal at 110 beats/min. She was vomiting but had no traumatic scars. Results of an arterial blood gas examination are shown in Table . Laboratory data revealed renal dysfunction and an elevated white blood cell count at 13,890/μL (normal range 3000–9000/μL) . Her DIC score was 5 points as per the DIC diagnostic criteria established by the Japanese Association for Acute Medicine (JAAM) on admission. On day 2, she met the criteria (5 points) of a different diagnostic system established by the International Society on Thrombosis and Hemostasis (ISTH) . Her blood culture was sterile. An electrocardiogram, chest X-ray, and two-dimensional transthoracic echocardiography showed normal results. Serology laboratory tests for venereal disease, human immunodeficiency virus, and viral hepatitis markers (hepatitis A virus (HAV), hepatitis B virus (HBV), and hepatitis C virus (HCV)) were negative. No abnormal lesion was found on the head computed tomography (CT) examination performed on arrival .
+The patient was diagnosed with severe heat stroke, placed under intensive care, and managed with rapid cooling, intravenous fluid therapy, antibiotic therapy, and anti-coagulation therapy for DIC . Anti-coagulation therapy consisted of treatment with recombinant thrombomodulin for 4 days (days 1–4) and recombinant antithrombin for 1 day (day 1). We transfused 10 U of platelet concentrate because her platelet count had decreased to 1.7×104/μL due to exhaustion on day 2.
+Head CT and magnetic resonance imaging (MRI) examinations were performed on day 3 because she was still unconscious. Diffuse-weighted imaging showed high-signal intensities in the bilateral cerebellar hemisphere, bilateral occipital lobe, and basal ganglia. Intracranial magnetic resonance angiography showed normal results. Imaging indicated new multiple cerebellar infarctions . As described above, she had no arrhythmia or organic cardiac disease, and the location of the infarcts included the cerebellum. It was thought that heat stroke with DIC complicated the acute infarctions. A tracheotomy was performed on day 9 because her unconscious condition had not improved. She was transferred to another hospital for subacute care on day 23.

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+This is a retrospective case study of a 56-year-old white man diagnosed as having an AOP infarct admitted to Umeå University Hospital, Sweden. The relevant radiology images were obtained from the hospital’s database (PACS) and evaluated by a neuroradiologist as bilateral paramedian thalamic infarcts as a result of an AOP occlusion. The medical records (SYStem Cross) at Umeå University Hospital were accessed and reviewed for his medical history, neurological work-up, and laboratory work-up (ROS). The diagnosis was based on symptoms of AOP infarction as described in the literature, radiological signs of AOP infarction, as well as exclusion of differential diagnoses.
+He was taken to our emergency department (ED) after he was found unconscious in his home with open doors and windows. He developed ventricular fibrillation on arrival at our ED. Cardiopulmonary resuscitation (CPR) was immediately initiated and sinus rhythm (SR) was achieved on second defibrillation. He was then put on cardiopulmonary bypass for rewarming. A third ventricular fibrillation then occurred and SR was achieved on first defibrillation within seconds of onset. The total estimated duration of ventricular fibrillation was less than 2 minutes.
+His medical history included overconsumption of alcohol. He smoked 20 cigarettes per day. On admission to our hospital there was no information available concerning his medication. On arrival at our ED his body temperature was 24.5 °C, blood pressure 145/70, heart rate 35 beats/minute, and respiratory rate 8 to 10 breaths/minute. Auscultation of his heart and lungs was unremarkable. He was unconscious with a Reaction Level Scale 85 (RLS-85) score of 4. RLS-85 gives a score between 1 and 8. An RLS-85 score of 4 indicates an unconscious patient who localizes but does not ward off when pain stimulated. He exhibited a slight anisocoria with his right pupil slightly bigger than his left.
+The laboratory work-up at admission included moderate electrolyte disturbances and elevated liver enzymes. Drug and alcohol screens were negative.
+An emergency CT of his head was performed and initially misinterpreted as normal with no signs of hemorrhage or acute infarction . In our intensive care unit (ICU), he was initially sedated and intubated with ventilator treatment. An attempt to extubate and wake him was made on day 3, but he still required ventilator support. He was re-intubated and sedated, and later given a tracheotomy. A complicated disease course followed with pneumothorax after CPR, pneumonia treated with antibiotics, bilateral pleural effusion requiring drainage, intestinal paralysis, acute pancreatitis, and ascites requiring paracentesis. The sedation was discontinued 2 weeks after admission to our ICU. He still required ventilation support. At this stage he could open his eyes when spoken to but otherwise he gave no contact. On neurological examination he withdrew his arms, moved his left foot, and grimaced upon pain stimulation. He had slight anisocoria, this time with his left pupil slightly bigger than his right. His pupillary reflexes were, however, symmetrical on direct and indirect stimulation. A follow-up CT performed on day 24 revealed bilateral ischemia in the medial areas of the thalami, as well as a smaller ischemic area in the left part of pons . At this point a senior neuroradiologist re-evaluated the first CT performed on admission and concluded that bilateral thalamic ischemia was discernable also on this CT . Electroencephalography (EEG) was pathological and showed an irregular theta/delta activity. However, there was no epileptiform activity.
+Four weeks after admission it was possible to extubate him. His neurological function remained unchanged. He was transferred to our medical acute ward. On day 35 of hospitalization he died and the postmortem examination revealed pulmonary infarctions and pneumonia. A timeline of events is given in Fig. .

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+A 68-year-old female with a history of hypertension, hyperlipidemia, type 2 diabetes mellitus, gout, rheumatoid arthritis, and bilateral knee replacements on clindamycin prophylaxis for past infections presented to our emergency department with 3 weeks of worsening left lower extremity pain. She was initially seen at an urgent care for erythema and swelling of the left shin. Plain radiographs were unremarkable at that time and she was treated for cellulitis with intramuscular ceftriaxone for 10 days without improvement. On arrival, she was well-appearing, afebrile, and hemodynamically stable with erythema, swelling, and tenderness of the left pretibial soft tissues . The area of erythema and swelling appeared to terminate before the knee joint and there was no appreciable joint effusion or limitation in range of motion on exam. Her pain was worse with ambulation, but she was able to bear weight on the affected leg. Repeat plain radiographs were performed and showed focal soft tissue swelling overlying the anterior aspect of the tibia . A point-of-care ultrasound was performed by sliding the linear probe over the area of erythema in orthogonal transverse and longitudinal planes. Ultrasound demonstrated a large heterogeneous fluid collection adjacent to the tibial cortex . There was a focal defect in the cortex and pulsatile fluid communicating with the medullary cavity. Alternating bidirectional flow was visualized with color flow and pulsed wave spectral Doppler . The WBC count was normal (7.7), and systemic inflammatory markers were elevated (CRP 38 mg/dL, ESR 91 mm/hr). CT was obtained and demonstrated a 5.7 × 2.4 × 7.1 cm fluid collection adjacent to the tibial cortex with sinus tracts into the medullary cavity concerning for abscess with adjacent cellulitis and osteomyelitis . She was given vancomycin and Piperacillin/Tazobactam, orthopedics was consulted, and she was admitted to the internal medicine service. An incision and drainage of the left pretibial abscess was performed. Neither wound nor blood cultures yielded any growth. Infectious Diseases was consulted and recommended treatment with vancomycin for 6 weeks.

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+A 32-year-old man presented with a 6-month history of intermittent dysphagia. Barium swallow showed an extrinsic compression of the lower thoracic esophagus. An upper gastrointestinal endoscopy was performed, which revealed a large submucosal mass in the lower thoracic esophagus without mucosal irregularity. Endoscopic ultrasonography (EUS) and computed tomography (CT) of the thorax showed a large homogeneous tumor in the esophageal muscular layer, measuring about 5 × 6 cm, without paraesophageal lymph nodes and projecting into the right pleural cavity . Routine laboratory and clinical findings were normal.
+The patient was intubated with a double lumen tube for one-lung ventilation and was positioned in the left lateral decubitus position. Three thoracic trocars were introduced . The camera port (10-mm) was placed at the ninth intercostal space, mid-axillary line. Two 5-mm trocars were introduced at the fifth intercostal space, anterior axillary line and the seventh intercostal space, posterior axillary line for using a "grasper" or coagulating device. The left lung was retracted to expose the lower thoracic esophagus. A simple hook was used to divide the mediastinal pleura overlying the esophagus. The lesion was then enucleated by careful dissection.
+Intraoperative endoscopy with air insufflation was performed to confirm esophageal integrity . The esophageal muscle was re-approximated with interrupted 3/0 Dexon. The specimen was removed within an endobag through the camera port. A 28 Fr chest tube was inserted through the camera port for postoperative drainage. The operative time was 2 hours and intraoperative blood loss was minimal.
+Barium swallow at day 3 after surgery revealed no leakage and the patient was started on a liquid diet on day 4. The pathological report showed a leiomyoma with mitotic figure 0–1 per10 high power fields (HPF). Immunoperoxidase stainings were positive for smooth mucle actin, and negative for S-100, CD34 and C-kit. The patient was discharged on postoperative day 6. The patient is currently asymptomatic three months after surgery.

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+A 51-year-old man with a history of atrial fibrillation (AF) presented to the emergency department with acute onset of the left-sided weakness 45 min after his last known well (LNW). Further, anamnesis revealed that in the past 6th month, he did not take oral anticoagulation for his AF. The baseline National Institutes of Health Stroke Scale (NIHSS) score was 14, with left hemiplegia, right conjugate eye deviation, dysarthria, and facial paralysis. On initial examination, the patient was afebrile and alert with a Glasgow Coma Score (GCS) of 15, blood pressure was 140/67 mmHg, and his respiratory rate was 20 breaths/ min. In addition to that, his pulse was low, around 36 beats/ min. The electrocardiogram revealed a junctional rhythm. Sulfas atropine and dopamine were administered to treat the bradycardia since the pulse decreased to 20 beats/min and GCS dropped to 11 (E3V3M5). After hemodynamic stabilization, a head non-contrast computed tomography (NCCT) was performed (i.e., 2 h after LNW). A head NCCT revealed a hyperdense right middle cerebral artery (MCA) sign, suggesting a hyperacute thrombotic stroke . All the laboratory studies were within a normal limit.
+At 4 h after LNW, the patient received IVT using recombinant tissue plasminogen activator (alteplase) (r-tPA). Under General anesthesia, he was taken for temporary pacemaker (TPM) insertion by cardiologist, followed by EVT by our endovascular surgeon. An angiogram of the right internal carotid artery at hour 6 confirmed occlusion of the M1 branch of the right MCA with no collaterals in the territory of the occluded vessel . The first attempt of manual aspiration thrombectomy successfully achieved modified thrombolysis in cerebral infarction 3 revascularization in 6 h 20 min . The occlusive thrombus was all removed using the direct aspiration first pass technique with a catheter aspiration system.
+Post-thrombectomy, the patient was still intubated and sedated. During observation in the intensive care unit, he developed an occasional premature ventricular contraction and upside-down blood pressure. Follow-up NCCT within 24 h following thrombectomy revealed petechial hemorrhage on the infarcted area and massive focal brain edema on the right frontotemporoparietal, resulting in a 13-mm midline shift (MLS).
+The patient was treated conservatively initially for his brain edema. After being given conservative treatment for 2 days, the patient was not on sedation but still unconscious with GCS of E2V × M5. He developed anisocoria pupils with diameters of 2 mm and 1 mm, on the right and left pupils, respectively. The diagnosis of MBE was made, and the patient was taken for emergent decompressive craniectomy (DC) to release the intracranial pressure.
+Two days following DC, the patient was allowed to awaken to the point where a limited neurologic examination was possible and subsequently extubated. He could move all four extremities on command but still had left hemiparesis, and his pupils were isochor. His NIHSS score was 6 for left hemiparesis and dysarthria. Follow-up NCCT was performed 4 days after DC and revealed decreased mass effect to 6 mm MLS. The TPM was changed into permanent pace maker after 7 days of its insertion . The patient was discharged home on hospitalization day 15. The Modified Rankin scale score was four in 1- and 3-month’s follow-up.

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+On March 14, 2022, a 7-year-old girl was admitted to Wuhan Children's Hospital, Tongji Medical College, Huazhong University of Science and Technology due to noticeable behavioral changes occurring over the past months. These changes included episodes of eye rolling, mouth twitching, and pronounced mouth breathing, lasting approximately 3-5 minutes, particularly when fatigued, happening about 4-5 times per day. Shortly after these episodes, the child would suddenly rise and move about in a seated position, engaging in self-talk and hand-and-foot movements for several hours. The child had been diagnosed with epilepsy at the age of 1, effectively managed with oral levetiracetam. In March 2021, the patient developed intermittent fever and a decrease in blood cell counts. After a thorough examination, the patient was diagnosed with Shwachman-Diamond syndrome (SDS), a genetic condition marked by bone marrow failure and an elevated risk of hematological malignancies. Using whole-exome sequencing, we identified a homozygous splice site variant and this c.258 + 2T>C variant at the 5’ splice site (ss) is associated with aberrant pre-mRNA splicing due to the usage of an upstream cryptic 5’ss at positions c.251-252, eventually resulting in an 8-bp deletion and frameshift (84Cfs3) . In November 2021, the patient underwent HSCT from an unrelated HLA9/10-compatible donor at the Department of Pediatrics, Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology. There were no signs of acute or chronic graft-versus-host disease after HSCT. There was no significant personal history of trauma, infections, tuberculosis exposure, toxin exposure, allergies, or familial metabolic diseases. Upon admission, the patient exhibited stable vital signs, appropriate responsiveness, and normal brain function. Physical examinations revealed a supple neck with non-palpable superficial lymph nodes. Assessments of the heart, lungs, abdomen, and limb muscle strength were normal. Kernig’s and Brudzinski signs were negative, and the heel-knee-shin test showed stability. Imaging tests, including diffusion-weighted magnetic resonance imaging (MRI) of the head, computed tomography scans of the chest, abdomen, and pelvis, superficial lymph node ultrasound, and positron emission tomography-computed tomography, showed no significant abnormalities. The EEG indicated a dominant rhythm without prominence, increased slow wave activity during wakefulness, and occasional paroxysmal multi-spike slow waves during sleep . Integrated sensory and cognitive assessments reported mild proprioceptive and body coordination issues. The self-rating anxiety scale, self-rating depression scale, children’s psychological counseling test report, and China-Wechsler children’s intelligence scale all exhibited normal results. Laboratory tests, including blood counts, blood coagulation, urine and stool routines, liver and kidney function, thyroid function, C-reactive protein, procalcitonin, electrolyte levels, myocardial enzymes, blood ammonia, lactic acid, blood glucose, anti-nuclear antibodies, and anti-extractable nuclear antigen antibodies, all returned within normal ranges. Lymphocyte subsets detection displayed abnormalities . The patient tested positive for Epstein-Barr virus core antigen, Epstein-Barr virus capsid antigen, cytomegalovirus antibodies, and herpes simplex virus I and II immunoglobulin G (IgG). However, fungal glucan, galactomannan tests, pre-transfusion infectious disease screening, tuberculosis microarray, and parvovirus B-19 yielded negative results. Routine cerebrospinal fluid biochemistry, exfoliative cytology, bacterial cultures, and smears (for common bacteria, cryptococci, and fungi) were all unremarkable. Moreover, 12 cerebrospinal fluid AE antibodies, along with oligoclonal bands and myelin basic protein, tested negative . Bone marrow cytology and immunophenotypes were generally normal. Double immunofluorescence cell staining revealed elevated anti-mGluR5 antibody levels in the serum (1:1000) . A final diagnosis of anti-mGluR5 AE was established. The patient received treatment with intravenous gamma globulin (400 mg/kg daily for 5 consecutive days) and methylprednisolone (20 mg/kg daily for 5 consecutive days), followed by oral prednisone. During hormonal shock therapy, omeprazole was administered for gastric protection, along with calcium and potassium supplementation. Levetiracetam and trihexyphenidyl were concurrently prescribed for epilepsy and dystonia, respectively. The abnormal behaviors notably improved after treatment, and EEG results improved . A re-examination in January 2023 revealed the absence of an SBDS gene mutation in peripheral blood. The patient remained symptom-free at the last follow-up in August 2023.

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+A 36-year-old white male patient suffering from headache and abdominal pain presented at our emergency department. Initial ECG showed a sinus rhythm (40/min.) with a single T-wave inversion in lead V2, and an incomplete right bundle branch block. Thrombocytes were decreased with 71.000/μl (normal range 150.000–450.000/μl), creatinine was elevated (2.0 mg/dl) with a maximum increase to 3.0 mg/dl (normal range 0.6–1.1 mg/dl) and massive proteinuria. C-reactive protein was also elevated: 8.6 mg/dl (normal < 0.5 mg/dl). Puumala virus IgG ELISA turned out to be positive, and specific antibodies (IgG and IgM) could be detected in the serum, and confirmed by immunoassay, also see Additional file . The patient was admitted to the nephrology department for supportive therapy.
+Six days later, the patient reported chest pain and dyspnea. High sensitivity troponin I rose up to 0.32 μg/l (normal range below 0.04 μg/l) with an increase of the creatinkinase to 319 U/l (normal max. 190 U/l), no dynamic ECG changes could be observed. The patient was admitted to the chest pain unit. Echocardiography revealed a normal left ventricular function (65%) without regional wall motion abnormalities, no pericardial effusion or valve abnormalities. Since creatinine has normalized in the meantime, coronary artery disease was ruled out by coronary CT angiography.
+CMR for work-up of suspected myocarditis was performed using a 1.5 T Magnetom Aera (Siemens Health Care, Germany). Cine-SSFPs revealed normal LV-EF (60%) with no wall motion abnormalities. A modified Look-Locker inversion recovery product sequence (MOLLI, MyoMaps) was used for T1-mapping and performed in a single mid-ventricular short-axis (SAX) slice at mid-diastole, prior and after application of contrast agent according to current recommendations . T2-mapping was performed in the corresponding mid-ventricular SAX before administration of contrast agent using an ECG-triggered T2-prepared single-shot steady-state free precession (SSFP) product sequence with multiple T2 preparation times . Normal values: native T1 < 1000 ms, T2 < 50 ms. Analyses were made by cvi42 software (Circle, Canada). Late gadolinium enhancement (LGE) images were acquired after contrast administration (Gadobutrol 0.15 mmol/kg) using segmented inversion-recovery fast low angle shot (IR-FLASH).
+Native T1-mapping demonstrated markedly elevated T1 values with preponderance in the inferoseptal wall (1068 ± 73 ms in the entire slice vs. 1122 ± 31 ms in the inferoseptal wall), also see Figs. and . Furthermore, T2-mapping revealed increased values (entire slice 52 ± 6 ms, inferoseptal wall 55 ± 6 ms), suggesting myocardial edema representing active myocardial inflammation by hantavirus infection. In contrast, the LGE image, potentially indicating irreversible myocardial damage if positive, in the corresponding slice was negative . Despite negative LGE, this patient was considered having hantavirus-induced myocarditis due to: 1) clinical symptoms, 2) increased cardiac biomarkers, 3) exclusion of CAD and 4) conspicuous native T1- and T2-mapping values detected by CMR.
+In the next few weeks, the patient’s state of health rapidly improved and symptoms of chest pain and dyspnea disappeared. Five months later, the patient was followed up by the same CMR protocol: Substantial decrease of native T1 values (957 ± 58 ms in the entire slice vs. 971 ± 36 ms in the inferoseptal wall) and T2 values (entire slice 44 ± 5 ms, inferoseptal wall 45 ± 3 ms) in the mid-ventricular slice position could be observed, again LGE-negative, suggesting myocardial healing .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1298_en.txt

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+A 38-year-old woman in her 19th wk of pregnancy (G2P1) was referred to our clinic for a sudden persistent pain on the left side of the waist on July 28, 2017.
+The patient’s physical examination revealed tenderness over the left kidney area. Her blood pressure was 120/85 mmHg, heart rate was 86 beats/min, and body temperature was 36.8 °C. The patient had no significant medical history. She had not undergone any related abdominal examination previously.
+The patient had no significant medical history. She had not undergone any related abdominal examination previously.
+The patient was hospitalized and given conservative treatment, but her left-side waist pain continued to be intense. Because the size of the tumor was so large, and the fetal heart rate was unstable, the patient decided to undergo left nephrectomy after the induction of labor.
+Laboratory tests indicated that the patient’s hemoglobin level was 80 g/L, and the hematocrit was 0.242 L/L. On the 2nd d, hemoglobin was 95 g/L, and the hematocrit was 0.286 L/L.
+Ultrasound examination of the urinary system (LOGIQ E9, GE) revealed a giant nonhomogenous lump in the left kidney area, which had caused the left kidney to move to the midabdomen. The size of the lump was approximately 159 mm × 100 mm, and the border was faintly visible. The lump showed a “striped sign” in which the outer part was hypoechoic with a strong stripe echo , and the inner part near the left kidney was hyperechoic . A stripe-shaped echoless zone was seen around the lump (arrow). Color Doppler flow image showed some spot-like blood flow signals around the lump . A hyperechoic nodule was seen in the right kidney with a size of 30 mm × 25 mm. There was a fetus echo in the uterus. Preoperative CT showed a large, mixed-density mass in the left kidney . The density of the area adjacent to the kidney was low, and the area far from the kidney showed high density.

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+Our patient is a 73-year-old male with a past medical history of polymyositis, hypertension, constipation, and insomnia, who presented to the emergency department with dyspnea. He had been experiencing weakness and changes in mental status since his last intravenous immunoglobulin (IVIg) treatment. Initial assessment revealed hypothermia, bradycardia, and hypoxia, prompting admission for acute hypercapnic respiratory failure secondary to a possible polymyositis flare.
+Upon admission, he received supportive care including fluid resuscitation, oxygen therapy, and antibiotic coverage. Patient was started on corticosteroids, bronchodilators, and bilevel positive airway pressure (BiPAP) for respiratory support. Investigations were undertaken to identify the cause of his respiratory distress, including blood cultures, urine analysis, and imaging studies, which were largely unremarkable.
+His clinical condition improved temporarily, but not soon after, he developed altered mental status owing to hypercapnia. An arterial blood gas analysis revealed respiratory acidosis with a compensatory increase in bicarbonate levels. A comprehensive plan was devised for continued management, including transitioning to home non-invasive ventilation (NIV). Shortly thereafter, he developed shingles and further complications arose, such as dysphagia confirmed on modified barium swallow study, thrombocytopenia, and debility requiring full assistance for activities of daily living.
+Consultations with neurology and rheumatology raised questions about the primary diagnosis of polymyositis, with a strong clinical suspicion for inclusion body myositis. In addition, the pattern of weakness and atrophy was more suggestive of inclusion body myositis than polymyositis. Further discussions with the patient's previous neurologist shed light on his extensive medical history, muscle biopsy report and IVIg therapy.
+Despite initial stabilization, his respiratory status deteriorated, necessitating transfer to the intensive care unit for closer monitoring and adjustment of his respiratory support. He tolerated BiPAP well during his ICU stay.
+Throughout his hospitalization, efforts were made to address his thrombocytopenia, constipation, and dysphagia. Oncology consultation was sought for further evaluation of his thrombocytopenia, while palliative care discussions were initiated given the complexity of his medical condition and declining respiratory status. Possible intubation, tracheostomy, and code status were elaborately discussed with the patient and family, following which the patient expressed a preference for a DNR/DNI order.
+Despite challenges with BiPAP adherence, patient showed improvement with consistent use of the device, leading to discussions on discharge planning. Physical therapy recommended a transfer to a subacute rehabilitation facility, but the patient wished to be discharged home. Arrangements were made for home health services, including physical therapy, and visiting nurse support.
+Prior to discharge, the patient's medication regimen was adjusted. Dietary modifications were recommended to address his dysphagia, and precautions were advised to prevent aspiration. Also, a tyrosine rich diet was recommended, which has been proven beneficial in patients with nemaline myopathy . Patient's discharge plan emphasized the importance of continued respiratory support with BiPAP, along with close follow-up with his primary care provider and neurologist. Home equipment, including cough assistance and suction devices, were provided to aid in airway clearance and ensure a safe transition to home care.

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+A 14-year-old Caucasian girl presented with a right-sided nasal obstruction and severe headache, which was most pronounced in the right forehead region. Our patient reported a headache persisting for three years, however, in the past three months, its intensity prevented her from attending school. In addition to difficult breathing on the right turbinate, she reported anosmia and occasional epistaxis on the same nostril. On several occasions, our patient was seen by a pediatrician, who considered her headaches to be related to puberty. When her headache turned so severe to prevent her attending school, a magnetic resonance imaging (MRI) scan of her brain was recommended to reveal a tumor of the right middle turbinate. A multislice computed tomography (MSCT) scan of her paranasal sinuses, taken for better visualization of the bone structure, showed a clearly delineated, heterogeneous (hyperechoic) tumor growth, which corresponded to the finding of a bone tumor with a inhomogeneous central portion and marginal mineralization . The tumor involved the right middle turbinate, complete anterior and incomplete posterior ethmoidal cells, and the frontal sinus ostium. Cribriform lamina was, in the most part, consumed by the tumor growth, while the skull base was mostly of normal bone structure. Lamina papyracea was free and clearly demarcated from the tumor. There was septum shift to the left, without septum perforation. The tumor was removed in toto by endoscopic technique and pathohistological analysis showed the osteoblastoma . As it was a bone tumor, it could not be excised en bloc, instead, the tumor was first cut by a bur in the region of the middle turbinate base, then the rest of the tumor was removed by diamond bur abrasion of the bone with removal of the most part of the cribriform lamina. On endoscopy, there was a clear margin between the healthy bone, which was white and compact, and osteoblastoma, which was of a honeycomb structure, reddish and more vascularized. Postoperatively, our patient denied headache, breathed normally through her nose and attended school regularly. But the six-month follow-up computed tomography (CT) scan showed a recurrence and we had to do an en bloc resection of the tumor. The CT scan one year later showed normal findings without recurrence and our patient did not have her headache any more .

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+An 80-year-old male patient was admitted to our hospital on Jan.5, 2022 with multiple medical conditions for several years. He has been diagnosed with chronic renal insufficiency (elevated serum creatinine) ten years ago and renal anemia seven years ago. He was intermittently treated with human erythropoietin. Two weeks before transferring to our hospital, the patient was administered continuous renal replacement therapy because serum creatinine rising to a level of 400 µmol/L and oliguria. His past medical history included hypertension, coronary heart disease, plasmacytoma, fungal pneumonia, bacterial pneumonia, hepatic insufficiency, and hyperhomocysteinemia. The patient presented asthenia, anuria, without fever and had no cough or sputum. He also had petechiae on the forearm and a 5×5 cm ecchymosis on the chest. Auscultation detected bilateral coarse breathing. He had a CRP plasma level of 59.7mg/L, a procalcitonin level of 0.931ng/mL, and a serum creatinine level of 467μmol/L. His erythrocyte and platelet counts were 1.87×1012/L and 42×109/L, respectively. His hemoglobin level was 68g/L, and his white blood cell count was normal. A chest CT scan revealed a dense opacity in the middle of the right lung, lung nodules, mild interstitial changes, and pleural effusion.
+Before transferring to our hospital, the patient’s blood culture was negative for Aspergillus spp. or Mucorales and positive for Candida, while the exact type of Candida had not been identified at that time, an intravenous infusion of 800mg fluconazole on the first day, followed by 400mg per day for several days, as an treatment strategy for this condition in another hospital. Because this was ineffective, he was treated empirically with piperacillin sodium tazobactam sodium at 2.25g three times a day in our hospital. His treatment history for plasmacytoma was unknown because of hospitalization in another hospital before. Leucogen was used to treat for his hypocytosis, Other treatment strategies included platelet transfusion, hemodialysis, antihypertensive therapy, acid inhibitory, liver protection therapy and treatment of anemia.
+The patient’s condition did not improve during the treatment course. His inflammatory blood markers of CRP and procalcitonin remained high , indicating a persistent infection. Although the patient had a normal body temperature when he was admitted to our hospital, it increased to 38.2°C on the fourth day, and fluctuated somewhat up and down, reaching 39°C only once briefly. Unfortunately, the patient died nine days after admission to our hospital .

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+A 59-year-old male was admitted to our ward with abdominal pain in the right upper quadrant, nausea, and vomiting; the symptoms had started about 24 hours before. Physical examination showed tenderness of the abdomen, positive Murphy's sign, negative Blumberg's sign. On admission, blood test showed WBC count of 17.200/mm3, whereas liver function tests, lipase, and amylase levels all resulted as normal. Abdominal ultrasound showed a single gallstone impacted in the infundibulum of a dilated gallbladder, with a thick and inflamed wall. The patient underwent emergency laparoscopic cholecystectomy. A three-trocar technique was used inserting the cannulas in the umbilicus (10 mm), subxiphoid (5 mm), and right lateral subcostal margin (5 mm). Preliminary evacuation of empyematous gallbladder was performed by a percutaneous 21-gauge needle . A fundus first approach was elected because of the severe inflammation of tissues surrounding the gallbladder and its hilum. The procedure lasted 45 minutes with repeated use of bipolar energy to control bleeding from the gallbladder bed. After removal of the gallbladder, thorough inspection of the hepatic bed was made and a little bile leak was identified from a duct of Luschka 1 cm away from the gallbladder hilum . Direct suture with 5/0 PDS was attempted first but failed because of the poor quality of the inflamed hepatic tissue. In order to avoid any deeper suture that would involve major hepatic vessels due to the proximity with the hepatic hilum, an alternative technique was chosen. We inserted a QuickClip Pro® clip (Olympus Medical Systems Corp., Tokyo, Japan) through the subxiphoid trocar. This endoscopic device was directed by means of a Johann clamp inserted through the right subcostal trocar to securely close the duct of Luschka . An abdominal drainage was left in place for 24 hours, and the patient was discharged on the second postoperative day.

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+A 45-year-old female patient presented with seizures, altered consciousness, incoherent speech, irritability, and urinary incontinence for a month. The brain magnetic resonance imaging (MRI) of the patient revealed the presence of multiple patchy and punctate hyperintense signals in the bilateral frontal lobes, left insular lobe, and left basal ganglia on both T1-weighted and T2-weighted MRI sequences. The T2 FLAIR sequence demonstrated high signal intensity, but no enhancement was observed (as shown in ). The laboratory tests revealed that the patient had a NMDAR antibody IgG titer of 1:300 in peripheral blood and 1:100 in cerebrospinal fluid. Additionally, the CA19-9 level was elevated at 48.44 U/mL, while the CA125 level was within the normal range at 21.9 U/mL. Due to the detection of abnormal NMDAR antibody IgG titers in both peripheral blood and cerebrospinal fluid, abnormal brain MRI findings, as well as symptoms of epilepsy, cognitive impairment, and speech disorders, the patient was ultimately diagnosed with anti-NMDAR encephalitis based on diagnostic criteria . Given the strong association between this disease and teratoma, a bedside ovarian ultrasound imaging examination was performed. The result revealed an oval mixed echo group measuring 54 × 37 mm in the adnexal area. The lesion exhibited clear boundary, a thin cyst wall, and homogeneous, dense, punctate hyperechoic areas, as well as liquid anechoic areas within. These findings suggest a possible teratoma in the left adnexal area. No lesions were detected in the peritoneum on ultrasound examination.
+The pathological gross examination (shown in a) revealed a pile of grayish-red fragmented tissue measuring 7 × 6 × 2.2 cm. Some of the tissue fragments were cystic, with a wall thickness ranging from approximately 0.1 to 0.8 cm. Two solid tissues with diameters of 1.3 cm and 1.8 cm were observed. The solid area appeared grayish white with a medium texture; no obvious hair was detected. Microscopic examination found that ectodermal components epidermis, skin appendages and mesodermal component mature adipose tissue were easily found (shown in b). Other mesodermal and endodermal derivative components were also found, such as bone tissue, mature cartilage tissue, respiratory epithelium tissue, and salivary gland tissue (shown in c). No mature or immature neural components were identified. These findings confirm the pathological diagnosis of MCT. Furthermore, the solid component of the gross tissue displayed histological features characterized by a significant proliferation of densely arranged astrocytes, exhibiting sparse cytoplasm and mild to moderate atypia (shown in a). There were variations in cell density, with some regions showing abundant cells and others showing sparse cellularity (shown in b). The surface was lined with ciliated columnar epithelium; beneath the epithelium, a neurofibroid-like matrix was present (shown in c). Mitotic figures are rare, and there is a small amount of blood vessels and lymphocytes in the interstitium, with no necrosis observed. We think that the morphology, particularly the presence of a relatively large glial cell proliferation area measuring approximately 1.3 cm, densely arranged cells with cellular atypia (shown in d), the absence of significant necrosis, strongly suggests a diagnosis of a low-grade glioma.
+Immunohistochemistry analysis of the solid area (shown in ) revealed diffuse and strongly positive cytoplasmic staining of GFAP, confirming its glial origin. The negative expression of EMA suggests the exclusion of ependymal origin, further supporting astrocytic origin. Olig-2 showed partial positivity, indicating the presence of oligodendroglial components. P53 and IDH1 R132H were negative. The Ki67 index was approximately 10% positive expression, suggesting the presence of low-grade glioma lesions . However, further molecular studies are required to confirm the diagnosis according to the 2021 WHO classification of the CNS tumors, which are unable to conduct in our institution.
+Based on these findings, the patient was diagnosed with malignant transformation of MCT into a morphology of low-grade glioma, not otherwise specified. The patient underwent laparoscopic resection of the left ovary and fallopian tube without any additional treatment for ovarian tumors. Peritoneal resection was not performed, and there is no history of peritoneal glioma. The patient was treated with immunosuppression and hormone therapy. A pelvic CT examination conducted 5 months after tumor resection showed no signs of teratoma recurrence. At the 6-month follow-up, the patient did not exhibit symptoms of seizures or altered consciousness but reported feeling slightly depressed and dreamy. The patient continued taking antipsychotic medication and received regular reviews.

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+A 77-year-old Japanese man presented to our hospital with complaints of loss of appetite for 2 mo and a 10-d history of palpable purpura.
+The patient had developed progressive palpable purpura over his lower legs without fever, chills, or other clinical signs.
+The medical history included hypertension, hyperlipidemia, old myocardial infarction, and appendicitis. The patient was on regular treatment with medications, including aspirin, lansoprazole, enalapril, valsartan, and carvedilol. He had no notable family or social history.
+His family history was noncontributory.
+On physical examination, the patient’s vital signs were normal: blood pressure, 102/58 mmHg; heart rate, 94 bpm; and percutaneous oxygen saturation, 99% in room air. However, multiple palpable purpuric lesions were noted on bilateral lower extremities, the lower abdomen, and part of the upper extremities . Lymphadenopathy was noted in bilateral inguinal, cervical, and supraclavicular nodes, measuring up to 1 cm in diameter. No clinically relevant abnormalities were observed on the electrocardiogram and chest radiograph.
+Laboratory data on admission was shown in Table : White blood cells and platelet counts were normal but normocytic normochromic anemia was seen. An elevated level of serum lactate dehydrogenase has been found. Although several abnormalities were observed, none of them were specific to the diagnosis.
+We performed skin biopsy, which demonstrated superficial perivascular dermatitis. However, this did not help in diagnosis. Subsequently, a right inguinal lymph node excisional biopsy was performed, which showed vascular proliferation with high endothelial cells, including small-to-medium-sized atypical lymphocytes and follicular dendritic cells. Immunohistochemical analysis revealed the expression of T-cell markers (CD2, CD3, CD4, and CD5) with CD10. These characteristics were consistent with those of AITL.
+Subsequently, several days after hospitalization, the patient developed progressive normocytic normochromic anemia. His hemoglobin levels remained much lower than normal at 4.9-6.0 g/dL, with normal white blood cell and platelet counts, similar to those on admission. His absolute reticulocyte count also remained extremely low at less than 10000/µL, necessitating blood transfusion support almost every day. Peripheral blood smear examination revealed a normochromic normocytic picture and there was no evidence of hemolysis. We performed bone marrow aspiration and biopsy for evaluation, which showed characteristic findings of relative erythroid hypoplasia. The myeloid and lymphoid series were essentially unremarkable, whereas the megakaryocytes were slightly increased in number and had normal morphology. Based on these findings, the patient was diagnosed with PRCA.

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+A 77-year-old African American woman with a medical history of hypertension presented with a systolic blood pressure of 200 mmHg. There was no significant family or social history. A renal ultrasound showed a 12 × 9 × 7.5 cm mass medial to the left kidney. A follow-up computed tomography (CT) scan showed an enhancing 9 × 6 cm mass anterior and medial to the left kidney. Laboratory studies revealed a normal dexamethasone suppression test and an elevated androstenedione level of 182 ng/dl. Given these results, an androgen-producing adrenal tumor was suspected. The differential diagnosis also included pheochromocytoma, lymphoma, and mesenteric gastrointestinal stromal tumor. The patient underwent robotic-assisted left adrenalectomy. The intraoperative finding of “focal invasion” into the renal parenchyma raised the possibility of adrenal cortical carcinoma; therefore, an additional left upper pole partial nephrectomy was performed. The specimen received was an 11 × 7.2 × 6.8 cm adrenal mass with attached portion of kidney. The mass was golden yellow, well circumscribed, and grossly adherent to the kidney. Histologic evaluation revealed an adrenal cortical adenoma without any features of malignancy, with a Weiss score of 0 . The adjacent adrenal parenchyma shared an incomplete capsule with the kidney and was in direct contact with the renal cortex, establishing the diagnosis of fusion between the two organs . The postoperative course was uneventful.

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+A 24-year-old male comes to the emergency department complaining of a history of sore throat, malaise, fever, and neck and facial swelling with a normal consciousness level. On examination, it reveals tonsilar swelling and tenderness with bilateral cervical lymphadenopathy. The blood pressure and heart rate were normal. The patient had no previous history of chronic disease, chronic drug usage, or allergy. A laboratory examination showed leukocytosis and high C-reactive protein serum. An ultrasound examination demonstrates left jugular vein thrombosis . Contrast-enhanced neck Computed tomography reveals fluid and air density collections with soft tissue phlegmon formation in the anterior cervical region, in both soft tissue of the anterior mandibular ramus, peritonsillar, left parapharyngeal area, and left carotid space, and also there is left jugular vein thrombosis . Preliminary differential diagnoses reveal Ludwig's angina and Lemierre's syndrome. The patient underwent surgical drainage in the ENT department and at the same time was treated with Penicillin g 1.2 unit 1 × 1 im for one dose, metrodenzol 3 × 1 iv and unacefen 1g 2 × 1, and Clexane 4000 IU 1 × 1. The blood culture was positive for Fusobacterium necrophorum and was ordered to continue treatment. The patient develops headaches and fever after 10 days. A contrast-enhanced MRI showed an intracranial epidural abscess on the left side of the brain . The patient was added to the treatment with intravenous clindamycin 600mg 1 × 3 and vancomycin 1g 3 × 1. After 45 days, the patient improved clinically and was discharged for a home treatment regimen with clavulanate 1000 mg 1 × 2; metro 500mg 1 × 3; and warfarin 5 mg 1 × 1. There were no other symptoms after a one-month follow-up clinically and with neck ultrasonography. This work has been reported in line with the SCARE 2020 .

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+A 38-year-old woman underwent an annual health checkup, and the ultrasonography identified a hepatic mass close to the portal vein. No specific findings were noted in her personal and family history. Her physical and laboratory data were unremarkable. CT showed a well-defined portal hepatic tumor with inhomogeneous moderate contrast enhancement . The tumor measured 4.2 cm × 6.8 cm. The clavate tumor showed low intensity on T1-weighted imaging and was isointense to fat on T2-weighted imaging . The tumor included cystic degeneration and extended along the intrahepatic bile duct . Both MRCP and endoscopic retrograde cholangiopancreatography showed focal bile duct compression without any biliary obstruction and dilatation . 18F-FDG accumulation was shown on PET after 5 months of the CT scan; the size of the tumor did not change during the interval , and the maximum standardized uptake value (SUVmax) was 5.0 and 6.5 in the early and late phases, respectively. Lymphadenopathy was not identified by any imaging methods. Because IgG4-related disease and portal hepatic malignancy, including malignant lymphoma and cholangiocarcinoma, were still of our concern, a needle biopsy via endoscopic ultrasonography was performed. Histological study showed the spindle cells close to the bile duct . The lymphocyte infiltration was not identified, but the small vessels had proliferated moderately. Immunohistological examinations showed that the tumor cells were strongly positive for S-100 but not for smooth muscle actin and c-Kit. Ki-67 staining was < 1% of the tumor cells. The diagnosis of portal hepatic schwannoma was made. Because of her age and possibly high invasiveness of the surgery for the portal benign tumor, we did not recommend the surgical procedures. She was followed up intensely in another institution.

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+A 27-year-old Burkinabe woman from the north of Burkina Faso had consulted for a recurrent scalp nodule that had been evolving for 13 years. The scalp nodule had relapsed for the seventh time 6 months ago after six surgeries. It began as a painless nodule of the scalp that would have benefited from iterative surgical resections without histologic analysis.
+The patient presented to our institution complaining of a dry cough lasting for 1 month. She was afebrile and in good condition. We noted an atrophic, indurated, scarring alopecic plaque measuring 15 cm in diameter in the center of her scalp, topped by a firm erythematous nodule measuring 3 × 2 × 2 cm in projection of the right parietal region. The nodular mass was slightly movable to the deep plane and painless.
+Three other nodules were also observed that were more palpable than visible, each measuring 1 cm in diameter, on the indurated alopecic plaque . The patient’s physical examination revealed a painless mobile nodule located in the axillary tail of the right breast. The result of the patient’s respiratory system examination was normal. The results of the rest of her physical examination were normal.
+Cranioencephalic computed tomodensitometry (CT) was performed, which showed a soft tissue mass in the exophytic right parietal skin, measuring 30 × 24 × 17 mm, enhanced after iodine contrast agent injection. There were no signs of damage to the cranial vault or the brain .
+Thoracic CT revealed four intrathoracic tissue masses that were straight to pleural contact and a nodule of the axillary tail of the right breast, measuring 23 × 22 × 18 mm . The breast and chest nodules had the same characteristics before and after iodine contrast agent injection. There were no evolutionary lesions in the abdominopelvic region. Ultrasound of the breast nodule revealed an oval hypoechoic formation with regular contours. The result of an abdominopelvic ultrasound was normal.
+A histologic study of the scalp nodule biopsy showed a proliferation of fibrous background fusiform cells carrying a storiform pattern. These cells had elongated, dark nuclei and showed some mitosis without atypia (three mitoses per 10 high-power fields at × 40 magnification). An immunohistochemical study demonstrated that the cells expressed CD34 intensely and diffusely, but the result was negative for PS100 and smooth muscle actin.
+Histologic and immunohistochemical study of the breast nodule revealed the presence of a breast mesenchymal tumor with the same characteristics as the scalp nodule, and the result was positive for CD34 . The combination of clinical, imaging, histologic, and immunohistochemical findings led us to a diagnosis of scalp DP with breast metastasis and probably pleuropulmonary metastasis. Surgery and chemotherapy with imatinib are being considered for our patient. ​After three rounds of chemotherapy, the breast and chest nodes partially regressed in size.

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+A 72-year-old right handed male diagnosed with poorly-differentiated, stage IIIB neuroendocrine carcinoma of the colon s/p hemicolectomy, small bowel resection and carboplatin-etoposide × 3 cycles presented to the emergency department with acute altered mental status and right facial droop.
+Four months prior, he presented with constipation and anemia. Colonoscopy revealed a large raised flat lesion in the transverse colon and CT abdomen demonstrated RLQ mesenteric lymphadenopathy. He underwent right hemicolectomy and small bowel resection weeks later. Pathology was significant for poorly-differentiated grade 3, neuroendocrine carcinoma with focal lymphovascular invasion and tumor invasion through the muscularis propria into the subserosa. Margins were negative, no perineural invasion and 1/33 lymph nodes were positive for carcinoma. There was an absence of non-neuroendocrine component. Immunohistochemical stains were positive for: AE1/AE3, CD56, chromogranin, and synaptophysin; Ki-67 of 60% proliferative index. He was staged as pathologic T3N1a, stage IIIB.
+In the emergency department, head CT was negative for an acute hemorrhagic process and did not demonstrate any suspicious lesions. Within one day of admission, the facial droop resolved. Further imaging, CT chest abdomen pelvis, revealed stable enlarged mediastinal lymphadenopathy and a subcentimeter retroperitoneal lymph node but no progression was evident. Two days into the hospital stay, the patient developed fever and subsequently neck stiffness. His chest x-ray and urinalysis were non-diagnostic; EEG showed diffuse slowing but no seizure activity. A lumbar puncture was performed with cytopathology of the CSF suggesting metastatic disease to the central nervous system , along with lymphocytic pleocytosis, normal glucose, and significantly elevated protein and lactic acid. Cytologic analysis showed tumor cells with characteristically-high nuclear to cytoplasmic ratio, relatively round nuclei with stippled “salt and pepper” nuclear chromatin and minimal cytoplasm, features consistent with metastatic neuroendocrine carcinoma . Immunohistochemistry showed the tumor cells were strongly positive for synaptophysin and Cytokeratin AE1/AE3 with a typical perinuclear dot pattern.
+Medical oncology and radiation oncology were consulted. No further chemotherapy was recommended as he had progressed after completing 3 of 6 cycles of carboplatin-etoposide. Enrollment in an erlotinib trial was discussed vs palliative therapy. While radiation was considered to be potentially palliative for his symptoms, radiation oncology deemed it would be unlikely to change his overall survival. He was started on palliative high-dose steroids and ultimately transferred to inpatient hospice care. The patient passed away within a week of entering hospice.

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+A 68-year-old man with ET visited our hospital for premature ventricular contractions (PVCs) and shortness of breath on effort. He had started taking anagrelide 1.5 mg daily, an inhibitor of megakaryocyte maturation and polyploidization, 1 month before his visit because his platelet count could not be controlled using hydroxyurea. He had normal physical findings with no clinical evidence of heart failure. He did not have any thrombotic or bleeding complications of ET. He underwent Holter monitoring, echocardiography, and coronary computed tomography (CT). Holter monitoring showed no sustained ventricular tachycardia, and the patient’s PVC burden was <20%. It was suspected that the PVCs had been induced by the anagrelide, and his palpitations gradually resolved without any changes to his medication. However, his shortness of breath persisted. Echocardiography showed normal left ventricular ejection function (70%), with no evidence of valve disease. Coronary CT showed severe stenosis of the left anterior descending artery (LAD), prompting coronary angiography (CAG) that revealed moderate stenosis of the left main trunk (LMT) and LAD . The instantaneous wave-free ratio value of the proximal LAD lesion was 0.88. To estimate the efficacy of the heparin, we checked the activated clotting time (ACT), which was 144 s, even after 8000 units of unfractionated heparin had been delivered intravenously. Therefore, heparin resistance was suspected. We did not measure fractional flow reserve because the patient had active asthma, PVCs, and an inadequate prolongation of ACT. The patient’s platelet factor 4, a protein in platelet α-granules released, was markedly increased (91.7 ng/mL; the normal range is <20 ng/mL), whereas he was negative for antithrombin (AT)-3 and heparin-induced thrombocytopenia platelet factor 4 antibody (HIT-Ab). Conventional anti-anginal therapy was implemented, but his shortness of breath persisted and a treadmill test showed significant ST depression in V4–V6. We planned to perform percutaneous coronary intervention (PCI) only after the patient’s platelet count had fallen below 600 000/μL. Meanwhile, the patient was treated by a haematologist at our hospital using hydroxyurea and anagrelide. Seven months after the initial CAG date, the patient’s platelet count was <600 000/μL. On the day before his PCI, his platelet factor 4 was 355.0 ng/mL, which was still markedly higher than the upper normal limit. We observed a de novo lesion in the proximal left circumflex artery (LCX) and stenosis progression in the LAD at the time of the PCI, neither of which had been detected at the previous CAG ( and ). During the PCI procedure, argatroban was infused to maintain the ACT above 250 s. Specifically, 1 mg/kg of argatroban was injected intravenously, followed by infusion at 31 mL/h. The PCI was performed successfully without any complications. Synergy stents were implanted in the LMT-LCX (diameter: 3.5 mm, length 24 mm) and LAD (diameter: 3.0 mm, length 24 mm; and ). After 9 months, follow-up CAG showed no restenosis, and no bleeding complications were observed during the course ( and ). The patient received dual antiplatelet therapy (aspirin and prasugrel) after stent implantation.

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+A 50-year-old man with a medical history of hypertension, diabetes mellitus, and dyslipidemia presented to our emergency department complaining of recurrent resting chest pain (Canadian Cardiovascular Society Class III). A physical examination revealed that the patient’s blood pressure was 80/40 mmHg, his pulse rate was 61 beats per minute, and that he displayed an absence of any abnormal cardiac or respiratory sounds. An electrocardiography showed normal sinus rhythm without significant ST-T wave abnormality, and chest X-ray findings were unremarkable. His serum troponin I peaked at 0.09 mcg/L (ULN ≤0.05 mcg/L) within 24 h of presentation. Under the clinical diagnosis of unstable angina, he was treated in accordance with acute coronary syndrome guidelines [, ].
+While using the femoral approach with a 6-Fr sheath, no luminal stenosis was apparent at the right coronary artery (RCA) in RCA angiography. Left main coronary artery could not be engaged with conventional diagnostic catheters, such as Judkins Left 4 and Amplatz 1.0, and nonselective angiography using pig-tail catheter raised suspicion that the left coronary artery (LCA) was originating from the right coronary cusp (RCC) with an up-to-90% occlusive lesion present at the proximal left anterior descending artery (LAD) . After a Judkins right 4 guiding catheter was placed around the left coronary ostium, a .014″ coronary long wire (RG3, Asahi-Intecc, Nagoya, Japan) was successfully introduced into the left circumflex artery (LCx). Because the Judkins right guiding catheter was too short to reach the left coronary ostium, it was exchanged with a Judkins left 3.5 guiding catheter instead, which was deeply intubated into the left main coronary artery with ballooning support on the LCx wire. Following guiding catheter stabilization, angiography clearly revealed a tubular eccentric proximal LAD with 90% stenosis . After passing an .014″ coronary guide wire (Runthrough®, TERUMO Inc., Japan) through the lesion, balloon angioplasty was performed with a 3.0 × 15-mm balloon. A 4.0 × 18-mm drug-eluting stent (XIENCE Alpine®, Abbott Vascular, Santa Clara, CA, USA) was then implanted with adjuvant ballooning performed with a 4.5 × 10-mm balloon. After successful proximal LAD revascularization, final angiography showed no residual stenosis or complications . The patient tolerated the procedure well, and appeared in good condition postoperatively. Two days later, computed tomography coronary angiography to establish the LCA system course revealed an anomalous origin of LAD and LCx from the right sinus of Valsalva .

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+A 48-year-old Thai woman with congenital mutism presented with a 3-month history of intermittent swelling of both lower limbs. She was otherwise well and did not report joint pain, headache, photophobia, rash, dyspnea, orthopnea, palpitations, hair loss, or bowel symptoms. Her appetite was normal. She had no history of clinically significant underlying diseases; she was not receiving any drug treatments; and she did not drink alcohol or smoke. Her physical examination revealed that she was well; her weight was 41 kg, and her body temperature was 37.2 °C, pulse rate was 103 beats/minute, blood pressure was 116/70 mmHg, and respiratory rate was 20 breaths/minute. She had no abnormal findings of her head, ears, eyes, nose, throat, heart, lungs, and abdomen. The only abnormal sign was bilateral pitting edema 3+ below the knee without erythema and increased warmth.
+Routine laboratory tests showed that she had a mild microcytic anemia (hemoglobin 9.4 mg/dl, mean corpuscular volume 73 fl). Her serum total protein and albumin concentrations were low, but she had hyperglobulinemia and raised liver enzymes (aspartate aminotransferase, alanine aminotransferase, and alkaline phosphatase). Her serum creatinine was 0.82 mg/dl, for an estimated glomerular filtration rate (eGFR) of 85.49 ml/min/1.73 m2, blood urea nitrogen (BUN) 21.20 mg/dl, sodium 137 mEq/L, potassium 4.0 mEq/L, and chloride 103 mEq/L. Her hepatitis (anti-hepatitis C virus antibodies, hepatitis B surface antigen) and human immunodeficiency virus serology results were negative.
+Her urine was yellow and turbid, and dipstick urinalysis (Roche Diagnostics, Mannheim, Germany) demonstrated a specific gravity of 1.021, pH 6.0, protein 3+, blood 3+, red blood cells 20–30 cells/high-power field (HPF), white blood cells 5–10 cells/HPF. Urine microcopy of the urine sediment showed few fine granular casts 0–1/low-power field (LPF) and coarse granular casts 5–10/LPF. By spot urine, her total protein and creatinine were 1.339.4 mg/dl and 143.79 mg/dl, respectively.
+Suspecting chronic kidney disease secondary to an autoimmune disease, we performed additional investigations, which revealed a positive antinuclear antibody. For the titer of 1280, it revealed the homogeneous and fine speckled patterns meanwhile the nucleolar, peripheral, and cytoplasm patterns were observed in the titer of less than 80. The patient’s C3 complement concentration was 50.0 mg/dl (normal 81–157 mg/dl), and her C4 complement concentration was < 8.0 mg/dl (normal 13–39 mg/dl). Her urinary protein excretion over 24 hours was 9.3 g, meeting the case definition of nephrotic proteinuria. The result of a second urine analysis was similar to that of the first analysis . The patient was diagnosed with clinically suspected SLE with lupus nephritis. A referral for a renal biopsy was made, and she was prescribed prednisolone 1 mg/kg. Two days later, a third urinalysis was performed . In addition to similar results as before, several rapidly moving, large, ovoid-shaped ciliated parasites were seen by video clip/light microscopy; these findings were confirmed by two additional microscopic analyses of her urine sediment. No antiparasitic treatment was given, and she was asked to come for follow-up 2 weeks later.
+At follow-up, a fourth urine analysis was done , and a spot urine protein (1679.0 mg/dl) and creatinine (100.34 mg/dl) were measured. Serum BUN and creatinine were 37.5 and 1.48 mg/dl, respectively. Numerous motile, ciliated trophozoites were seen in three consecutive urine samples by wet preparation and Wright-Giemsa staining that were identified as B. coli . Three daily stool examinations by formalin-ethyl acetate concentration were negative for ova, cysts, and parasites. She was prescribed tetracycline 500 mg four times daily for 10 days, after which the result of a post-treatment urine examination was negative for B. coli.

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+A 54-yr-old Caucasian male was referred for evaluation of a rapidly increasing neck tumor noticed for the first time four months earlier. He complained of sporadic dysphagia without weight loss. He was a heavy smoker until recently but had no previous medical history. He worked as a house painter, for seven years, in his thirties. The physical examination revealed an asymmetric multinodular goiter with a left dominant nodule with firm consistency and no palpable regional nodes. Serum TSH was 1.3 μUI/ml (normal: 0.5–4.7 μUI/ml), T4 7.3 μg/dl (normal: 5.4–11 μg/dl) and T3 126 ng/dl (normal: 52–160 ng/dl). Antimicrosomal and antithyroglobulin antibodies were negative. A thyroid ultrasound demonstrated a multinodular gland with the right and left lobes measuring 6 × 4 × 3 cm and 9 × 7 × 6 cm respectively. A computed tomography (CT) scan of the neck showed a slight tracheal deviation to the right without compression. A Tc-99 m scintigraphy disclosed irregular uptake in both lobes of the thyroid and a large cold nodule in the left lobe. FNAC from both lobes revealed a clear-cell carcinoma with an immunocytochemical profile suggestive of a secondary tumor from the kidney (refer to section pathology).
+FNAC results prompted a clinical and radiographic investigation. An abdominal CT scan revealed a tumor of the left kidney measuring in greatest diameter 10 cm. Bone scan, chest computed tomography scan, liver ultrasound and laboratory data were normal and there was no evidence of other distant metastases.
+Initial treatment included a left radical nephrectomy and a total thyroidectomy. One year later, there was evidence for cervical nodal metastases. The patient was then submitted to right radical neck dissection with internal jugular vein ligation and section of spinal accessory nerve and left modified radical neck dissection type III. At histological examination, only right nodes were metastatic.
+Both thyroid lobes were sampled. Smears were air dried and acetone fixed and stained with May-Grünwald-Giemsa (MGG) and Papanicolaou (PAP) stains, respectively. An additional sample was fixed in formalin and processed as a cell-block using the Shandon Cytoblock® Kit (Thermo Electron Corporation, Pittsburgh, PA, USA). Cell block (CB) sections were stained with hematoxilin-eosin. Immunocytochemistry was performed on CB sections, using an avidin-biotin method with diaminobenzidine as the chromogen for the following antibodies: thyroglobulin, calcitonin, vimentin, CD10, TTF1 (Dakocytomation, Denmark A/S) and cytokeratin AE1/AE3 (Zymed Laboratories, Inc, San Francisco, CA).
+Smears consisted of a clear, large cell neoplasia with large nuclei, prominent nucleoli and finely vacuolated cytoplasm, with indistinct borders. The tumor cells were arranged in aggregates of variable size and shape, many of them centered by thin walled capillaries. This intimate relationship of neoplastic cells and vessels was better appreciated on cell-block sections. These cells were immunoreactive for pancytokeratin (AE1/AE3), vimentin and CD10 and were negative for thyroglobulin, thyroid transcription factor1 (TTF1) and calcitonin .
+The smear pattern together with the immunocytochemical profile was consistent with the diagnosis of secondary tumor, most probably from renal origin.
+The nephrectomy specimen showed a renal cell carcinoma, clear cell type. It was classified as Fuhrman 3 and showed extra renal local spread and no vascular invasion.
+The thyroid gland was multinodular and all the nodules consisted of metastasis of a clear cell neoplasia. The histological pattern was similar to the renal tumor. Immunocytochemical study was performed using the same antibodies that were tested on cytological samples with identical results.
+RNA from cells left inside of the needle used for FNAC was isolated with the QuickPrep micro mRNA Purification Kit (Amersham Pharmacia Biotech, Buckinghamshire, UK), according to the manufacturer's instructions. Half of the RNA was reversed transcribed with Superscript (Invitrogen Corporation, Carlsbad, CA, USA) in 20 μl reaction volume with random primers and cDNA kept frozen. To screen for VHL mutations in thyroid aspirates, 2,5 μl of first-strand cDNA was used as a template for PCR using primers designed by us (F-5'-TCAGAGATGCAGGGACACAC-3', R-5'-TGACGATGTCCAGTCTCCTG-3').
+Somatic DNA was extracted from samples corresponding to renal carcinoma and thyroid metastases obtained during surgeries and immediately frozen with liquid nitrogen until nucleic acid extraction using TRIzol Reagent (Life Technologies, Inc., Gaithersburg, MD, USA). Genomic DNA was also obtained from peripheral venous blood and isolated by a manual method adapted from Bowtell .
+DNA samples were amplified by PCR using primers previously described . The screening of VHL mutations was performed by single-strand conformational polymorphism analysis (SSCP). To further characterize the abnormal pattern observed in the SSCP, PCR purified products were either sequenced directly using the ABI PRISM® BigDye™ Terminator Cycle Sequencing Ready Reaction Kit (Applied Biosystems, Foster City, CA, USA) and the ABI PRISM 310 Genetic Analyser or subcloned into pGEM®-T Easy Vector (Promega, Madison, USA), and subsequently sequenced using the ABI PRISM® BigDye™ Terminator Cycle Sequencing Ready Reaction Kit (Applied Biosystems, Foster City, CA, USA) and the ABI PRISM 310 Genetic Analyser. Restriction analysis, using the restriction endonuclease BstZ17 I (New England BioLabs®, Inc., Beverly, USA) was also performed.
+The same alteration, a heterozygous 680delA (codon 156/exon 3) of the VHL gene was identified in thyroid aspirates, renal carcinoma, thyroid metastases and lymph node metastases. It causes a frame-shift and creates a premature stop predicting a truncated pVHL . Constitutional DNA (peripheral venous blood) was analyzed and did not show the mutation. No other alterations were observed in exons 1 and 2 of VHL.

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+A 54-year-old Moroccan man with a history of psoriasis in remission presented with a 3-month history of erythematous nonpruritic lesions of the face with hypersensitivity to heat. A clinical examination revealed erythematous, telangiectatic, confluent papules of the lateral side around the eyes without any scales, crusts, or pustules. In the differential diagnosis, we included GR, sarcoidosis, lupus vulgaris, and lupus erythematosus tumidus. Dermoscopy revealed linear vessels characteristically arranged in a polygonal network, creamy and whitish linear areas, and white grayish plugs surrounded by an erythematous halo filling the follicular openings .
+Histological examination of a punch biopsy specimen of the lesion showed granulomatous dermatitis with the presence of Demodex folliculorum on the biopsied tissue. These clinical, dermoscopic, and histological findings were consistent with the diagnosis of GR , and the patient was treated with topical metronidazole for a total of 10 weeks, which led to a significant improvement.

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+In 2015, a then 52-year-old man was referred to our radiation oncology department for evaluation of hemostatic treatment. He presented with chest pain, dyspnea, fatigue, loss of appetite, weight loss, recurrent respiratory infections, and episodes of significant hemoptysis. Medical history included pulmonary TB in 1995 , which was adequately treated with antitubercular medications for 6 months, resulting in a residual cavity in the left lower lobe. Hemoptysis first occurred a couple of years after initial TB treatment and symptoms had become aggravated since then. In 2007, the patient presented with a new episode of hemoptysis. His medical history and a CT scan of the chest lead to the differential diagnosis of pulmonary aspergillosis. The patient was hemodynamically stable and a hemoglobin of 155 g/L (reference value 135–168 g/L) was measured. Since bronchoscopy confirmed endobronchial bleeding from the segments where the lesion was located, partial resection of the left inferior lobe was performed in the same year. Aspergilloma was confirmed by histopathological examination of the resected lung tissue. A post-interventional CT scan of the chest, however, showed persistence of the aspergilloma. In addition, persistence was suggested microbiologically by positive Aspergillus cultures from bronchoalveolar lavage fluid and sputum at different timepoints. In the following years, three attempts at endovascular embolization of pulmonary arteries, the first in 2008, were performed due to recurring hemoptysis, without achieving lasting hemostasis. Therefore, long-term antifungal therapy with itraconazole was initiated in 2009 and continued for 2.5 years. In addition to the aspergillosis, the patient was diagnosed with a pulmonary actinomycosis in 2015, a rare opportunistic bacterial infection of the lung. Actinomyces were also isolated from a bronchoscopic biopsy in the left lower lobe. Although Aspergillus cultures and Aspergillus precipitin could not reaffirm aspergilloma persistence at that time, these results did not definitely rule out a concomitant fungal and bacterial infection. The patient’s pulmonary function was further reduced after suffering multiple pulmonary emboli. The last complete pulmonary function testing prior to radiotherapy was performed in 2013. It revealed a vital capacity (VC) of 2.15 L (44% of reference value), forced expiratory volume in one second (FEV1) of 1.55 L (41%), and a diffusing capacity of the lungs for carbon monoxide (DLCO) of 7.4 mmol/min/kPa (71%), so that the patient was considered unfit for further surgical interventions. During the first consultation in our clinic, the patient reported recurrent episodes of hemoptysis causing blood loss of more than 100 ml per day. A CT of the chest showed a persistent, spiculated, partly cavernous lesion in the left lower lobe with a diameter of approximately 5 cm . Treatment planning also included an 18F‑FDG-PET/CT scan to localize the fungal manifestation and identified the metabolically active inflamed vascular lining of the cavity as the most likely cause of bleeding . SBRT with a total dose of 16 Gy was applied in two fractions of 8 Gy on consecutive days with a robotic arm-mounted linear accelerator equipped with an iris collimator (CyberKnife®, Accuray Inc., Sunnyvale, CA, USA; Fig. b). Dose was prescribed to the 80% isodose line and the ray-tracing algorithm was used for dose calculation. After acquisition of a 4D-planning CT to account for respiratory motion, the planning target volume (PTV) was generated from an internal target volume (ITV), adding a 2-mm margin. Despite an irregularly shaped PTV, the chosen irradiation technique allowed us to achieve a conformal dose distribution of the target volume and tolerable doses for relevant organs at risk (OAR) as shown in the dose–volume histogram (DVH; Fig. c). The treatment was well tolerated, and no side effects were reported by the patient. During the 6 years of follow-up at our department, the patient has reported a significant decrease in hemoptysis frequency and volume, and no new long-term medication or invasive treatments have been necessary since then. When he presented at the hospital’s emergency unit with dyspnea and small-volume hemoptysis in 2016, there were no signs of an active or older bleeding evident in CT or bronchoscopy. Hemoglobin level remained stable at around 140 g/L over the years and fell below 120 g/L only once during an episode of community-acquired pneumonia in 2016 not accompanied by hemoptysis. Regular CT scans of the chest confirmed a stable size of the pulmonary lesion after an initial pseudoprogression, which is often observed after SBRT for large target volumes .

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+A 25-year-old man with paraphimosis was referred from another clinic. He suffered with schizophrenia stabilized with oral medication. Paraphimosis occurred following masturbation. He visited a local hospital 1 week after paraphimosis onset. An attending urologist referred him to our hospital. On presentation, the penile glans and prepuce were hard and swollen, and the ring of preputial skin constricted the distal penis so tightly it was pale. These findings suggested an advanced ischemic condition. He did not complain of pain. The day after presentation, we tried surgical repair of his paraphimosis. During surgery, we first tried to correct blood congestion in the penile glans. We penetrated the glans penis with a sharp scalpel blade and removed blood from the glans; the glans was collapsed. We then circumcised the constricting ring of preputial skin that was already necrotic. We speculated that penile necrosis and failure of sutures would occur due to tissue necrosis. We informed the patient and his mother of this possibility. They agreed to long-term follow-up with hospital management.
+On the 10th postoperative day, the surface of the glans was covered with a hard black dried scab. Deeper necrotic tissues were observed following removal of the scab. We debrided necrotic tissues in bed side . He did not feel any pain in debridement without anesthesia. The external urethral meatus was returning to the coronal sulcus level due to glandular necrosis . To prevent local and systemic infection and further damage by a transurethral catheter, cystostomy was performed. At this time, no sign of systemic inflammatory response syndrome was evident due to physical examination, body temperature, and blood test in contrast to the surgical case in the previous report. In addition, his personal situation permitted for long-term hospitalization. Then we decided on conservative management to prevent penile partial amputation as he was 25 years old. Partial amputation may impact on his mentality and body image significantly. Thus, we aimed to preserve his natural shape of penis and penile length as long as possible.
+On the 30th postoperative day, most necrotic tissue was gone, and healthy tissues had appeared. Two months after surgery, the surface of the penile glans was covered with healthy tissue without infection. The external urethral meatus was repositioned at the level of the coronal sulcus without stenosis. The patient could urinate from the external meatus. The cystostomy was removed. His penis has retained natural shape of the penile glans and shaft . We decided that the patient could be discharged.
+His penis has retained the natural shape of the penile glans that covered with epithelium and shaft, and voiding and erectile functions were normal at 1 and 2 years after treatment, although the penile glans is somewhat smaller than it was prior to the event. He did not feel any pain in ordinary life and sexual activity. He can ejaculate with full erection by masturbation, although sensation of his glans has dull senses.

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+An 85-years old woman was referred because of worsening asthenia, lumbar pain, generalized myalgia and arthralgia. The patient had a history of toxic multinodular goiter, hypertension, atrial fibrillation treated with metimazole, irbesartan and dabigratan, respectively. An accurate cardiological evaluation, including electrocardiogram and echocardiography, excluded that the impairment of the symptoms was due to the cardiovascular alterations. Moreover, general hematologic tests, as well as the thyroid function resulted normal.
+Clinical picture was negative, except for NYHA class II, whereas chest x-ray showed the presence of a very small nodule in the middle lobe of the right lung. However, a computed tomography (CT) scan did not confirm the x-ray picture, whereas evidenced two large bilateral adrenal masses (85 × 75x62 mm on the right, and 62 × 59x24 mm on the left side), with positive contrast enhancement and reduced washout on delayed images. The masses displayed a right extension to the aorto-caval space, incorporating the renal vessels and imprinting the inferior vena cava . These radiological features were highly suspicious for primary adrenal tumor. Normal values of the urinary metanephrines ruled out the hypothesis of pheochromocytoma. Moreover, the diagnosis of adrenal carcinoma was unlikely, since circulating levels of androgens (testosterone, Dehydroepiandrosterone-sulfate, Delta4 androstenedione) were low or normal, except for an increase of 17-hydroxyprogesterone (17-OHP). This finding was confirmed through two repeated measurements (2.88 mcg/L and 2.79; normal value between 0.13 and 0.51). The 17-OHP levels were assayed by radioimmunoassay. Assay sensitivity was 0.01 ng/dL, whereas intra- and inter-assay coefficients of variation were both 9.0%). The remaining hormonal assessment revealed very low levels of morning plasma cortisol and the 24-h urinary free cortisol in the lower range of normality, elevated ACTH levels with low plasma concentration of aldosterone, pointing to the diagnosis of PAI .
+Radiological assessment ruled out the presence of adrenal haemorrhages that may occur during chronic anticoagulant therapy, particularly during dabigratan treatment. Although previously described , this is a very rare, difficult to diagnose and potentially fatal condition if not recognized and promptly treated.
+After diagnosis of PAI our patient started glucocorticoid and mineralcorticoid replacement therapy (cortisone acetate and fludrocortisone) with a partial clinical benefit. In order to further characterize the adrenal lesions, adrenal biopsy, initially refused by the patient, was performed 4 months later, when a second CT scan depicted a significant increase of the two adrenal masses (the right resulted 150 × 110x120 and the left 110 × 95x44 mm) . The histology revealed a high grade non-Hodgkin lymphoma with an immunophenotype consistent with intermediate aspects between diffuse large B-cell and Burkitt lymphoma, with a high proliferation index (KI-67 > 90%) .
+Due to the complex clinical presentation, as well as the atypical classification, the patient received chemotherapy with epirubicin, vincristine, cyclophosphamide, and rituximab (anti CD20 monoclonal antibody), associated with methylprednisolone that resulted in a complete clinical and radiological remission within one year . After 2 years from the diagnosis and a total of 6 cycles of rituximab, the patient is in very good clinical condition and is currently taking only the replacement therapy for the adrenal insufficiency.
+Considering the high levels of 17-OHP at diagnosis we hypothesized a partial 21-hydroxylase deficiency, that could have led, together with the mass effect, to the onset of PAI. However, after two years ACTH test evidenced a normal 21-hydroxylase activity (baseline and stimulated 17-OHP were 0.34 and 0.46 mcg/L, respectively).

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+A 47-year-old African American male with a past medical history of glucose-6-phosphate dehydrogenase deficiency presented with three months of worsening bilateral upper extremity radicular pain/numbness and tingling radiating to both shoulders. On examination, he had bilateral hyperreflexia, bilateral Hoffmann’s and Babinski’s signs, all reflecting the presence of significant cervical myelopathy.
+The cervical magnetic resonance imaging (MRI) demonstrated congenital spinal stenosis and a 2.5 cm intramedullary C4–C6 spinal cord lesion that enhanced with contrast on the T2 image and was diffusely hyperintense on the T2-weighted studies [-]. The abdominal-chest computed tomography and endobronchial ultrasound-guided fine-needle aspiration (i.e., of mediastinal hilar lymphadenopathy) revealed non-caseating granulomas consistent with sarcoidosis. The cardiac positron emission tomography scan also confirmed cardiac sarcoidosis characterized by a patchy abnormal increased signal u in the left ventricle. Further, the cerebrospinal fluid (CSF) protein level was high (>390) .
+With the initial diagnosis of multisystemic sarcoidosis/probable neurosarcoidosis, the patient was started on daily IV methylprednisolone (dose of 1 g). After developing a left punctate pontine stroke (i.e., resulting in left internuclear ophthalmoplegia), vertical nystagmus, and mild left ptosis, he was started on clopidogrel and aspirin. However, as the subsequent contrast brain MRI revealed pachymeningitis, leptomeningitis, and a T2-hyperintense lesion in the pons, the patient was subsequently started on infliximab (5 mg/kg) and referred to neurosurgery with the diagnosis of severe cervical myelopathy secondary to a cervical C4–C6 intramedullary neurosarcoid lesion.
+To decompress but not biopsy the C4–C6 intramedullary mass, the patient underwent a C3–C6 laminectomy and C3– C7 posterior spinal fusion. Although one day postoperatively, he developed a new right-sided motor hemiparesis that lasted for two weeks; the repeat MRI scan did not show any new cord lesions or increased intrinsic/extrinsic cord compression. Nine months later, the patient experienced four transient relapses of hemiparesis/quadriparesis (i.e., none of which warranted or were treated surgically due to no new MR findings) for which he received varying doses of rituximab, methotrexate, and corticosteroids .

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+A 50-year-old male patient, who is self-employed, presented to our hospital in January 2022 with a chief complaint of a persistent cough for the past 2 months, without significant shortness of breath, palpitations, or fever. His medical history revealed a previous hepatitis B infection, which resulted in hepatic failure 10 years ago. Additionally, he was diagnosed with HIV infection. However, he ceased taking antiviral treatment with the medications provided free of charge by the Chinese government for a period of three years. During this hospital visit, his CD4 + T-cell count was found to be 26/μL (normal range: 500–1612/μL), HIV-1 RNA was 1.1 × 105 copies/ml, and HBV-DNA was negative. Chest computed tomography (CT) scan revealed nodular and patchy lung lesions . The BALF shows positive acid-fast staining. Further assessment of the BALF using XpertMTB/RIF PCR revealed resistance to rifampicin, and the tuberculosis drug susceptibility test of the BALF (liquid culture, medium MGIT 960) indicated resistance to rifampicin, isoniazid, and streptomycin. Considering the World Health Organization (WHO) guidelines for drug-resistant tuberculosis, the patient’s drug susceptibility results, and the co-infection of HIV and HBV, an individualized treatment plan was tailored for him. The treatment plan included BIC/TAF/FTC (50 mg/25 mg/200 mg per day) for HBV and HIV antiviral therapy, as well as linezolid (0.6 g/day), cycloserine (0.5 g/day), moxifloxacin (0.4 g/day), pyrazinamide (1.5 g/day), and ethambutol (0.75 g/day) for anti-tuberculosis treatment, along with supportive care.
+Unfortunately, after 3 months of follow-up, the patient discontinued all medications due to inaccessibility of the drugs. He returned to our hospital (Nov 12, 2022, day 0) after discontinuing medication for six months, with a complaint of poor appetite for the past 10 days. Elevated liver enzymes were observed, with an alanine aminotransferase level of 295 IU/L (normal range: 0–40 IU/L) and a total bilirubin(TBIL) level of 1.8 mg/dL (normal range: 0–1 mg/dL). His HBV viral load increased to 5.5 × 109 copies/ml. Considering the liver impairment, elevated HBV-DNA and the incomplete anti-tuberculosis treatment regimen , we discontinued pyrazinamide and initiated treatment with linezolid, cycloserine, levofloxacin, and ethambutol for anti-tuberculosis therapy, along with BIC/TAF/FTC for HIV and HBV antiviral treatment. Additionally, enhanced liver protection and supportive management were provided, involving hepatoprotective effects of medications such as glutathione, magnesium isoglycyrrhizinate, and bicyclol. However, the patient’s TBIL levels continued to rise progressively, reaching 4.4 mg/dL on day 10 . Suspecting drug-related factors, we discontinued all anti-tuberculosis medications while maintaining BIC/TAF/FTC for antiviral therapy, the patient’s TBIL levels continued to rise persistently. We ruled out other viral hepatitis and found no significant evidence of obstructive lesions on magnetic resonance cholangiopancreatography. Starting from the day 19, due to the patient’s elevated TBIL levels of 12.5 mg/dL, a decrease in prothrombin activity (PTA) to 52% , and the emergence of evident symptoms such as abdominal distension and poor appetite, we initiated aggressive treatment methods. Unfortunately, on day 38, his hemoglobin level dropped to 65 g/L (normal range: 120–170 g/L, Fig. A), and his platelet count decreased to 23 × 109/L (normal range: 125–300 × 109/L, Fig. C). Based on a score of 7 on the Naranjo Scale, it was highly suspected that “Linezolid” was the cause of these hematological abnormalities. Therefore, we had to discontinue Linezolid for the anti-tuberculosis treatment. Subsequently, on day 50, the patient developed recurrent fever, a follow-up chest CT scan revealed enlarged nodules in the lungs . The patient also reported mild dizziness and a worsening cough. On day 61, the previous blood culture results reported the growth of Cryptococcus. A lumbar puncture was performed on the same day, and the cerebrospinal fluid (CSF) opening pressure was measured at 130 mmH2O. India ink staining of the CSF showed typical encapsulated yeast cells suggestive of Cryptococcus. Other CSF results indicated mild leukocytosis and mildly elevated protein levels, while chloride and glucose levels were within normal limits. Subsequently, the patient received a fungal treatment regimen consisting of liposomal amphotericin B (3 mg/kg·d−1) in combination with fluconazole(600 mg/d). After 5 days of antifungal therapy, the patient’s fever symptoms were well controlled. Despite experiencing bone marrow suppression, including thrombocytopenia and worsening anemia, during this period, proactive symptom management, such as the use of erythropoietin, granulocyte colony-stimulating factor, and thrombopoietin, along with high-calorie dietary management, even reducing the dosage of liposomal amphotericin B to 2 mg/kg/day for 10 days at the peak of severity, successfully controlled the bone marrow suppression. However, within the following week, the patient experienced fever again, accompanied by a worsened cough, increased sputum production, and dyspnea. Nevertheless, the bilirubin levels did not show a significant increase. On day 78 the patient’s lung CT revealed patchy infiltrates and an increased amount of pleural effusion . The CD4 + T-cell count was 89/μL (normal range: 500–700/μL), indicating a significant improvement in immune function compared to the previous stage, and C-reactive protein was significantly elevated, reflecting the inflammatory state, other inflammatory markers such as IL-6 and γ-IFN were also significantly elevated. On day 84, Considering the possibility of IRIS, the patient began taking methylprednisolone 30 mg once a day as part of an effort to control his excessive inflammation. Following the administration of methylprednisolone, the man experienced an immediate improvement in his fever. Additionally, symptoms such as cough, sputum production, dyspnea, and poor appetite gradually subsided over time. A follow-up lung CT showed significant improvement, indicating a positive response to the treatment. After 28 days of treatment with liposomal amphotericin B in combination with fluconazole, liposomal amphotericin B was discontinued, and the patient continued with fluconazole to consolidate the antifungal therapy for Cryptococcus. Considering the patient’s ongoing immunodeficiency, the dosage of methylprednisolone was gradually reduced by 4 mg every week. After improvement in liver function, the patient’s anti-tuberculosis treatment regimen was adjusted to include bedaquiline, contezolid, cycloserine, moxifloxacin, and ethambutol. The patient’s condition was well controlled, and a follow-up lung CT on day 117 indicated a significant improvement in lung lesions .

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+Then, a 13-year-old right-hand dominant boy sustained a bony mallet injury to his right long finger while jumping on a fumbled football. Injury radiographs revealed an avulsion-type fracture of the base of the right long finger distal phalanx involving 30% of the joint, in which the distal fragment was subluxed volarly . The patient’s examination was significant for loss of active extension at the long finger DIP joint as well as generalized ligamentous laxity. The patient had hyperextension of both his elbows and knees, could extend his thumb back to his forearm, and hyperextend his 2nd metacarpal phalangeal (MCP) joint to 90°. Several family members had similar traits but no formal diagnosis had been made.
+He was offered surgical treatment based on the amount of joint subluxation and underwent closed reduction, percutaneous pinning of the right long finger DIP joint 9 days from injury. A two-pin technique was used, one across the DIP joint and the other to block the bone fragment from retracting . The pin was left in place for 6 weeks and removed without complication. He went on to heal with residual DIP joint stiffness and only 20° residual motion that was noted on follow-up 2 years later during an examination for an injury to the opposite hand .
+The patient was seen for an unrelated injury 7 years later and was found to have no motion at the right long finger DIP joint. X-rays of his right long finger showed a complete fusion of bone across the DIP joint . He reported unrestricted use of his right hand despite the DIP fusion and even played collegiate baseball for 4 years.

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+The initial dermatologic consultation of our 61-year-old Caucasian female patient occurred two years ago when she presented with a reddish, indolent nodule of the scalp 5 mm in diameter with local alopecia that she had noticed for the first time four months before. A small punch biopsy of her scalp exhibited solid proliferations of monomorphous tumor cells with a cytoplasm rich in vacuoles and sebaceous differentiation. Subepidermal spreading of the cells was knobby; a sclerodermiform-like spreading was predominant within the reticular dermis. The cells expressed pancytokeratin (MNF116) and epithelial membrane antigen (EMA) but staining for BerEP4 and carcino embryonal antigen (CEA) was negative. Therefore, we initially established the diagnosis of a primary cutaneous carcinoma with sebaceous differentiation. Upon thorough review of our patient's personal history she informed us of a previous diagnosis of a poorly differentiated invasive solid ductal breast carcinoma of her left breast five years previously, which was positive for estrogen receptor (ER) and progesterone receptor (PR), but negative for human epidermal growth factor receptor 2 (HER-2/neu) . At that time, our patient underwent ablatio mammae left sided with ipsilateral dissection of the axillary lymph nodes (18 out of 19 lymph nodes being positive) and contralateral plastic surgery reduction of the right breast, followed by radiochemotherapy with paclitaxel. Regular follow-up over five years showed no clinical or mammographic recurrence of the disease.
+Further examination of our patient was then initiated. It showed a second moderately differentiated invasive ductal breast carcinoma of her right breast with a sonographic tumor thickness of 5 mm . Computed chest tomography revealed multiple pulmonary and lymphatic metastatic lesions within the ipsilateral axillary lymph nodes. This ductal breast carcinoma was positive for ER and PR. Ki67 expression demonstrated that 20% of the tumor cells were proliferating. No overexpression of HER-2/neu was observed.
+The tumor of the scalp was surgically removed in our department. Histopathological examination of this tissue showed a solid tumor consisting of large monomorphous cell proliferations with sebaceous differentiation, similar to the features found in the previous biopsy . The immunophenotype was identical. Additionally, the cutaneous tumor cells were positive for ER and PR, with no evident overexpression of HER-2/neu . Moreover we performed an adipophilin stain that was negative in the tumor cell fraction. Sebaceous glands expressing adipophilin served as internal control .
+Our patient received axillary right sentinel node biopsy, ablatio mammae right, and one cycle of chemotherapy with paclitaxel and bevacizumab, but died due to sepsis two months after the diagnosis of cutaneous metastatic breast carcinoma. Detailed clinical data are given in table .
+We were able to establish the final diagnosis of metastatic breast cancer with the histologic appearance of a sebaceous differentiated primary cutaneous carcinoma. Our patient had bilateral ductal breast cancer with identical hormone receptor status within five years. It remains unclear whether the cutaneous metastasis originated from the initially diagnosed breast cancer of her left mammary or from the second ductal carcinoma of her right breast.