diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1005_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1005_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1cfc4ce6ea93b4b927b989e9cea98bafa3e84018
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1005_en.txt
@@ -0,0 +1,2 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_100_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_100_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fa8add071de5afb422e075f6cd92a5143d340802
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_100_en.txt
@@ -0,0 +1,4 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1011_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1011_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e9b0b8dee25b0c63361e1ea4ba827c0b4c8c5a0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1011_en.txt
@@ -0,0 +1 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1014_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1014_en.txt
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index 0000000000000000000000000000000000000000..1236fa631a667e1c0457c59c557bb057f12965ef
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1014_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1031_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1031_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0d685fcedd6f10ab307a135084b5fb85be3f084d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1031_en.txt
@@ -0,0 +1 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1046_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1046_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..59bd286270f26625d36161dbb0fb1cbb3c50bf1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1046_en.txt
@@ -0,0 +1,5 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_106_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_106_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f650cad006fa2e2520d60c8cbf2a396169561993
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_106_en.txt
@@ -0,0 +1,3 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1088_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1088_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6f7ee818b8bb5bac3db7487129a23c3996bc8b82
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1088_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_109_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_109_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..17149b86db234ca6634ea4fcc3cb805f12a5793a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_109_en.txt
@@ -0,0 +1,2 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1100_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1100_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a99537da9018360836d88452393f6fda8950e79
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1100_en.txt
@@ -0,0 +1,4 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1115_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1115_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10b2789b8c20f1254c0313ff43b25d08bdc7d349
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1115_en.txt
@@ -0,0 +1,4 @@
+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_111_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_111_en.txt
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index 0000000000000000000000000000000000000000..fbb267c67866bd33fb0ef04128e699199cdc515b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_111_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1144_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1144_en.txt
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index 0000000000000000000000000000000000000000..26b07ada986acaf2b8efac0c00dac9498492abb2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1144_en.txt
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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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1149_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1149_en.txt
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index 0000000000000000000000000000000000000000..9cc5d76613d17ea43e26a277de28372df2d49252
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1149_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_115_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_115_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..38a71add5f116020ed4ca448ec12c5b5509af409
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_115_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1170_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1170_en.txt
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index 0000000000000000000000000000000000000000..3e8065a571d4e12c37d86545a5779162ac7a95d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1170_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1172_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1172_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a784df52e3c58bd8e1a5831ef80912529e1f05eb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1172_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1183_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1183_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..538f59b7985a547e04397b4d86f4149d06e1fd90
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1183_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1209_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1209_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d4be52e63595e08a8f304fca83a43a750b2b185a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1209_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1256_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1256_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd7e15a30eceee41dc5b9eb3c1bbab94d55676f2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1256_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1257_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1257_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5138b970ae6e0aae862edac6a516da6b6ff3d01
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1257_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1277_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1277_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..de9420dbc68dbf73faaf5ad84ca05457418f2d4e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1277_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1282_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1282_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3c347b696c5de2e01b148568116c04ca3fc8409
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1282_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1290_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1290_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..79c08f4f0cff64ab3cd6bf94e49efcb9ba3275ea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1290_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1294_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1294_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..57b4677a59286f6e7da5ab8619f41865da1cc25f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1294_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1295_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1295_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4dfb941c611c1813bc34f5ad2f07fc4a01ce15e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1295_en.txt
@@ -0,0 +1,5 @@
+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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1298_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1298_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fdf1423b6afdcba5b08a5110873d64dbb3088ebe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1298_en.txt
@@ -0,0 +1,6 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1301_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1301_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c94b3682cde42e2557c801a0b5fc9d88601a384b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1301_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1308_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1308_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0810b10604881628d1873db5690addad0bbf63ec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1308_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1316_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1316_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1008635feb00ebe8ef00d80090b245ecf7bebb76
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1316_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_131_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_131_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..730aa7c091e3989fcdd616ea37bdc23b503945aa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_131_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1335_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1335_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..562f0ca4cf52d6c290b2dfd8d57dbdad8e6cb0c6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1335_en.txt
@@ -0,0 +1,4 @@
+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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1339_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1339_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..43e5aba8a4508cb8ffef0ee340c081fa0ea6cb86
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1339_en.txt
@@ -0,0 +1,8 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1363_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1363_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1f7f3c9b0dfebe37a7cb3ccc2a96be7ff9caf00
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1363_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1379_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1379_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2f58f012e5885f12ca058b59d80ef368109f47c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1379_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_137_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_137_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42e699763ad3f68ee4308b7e2e9f9c3d5bfcd30f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_137_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1391_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1391_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a07203cc91203945b0175fd96491f05b8f2c35f3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1391_en.txt
@@ -0,0 +1,7 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1392_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1392_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18709cb2bb9b24579688d43b6a5847be6041df45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1392_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1396_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1396_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f77f2734664411f5c48d203441d7a0a8c3ca20e1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1396_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1401_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1401_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fe2b18379670b334d03c2fb0f51cd2ba4ed3f5e5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1401_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1411_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1411_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b1a4a94ee32a20424c842239f06d8bae51ee74c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1411_en.txt
@@ -0,0 +1,5 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1412_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1412_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a76034c0034d875961f6f9b2ca3ed0d129532fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1412_en.txt
@@ -0,0 +1,12 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1415_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1415_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4719702b99c27f9bf0912ef56af84a86cb40a8be
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1415_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1421_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1421_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cc4f76c8e29f938a7248243ea345258be30a89b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1421_en.txt
@@ -0,0 +1 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1428_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1428_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e20c64280bc3d2ec86a28eaf1a9e8116a34f828f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1428_en.txt
@@ -0,0 +1,4 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1430_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1430_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d919724c372769d9b8123590653b9212ebdfa86
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1430_en.txt
@@ -0,0 +1,6 @@
+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).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1432_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1432_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..792ebee2b26e6990565758011056185245493cf5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1432_en.txt
@@ -0,0 +1,4 @@
+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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1437_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1437_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9251da54390897e1870aa9bef45ed0cbc3f806a6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1437_en.txt
@@ -0,0 +1,2 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1443_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1443_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5f77e2d66a31911814790a668ab689e7d4a5951b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1443_en.txt
@@ -0,0 +1,3 @@
+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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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1446_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1446_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09a290ff16cfec72a46885c89a915e0a7a27ebc2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1446_en.txt
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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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1465_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1465_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a3efb857381c93871a2c03d149b426ff770e2461
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1465_en.txt
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+A 72-year-old Japanese woman presented to our hospital with a one-year history of productive cough and progressive dyspnea on exertion. Her past medical history included only osteomyelitis at 35-years-old and she was not taking any medications. She had never smoked or inhaled dust as an occupational hazard. Her vital signs were as follows: body temperature of 36.6°C, blood pressure of 130/80mmHg, heart rate of 67 beats/min, and SpO2 level of 80% (room air). Her arterial blood gas analysis revealed a pH of 7.44, PaO2 level of 43.2mmHg, PaCO2 level of 39.2mmHg, and HCO3− level of 26.4mEq/L on room air. Her chest radiographs (CXR) showed bilateral infiltrates in her mid and lower lung zones , and her chest CT scan showed bilateral ground glass opacities with thickened interlobular septa, an appearance known as the ‘crazy-paving’ pattern .
+Her laboratory tests revealed a normal complete blood count, high lactate dehydrogenase (543/mL), and high Krebs von den Lungen-6 level (16,189U/mL). Her pulmonary function tests taken on admission revealed a vital capacity (VC) of 1.49L, %VC of 68.6%, forced expiratory volume in one second (FEV1) of 1.17L, FEV1/forced vital capacity (FVC) predicted ratio of 76.0%, and FEV1/FVC actual ratio of 84.2%. We retrieved 26/100mL of bronchoalveolar lavage fluid (BALF), which was milky in appearance. Her BALF total cell count was 6.0×104/mL; cell differentiation revealed 23% neutrophils, 1% eosinophils, 17% lymphocytes, and 59% macrophages. Her BALF contained copious eosinophilic, periodic acid Schiff-positive granular material, a finding that supported a diagnosis of PAP. In addition, a high level of anti GM-CSF antibody was detected in her serum (57.5μg/mL), leading to a diagnosis of autoimmune PAP. Her disease severity score (DSS) was classified as DSS 5, based on severe hypoxemia (PaO2 level of 43.2mmHg).
+Considering her severe DSS, we recommended treatment with WLL under general anesthesia or inhaled GM-CSF therapy. However, she refused both treatments because of concern about complications and medical costs; she also refused hospitalization. Therefore, we started domiciliary oxygen therapy and an alternative treatment of 45mg/day of ambroxol (TEIJIN PHARMA, Tokyo, Japan). She was discharged, with frequent scheduled checkup examinations at our outpatient clinic. A few days after starting ambroxol, she showed loosened phlegm and reduced cough, with progressively improving dyspnea. Her oxygen saturation level in room air rose to 95%, and her CXR results showed improvement after one month . Her chest CT scan after five months of treatment showed almost no abnormal shadows , and her pulmonary function was improved (VC of 1.88L and %VC of 90.4%). She has continued ambroxol treatment for 17 months without disease progression.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1467_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1467_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..93fee0459d0cce8c6f7bad4979c60d0d41dfd08a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1467_en.txt
@@ -0,0 +1 @@
+A 74-year-old non-smoker woman was admitted to our hospital for acute confusional state with rapid onset of amnesia and dyspnea in July 2017. She had no significant medical history. Brain magnetic resonance imaging (MRI) scan and a whole-body computed tomography (CT) scan documented a pulmonary mass, mediastinal lymphadenopathies and multiple brain metastases, the largest one of 5.6 cm was in the left temporal lobe. An adenocarcinoma of the lung was diagnosed by biopsy performed via bronchoscopy. Fluorescent in situ hybridization (FISH) analysis of biopsied tumor tissue revealed the presence of ALK gene rearrangement. In August 2017, the patient started the crizotinib treatment after the whole brain radiotherapy. After 3 months, a CT scan showed a partial response of the disease in the chest and brain metastases were stable. After 8 months of the crizotinib therapy, a CT scan confirmed the stable disease for all lesions but it showed the appearance of multilocular cysts in both kidneys, the biggest of 3 cm, and a multilocular cyst starting from the right kidney to the perirenal adipose tissue and the posterior renal fascia . The patient had an Eastern Cooperative Oncology Group (ECOG) Performance Status 0; serum creatinine, C-reactive protein (CRP) and erythrocyte sedimentation rate were within normal ranges; blood cultures were negative for both bacteria and fungi. Taking into account the clinical benefit, the patient continued the crizotinib treatment. In September 2018 a CT scan confirmed that the disease was stable, but it documented confluent cystic formations bounded by solid walls, extended posteriorly and bilaterally from the kidneys along the perirenal and pararenal spaces: a cyst of 8 cm infiltrated the diaphragm and another one of 12 cm invaded the left iliopsoas muscle; two cystic hepatic lesions with thick walls also appeared, the biggest of 3 cm . The patient reported abdominal pain. Thus, the therapy was changed from crizotinib to alectinib, a second generation of ALK inhibitor approved for the treatment of metastatic NSCLC. In December 2018, after 3 months of the alectinib therapy, a CT scan confirmed that the disease was stable for the metastases affecting the brain, the chest and the abdomen and it showed the regression of cystic lesions in the kidneys, in the perirenal space and in the liver with a relevant reduction in size of the cystic lesion of the left iliopsoas muscle (2.8 cm versus 12 cm) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1473_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1473_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..47a4e1c390d9ab3ed6797bddd3798d327d3fedf8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1473_en.txt
@@ -0,0 +1,2 @@
+We present a 30-year-old male with selective anti-polysaccharide antibody deficiency (SPAD) and peripheral blood CD5+/CD19+ B-cell predominance (97%, control 52.5 ± 17.3%) diagnosed at 5 years old. His past medical history was significant for persistent childhood sinopulmonary infections, severe hemorrhagic varicella at 2 years old, ulcerative colitis in early adolescence, and ongoing autoimmune hepatitis. His initial immunological evaluation revealed seronegativity of 12 Streptococcus pneumoniae subtypes, Neisseria meningitidis A and C, Haemophilus influenza b, human parainfluenza viruses 1 to 3, influenza A and B, poliovirus 1 to 3, and respiratory syncytial virus. Post-vaccination antibody titers demonstrated negative pneumococcal valent conjugate serology but clinically adequate (≥.01 IU/mL) response to protein antigens tetanus and diphtheria anti-toxoids. Other immune laboratory assessments included persistently stable hypogammaglobulinemia. Blood leukocytes and mitogen- and antigen-induced lymphocyte proliferation panel were within normal limits. Serologic evidence of human immunodeficiency virus, EBV, and cytomegalovirus was absent. Immunological re-evaluation at 28 years old confirmed CD5 + B-cell predominance and revealed a MAGT1 mutation (c.923-1_934del) and reduced CD16 + CD56 + natural killer- and/or CD8 + T-cell receptor, Group 2, Member D (NKG2D) expression consistent with the XMEN genotype and phenotype.
+The patient presented for a routine office visit with no acute symptoms. He denied recent history of COVID-19. COVID-19 vaccination and associated serology antibody testing was recommended. Anti-SARS-CoV-2 immunoglobulin (Ig)M and IgG antibodies before and after the first BNT162b2 (Pfizer/BioNTech) mRNA COVID-19 vaccine doses, as well as nucleocapsid antibody, were negative . S protein total antibody was reactive after the second dose.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1487_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1487_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..714be1d59ea8b2e828fea91cafa92a6eb0bf88ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1487_en.txt
@@ -0,0 +1,8 @@
+A 91-year-old man hospitalized in our geriatric center for delirium. His medical history consisted of a non-investigated major neurocognitive disorder and peripheral neuropathy of the lower limbs for 4 years with no etiological diagnosis. His usual treatment was ginkgo biloba extract and grape seed extract. He lived at home. His family reported an increase in behavior disturbances associated with cough over the 3 previous weeks.
+At admission, the physical examination revealed fever, rhinorrhea, cough and widespread bronchi attributed to bronchitis. The neurological examination showed a bilateral loss of epicritic sensitivity in the lower limbs, but normal motor function. Delirium was also noted. There was isolated cervical lymphadenopathy. Initial biological tests showed normal levels of hemoglobin, platelets and leukocytes. A nasopharyngeal swab was taken on admission in order to perform molecular assay for respiratory viruses (i.e., multiplexed in-house RT-PCR for Influenza virus A and B, Rhinovirus/Enterovirus, human Metapneumovirus, Parainfluenza virus, adenovirus, non-SARS-Cov-2 coronavirus) identified a human metapneumovirus (hMPV) infection. Serology for hMPV was not performed.
+The initial course was favorable with symptomatic care (aerosols of saline solution, paracetamol and respiratory physiotherapy) plus low-dose benzodiazepine for the delirium. Five days after viral diagnosis, the lymphocyte count increased from 1.16 to 10.86 × 109 cells/L, while the symptoms of the infection remained under control. Serum protein electrophoresis suggested inflammation. The immunophenotyping of lymphocytes showed a profile of CD 5+, CD 23+, low FMC-7, and CD19b-, which is consistent with B-chronic lymphocytic leukemia.
+We did not find other lymphadenopathies, splenomegaly or hepatomegaly during the physical examination or on imagery. He had no B symptoms other than fever consecutive to his infection (i.e., nighttime sweats and weight loss).
+The lymphocyte count fluctuated considerably during hospitalization, with a maximum of 12.39 × 109/L . We did not perform FISH or IGHV mutation testing.
+Because of the novel hematological finding and the unclear history of peripheral neuropathy, other laboratory tests, including for cryoglobulins, were performed. Renal and hepatic function were normal. The lab results found monoclonal IgG K cryoglobulinemia (0.1 g/L) associated with an increase in the activity of rheumatoid factor (7.5 IU/mL; normal < 3.5) and C3 (1.756 g/L; normal 0.811–1.570). There was a decrease in C4 activity (0.017 g/L; normal 0.129–0.392). Hepatitis C serology was negative, as were antinuclear antibodies.
+The diagnosis of CLL associated with type-1 IgG K cryoglobulinemia revealed by hMPV infection was retained. The peripheral neuropathy was linked to an isolated clinical manifestation of cryoglobulinemia.
+Given the absence of disability, significant gait disorders or skin lesions, the advanced neurocognitive condition, a Binet A (or Rai stage 1) CLL classification and the patient’s age, the care team decided not to treat the CLL. After discharge from the hospital, the patient was admitted to a nursing home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1490_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1490_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d67525145b31776c37febd50460d02be744b2ab2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1490_en.txt
@@ -0,0 +1,4 @@
+A 23-year-old Arabic single woman was brought to our emergency department (ED) by her family around 4 hours after intentional metformin ingestion. She was on metformin for weight reduction (her body mass index was 28), as she was found to have polycystic ovarian syndrome (PCOS). She ingested around 60 tablets of 500 mg metformin as a suicide attempt after she experienced a stressful social event. Four years prior, she had undergone a kidney donation to her brother, who had renal failure due to an unknown cause, and otherwise she was healthy. She was not known to have any psychiatric illness or previous suicidal ideation or attempt. There was no history of smoking or alcohol intake. She does not have any family history of diabetes mellitus or mental illnesses. On examination, she was alert and well-nourished but generally fatigued, with no pallor, jaundice, or cyanosis. Her vital signs were as follows: blood pressure 119/65 mmHg, heart rate 122 beat/min, respiratory rate 20 breaths/min, pulse oximetry oxygen saturation 100% on room air, and oral temperature 36.9 °C. She had dry and cool skin, and bilaterally mid-sized pupils, equal and reactive. The rest of her physical examination was unremarkable.
+Her bedside point-of-care capillary blood glucose level was checked, and it was low. A peripheral intravenous cannula was inserted, and blood extracted followed by administration of 50 ml (25 g) of 50% dextrose (D50) solution. Her blood glucose level was 6.3 mg/dL in serum chemistry; however, it increased to 106 mg/dL after the D50. After that, 5% dextrose-water solution was initiated as a maintenance infusion. Her blood investigation results are summarized in Table . They were unremarkable except for a very low blood glucose level, leukocytosis, hypocalcemia, hyperphosphatemia, and mild creatinine elevation. An initial venous blood gases reading revealed pH: 7.18; PO2: 76.9 mmHg; PCO2: 40.3 mmHg; and bicarbonate of 14.3 mmol/L. Her first lactate level was elevated (8.4 mmol/L), and so a 1 L bolus of Ringer lactate solution was given. Her serial venous blood gases and lactate measurements are shown in Table . Results of analyses of her acetaminophen and aspirin levels were negative. In addition, urine analysis as well as urine pregnancy test results were negative.
+Two hours later, her capillary blood glucose dropped to 38 mg/dL, and another 50 mL ampule of D50 was infused, which increased her glucose level to 319 mg/dL. During the hospital stay, her blood sugar was monitored frequently . As our patient had worsening lactic acidosis, a nephrologist was urgently consulted, and she was admitted to the intensive care unit (ICU). She had a drop in her blood pressure, and so norepinephrine infusion was initiated. After that, continuous renal replacement therapy (CRRT) was started. At around 3 hours later, her blood sugar dropped to 42 mg/dL, and another dextrose bolus was given. After 13 hours of CRRT initiation, the norepinephrine infusion was discontinued, and our patient was hemodynamically stable. The CRRT was continued for 24 hours. Our patient’s renal and liver function tests did not worsen and remained within normal limits till hospital discharge.
+On day 3, she was transferred to the ward with normal mental status and vital signs. She was tolerating oral intake and did not develop any more hypoglycemic attacks. The psychiatrist was consulted for further assessment and treatment. On the fifth day of hospitalization, our patient was discharged home with a good health status. This patient was provided, as a part of our multidisciplinary discharge planning, with follow-up appointments within 1 month for internal medicine, nephrology, and psychiatry. As per our medical records, this patient did not show up for any of these outpatient follow-up appointments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1503_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1503_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9752dcf72d62923c65c12282f3038a526e1715ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1503_en.txt
@@ -0,0 +1,5 @@
+A 55-year-old man (height, 176 cm; weight, 95 kg) with rhegmatogenous retinal detachment presented to the hospital after experiencing sudden blackout of vision in the right eye for over 20 days prior to his visit. He had a medical history of claustrophobia for over 40 years and severe obstructive sleep apnea syndrome (OSAS); however, he had not undergone any treatment. He had no medical history of chronic systemic diseases such as hypertension, diabetes, coronary heart disease, allergies, or surgery. The preoperative physical examination was unremarkable.
+Surgery under local anesthesia was initially planned to take place in an ophthalmic operating room. The first operation failed, as the patient experienced a panic attack upon entering the operation room. The ophthalmologist subsequently applied for anesthesia sedation surgery the next day and consulted the anesthesiology department. After consultation with the anesthesiology department, it was found that the patient had severe OSAS, and thus, the risk of adverse events surrounding surgery under sedation in the ophthalmic operating room was high. As a result, the patient’s safety could not be guaranteed, and general anesthesia surgery was recommended in the anesthesiology operating room. On the day of the surgery, the patient was so resistant to the unfamiliar environment of the anesthesiology operating room that the operation had to be canceled again. After building trust with the patient, the anesthesiologist accompanied the patient to the anesthesiology operating room. However, the patient still experienced a panic attack when he entered the room. He complained of a severe headache, throat obstruction, near suffocation, and an uncontrollable and desperate need to escape the operating room. Neither the nurse nor the doctor could comfort him effectively. Finally, the operation was canceled again. After multidisciplinary consultation, the anesthesiologist recommended that the patient be accompanied by family members for anesthesia sedation outside the operating room of the anesthesiology department, followed by completion of the operation under general anesthesia in the operating room.
+The patient underwent routine fasting. On the day of the surgery, the patient, accompanied by his family members, went to the hall outside the operating room of the anesthesiology department. He half-laid on the surgical transfer bed, facing a large window in the hall. The patient felt comfortable looking out of the window, and the anesthesiologist relaxed the patient through conversation. After cannulating an upper extremity peripheral vein, intravenous midazolam (3 mg) and propofol (30 mg) were administered for induction, and the patient was quickly transferred to the operating room after he lost consciousness. He was administered high-flow oxygen via mask for FiO2 100%, oxygen flow 6 L/minutes, with routine monitoring of vital signs. Heart rate was 65 beats per minute, blood pressure 112/55 mm Hg, oxygen saturation 100%, temperature 36.5°C, and bispectral index 75. Intravenous injection of etomidate (20 mg), sufentanil (10 μg), and dexmedetomidine hydrochloride infusion (1 μg/kg during the first 10 minutes) were administered. After stabilization of the heart rate and blood pressure, intravenous injection of cis-atracurium (15 mg) was given to complete anesthesia induction. Oxygen was administered via a mask to assist with breathing, and mechanical ventilation was started after oral placement of a No. 4 laryngeal mask following muscle relaxation. Subsequently, intravenous targeted infusion of propofol (3.0–6.0 μg/mL) and remifentanil (2.0–8.0 ng/mL) and an intravenous dexmedetomidine pump were started for intraoperative maintenance of bispectral index 40 to 60. The surgery took 55 minutes. The operation went smoothly, and the intraoperative vital signs were stable. After the operation, the patient was taken to the hall outside the operating room and kept in a supine position facing the window of the hall. The oxygen bag provided oxygen compound air for spontaneous breathing with a heart rate of 55 beats per minute, blood pressure 96/62 mm Hg, and oxygen saturation 100%. After spontaneous breathing with oxygen saturation ≥ 98% under room air, the laryngeal mask was removed once extubation conditions were reached. The patient had no difficulty in breathing after removing the laryngeal mask, and the semi-recumbent position kept the patient’s airway open and comfortable. After 30 minutes of observation, the patient was fully conscious, breathing was completely restored, and he could communicate normally. He was then sent back to the ward, and all his vital signs remained stable after the operation.
+After a few days, the patient was interviewed over the telephone. He had returned to his daily routine, and there were no long-term postoperative adverse events. He described having a fear of enclosed spaces that could be traced back to childhood experiences. He said that he could consciously control his emotions before the surgery, but still experienced uncontrollable fear unconsciously during the operation; however, the extra-operative anesthesia and awakening experience were comfortable.
+Written informed consent for publication of this report was obtained from the patient and his family.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_150_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_150_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64f6329afaad34e91217ef7a85c8694ccd51886e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_150_en.txt
@@ -0,0 +1,4 @@
+A 71-year-old man presented to a regional hospital with gradually worsening dysphagia for two years. He had not experienced any dysphagia or vomiting before, nor had he ever undertaken an endoscopy. Esophagogastroduodenoscopy revealed a giant M-ED and multiple small diverticula in lower esophagus with mild stenosis, although the endoscope passed through it without difficulty . He was referred to our hospital for surgery.
+Computed tomography revealed an 8-cm-long M-ED on the right side of the esophagus. Barium swallow test confirmed the diagnosis of M-ED and multiple small diverticula in lower esophagus with some narrowing though barium promptly passed through the esophagogastric junction (EGJ) . HRM (Starlet, Star Medical, Inc, Tokyo, Japan) revealed a median integrated relaxation pressure (IRP) of 14.6 mmHg (upper cutoff; 26 mmHg), a distal latency (DL) of 6.4 s (lower cutoff; 4.5 s), and an average maximum IBP of 35.7 mmHg . The patient did not meet the criteria for an esophageal motility disorder according to the Chicago classification (version 4.0) ; however, elevated IBP (> 20.1 mmHg) suggested the presence of an underlying structural restriction or obstruction at the EGJ .
+Thoracoscopic resection of the M-ED and myotomy of the lower esophagus were performed. Briefly, the patient was placed in a prone position with bilateral lung ventilation and approached from the right chest under artificial pneumothorax at 10 mmHg with carbon dioxide. A 12-mm camera port and three working ports were inserted at the 5th, 7th, and 9th intercostal spaces. The diverticulum in mid esophagus was identified through the pleura as a pulsion diverticulum without muscularis propria, and the right vagus nerve was running near the ED. The root of the ED was exposed preserving the right vagus nerve and longitudinally transected using linear staplers, and the muscle layers were sutured with 3–0 proline to bury the staple lines. Myotomy was performed in the right posterior wall of the esophagus, extending from immediately below the ED to the level of the diaphragm, ~ 12 cm in length. The lower esophagus looks normal in appearance, but the muscular layer was thickened just as same as achalasia during the myotomy. Finally, intraoperative endoscopy confirmed sufficient opening of the midthoracic esophagus and improvement of the stenosis in the lower esophagus. The operation duration was 119 min, and intraoperative blood loss was minimal.
+Histopathologic investigation revealed that M-ED was composed of mucosa and submucosa without the muscle layer and was diagnosed as pseudodiverticulum. Postoperative esophagography showed smooth passage of the contrast medium without leakage or stenosis . The postoperative course was uneventful, and the patient was discharged on postoperative day 13. His dysphagia had completely resolved at the 3-month follow-up visit, and the HRM test performed at that time demonstrated that the average maximum IBP was declined to within the normal range .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1512_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1512_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e88e45b30e94b2a4d89fd7845ea1458132d57cab
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1512_en.txt
@@ -0,0 +1,16 @@
+A 48-year-old caucasian woman (weighing 60 kg) was transferred from the emergency room (ER) of Boscotrecase (Naples, Italy) to the intensive care unit (ICU) of University of Campania “L. Vanvitelli” for suspected pyelonephritis with systemic impairment, fever, sepsis, and altered mental state (coma). She had no history of relevant comorbidities or particular risk factors such as immunosuppression.
+In the ER, she underwent a computerized tomography (CT) scan of abdomen, chest, and brain with and without contrast enhancement. The CT scan demonstrated “moderate ectasia of the right renal calyx with peripheral medullar densitometric alterations,” being suggestive for pyelonephritis. On admission in our ICU, the patient was sedated, intubated with an orotracheal tube, monitored, and ventilated in a controlled mode. Vital signs on admission were arterial pressure 80/40 mmHg [mean arterial pressure (MAP), 53 mmHg]; heart rate 110 beats per minute (bpm), peripheral saturation of O2 (SpO2) 100%. Her body temperature was 39 °C; lactate values were 6.2 mmol/l. Right after admission, the patient’s monitoring was switched from noninvasive to invasive, with cannulation of the left radial artery and monitoring of hemodynamic parameters with the Vigileo system (a device that analyzes arterial blood pressure waveforms and their variations).
+The hemodynamic parameters monitored with Vigileo showed cardiac output (CO) 2.1 l/minute (normal range 4.0–8.0 l/minute), systemic vascular resistance (SVR) 350 dyne seconds/cm5 (normal range 800–1200 dyne seconds/cm5) (MAP 53 mmHg).
+Routine blood tests were performed, in addition to procalcitonin (PCT) sampling, serology for hepatotrophic viruses and human immunodeficiency virus (HIV), and a multiplex polymerase chain reaction (PCR) molecular biological blood sampling for detection of nucleic acids of bacteria, viruses, and fungi. Urine routine analysis along with microbiological tests was performed as well. A brief sedation window was performed, and neurological examination demonstrated a coma state with a Glasgow Coma Scale (GCS) score of 5 (Eye 1, Vocal 1T, Motor 3), with a decorticated response to pain, bilaterally myotic pupils with a torpid pupillary response, and a bilaterally positive Babinski sign.
+Early fluid resuscitation began with a bolus of 30 ml/kg of crystalloid in 3 h, and norepinephrine infusion began at a rate of 0.2 µg/kg/minute [, ].
+Empirical antibiotic therapy with ceftazole/tazobactam (1 g/0.5 g every 8 hours), meropenem (1 g every 8 hours), and aciclovir (250 mg) was administered. Dexamethasone was added as adjuvant therapy (10 mg once per day for 4 days) .
+Blood samples revealed white blood cells (WBC) 11.00 × 103/μl (normal range 4.2–9.0 × 103/µl) (neutrophils 86.0%, lymphocytes 12.6%), red blood cells (RBC) 3.97 × 106/μl (normal range 4.5–6.1 × 106/µl), hemoglobin (HB) 10.2 g/dl (normal range for women 12–16 g/dl), platelets (PLT) 54 × 103/μl (normal range 150–450 × 103/μl), procalcitonin (PCT) 61 ng/ml (normal range < 0.5 ng/ml), and C-reactive protein (CPR) 17.5 mg/dl (normal range < 0.5 mg/dl).
+Furthermore, blood PCR analysis was positive for E. coli. The analysis was negative for N. meningitidis, H. influenzae, and S. pneumoniae.
+Urine microbiological examination was also positive for E. coli, with a total microbial load (colony-forming units, CFU) of 10,000 CFU/ml. The antibiogram showed high sensitivity of E. coli to meropenem. We therefore decided to suspend ceftazole/tazobactam and continue therapy with meropenem.
+After etiologic diagnosis, in consideration of the septic shock condition and the relatively young age of the patient, it was decided to introduce an immunoglobilins (Ig)M-enriched intravenous immunoglobulin (IVIG) preparation (Pentaglobin®) at a dosage of 250 ml/kg per day for 4 days. Pentaglobin® (immunoglobulin IgM-enriched; Biotest) is a plasma-derived solution with the following composition: 12% IgM, 76% IgG, 12% IgA. Although the Surviving Sepsis Campaign guidelines advise against the use of IVIG in patients with sepsis or septic shock, given the lack of a statistical significance for survival benefits [, ], our recent positive outcome in treating septic shock with an IgM-enriched formulation as an adjuvant therapy and the Gram-negative etiology of the patient’s condition were a convincing rationale, as IgM-enriched IVIGs were found to have higher antibody levels against Escherichia
+coli and other Gram-negative bacteria than did normal IVIG preparations .
+After 24 hours of therapy, the patient showed an improvement in blood chemistry (CPR 8.3 mg/dl; PCT 7.7 ng/ml; lactate 4.1 nmol/l) and hemodynamic parameters (CO 3.2 l/minute; SVR 550 dyne seconds/cm5, MAP 70 mmHg). Her body temperature was 36.5 °C. GCS score remained 5 (E1, V1T, M3) when another sedation window was performed. Her hemodynamic stability allowed her to undergo a brain magnetic resonance imaging (MRI) scan . The MRI scan revealed an altered signal and post-contrast enhancement of the leptomeninges. Moreover, multiple T2 and fluid-attenuated inversion recovery (FLAIR) hyperintense and sometimes confluent lesions were detected: in the thalamus, which appeared swollen; in the pons, in the cerebellar peduncles, and in cerebellar hemispheres, also appearing swollen; in the ventricles (mostly in the lateral ventricles and in the occipital horn bilaterally); and in the parahippocampal region bilaterally. All these lesions were also characterized by a reduced diffusivity in diffusion-weighted imaging (DWI) scans.
+Finally, multiple comminute T2/FLAIR white-matter hyperintense lesions were demonstrated, located in the juxtacortical white matter, especially in frontal regions, in both the corona radiata, and in periventricular regions bilaterally.
+After 48 hours from the start of Pentaglobin treatment, there was a remarkable improvement in hematochemical and hemodynamic parameters. In particular, the patient no longer needed inotropic support, and we therefore suspended continuous infusion of norepinephrine. Ventilation was switched to an assisted mode to wean the patient from the ventilator. Three days after admission, hemodynamic parameters of the patient were still improving, she was not febrile anymore, and lactate levels were dropping; on the other hand, her neurological condition was still severe, with a persistent altered mental state, bilateral miosis with a torpid papillary response, nystagmus, dyplegia with bilaterally positive Babinski sign and hyperelicitable osteotendinous reflexes.
+96 hours after Pentagoblin introduction, there was an evident improvement in the patient's clinical condition. GCS score increased to 10 (E3, V1T, M6). The patient was also able to be extubated, breathing spontaneously. Blood chemistry values were CPR 5.18 mg/dl, PCT 1.2 ng/ml, and lactate 1.2 mmol/l. Hemodynamic values were CO 5.4 l/minute, SVR 1200 dynes second/cm5, MAP 90 mmHg final. Neurological examination showed normal pupils and pupillary response, dyplegia with bilaterally positive Babinski sign, and hyperelicitable osteotendinous reflexes. Other cerebellar signs besides nystagmus became evident, with dysarthria and dysmetria of the upper limbs. A mild cognitive impairment was also detected, as the patient showed apraxia and executive functioning deficits. As the patient was more responsive, both a physiatrist and speech therapist assessment were scheduled to evaluate her and commence rehabilitation.
+Six days after admission, the patient underwent a control CT scan, which demonstrated a partial resolution of the renal alterations suggestive of pyelonephritis. She also underwent a control brain MRI on day 9 after admission. The MRI scan showed a reduction of all the previously detected lesions, with less swelling of the thalamus and cerebellum. On the other hand, the multiple juxtacortical and periventricular white-matter lesions remained substantially unchanged, also showing some microbleeding spots The patient remained in our department for the continuation of antimicrobial therapy and close monitoring. Twenty-one days after admission the patient was remarkably improved, showing only mild cerebellar signs (mostly dysarthria, along with dysmetria and a slight action tremor), slight hyposthenia of the four limbs, and mild apraxia on neurological examination. She was discharged and transferred to a rehabilitation center for post-intensive care rehabilitation to regain limb strength and coordination and to improve her speech abilities. Physiatrist, speech therapy, and neurological out-patient consultations, as well as a 6-month control brain MRI scan, were scheduled. Three months after discharge, a striking improvement of her condition was reported, as she was almost free from any neurological sign or symptom and almost fully recovered from her condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1513_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1513_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9b0ed331f8c64968db3d33905b5fcca1b5c8e8dd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1513_en.txt
@@ -0,0 +1,3 @@
+An 11-year-old boy consulted a family doctor for bloody diarrhea. The patient had no specific medical or family history. A colonoscopy from the rectum to the sigmoid colon led to the diagnosis of pediatric UC with a pediatric ulcerative colitis activity index (PUCAI) of 30. He was administered 5-aminosalicylic acid (5-ASA) suppositories (1 g/day) and was referred to our hospital for subsequent treatment. His symptoms promptly improved to a PUCAI of 5. His blood examination results were unremarkable but the fecal calprotectin (FC) level was elevated to 3,190 mg/kg. A complete colonoscopy was performed, which revealed inflammatory findings from the rectum to the transverse colon. Moreover, the cecum and ascending colon showed loss of vascular permeability and adherent purulent mucus . The patient was prescribed oral 5-ASA (3,000 mg/day). The FC level gradually decreased to 33.2 mg/kg by week 15 .
+At 12 years old, he complained of epigastric pain on an empty stomach, which was relieved with dietary intake (week 19). He reported no UC symptoms, including diarrhea and bloody stools (PUCAI, 0); however, an elevated FC level was noted (week 20). Esophagogastroduodenoscopy (EGD) findings indicated an A1 ulcer on the lower wall of the duodenal bulb . A rapid urease test was positive, and he was diagnosed with a duodenal ulcer due to H. pylori infection. The H. pylori infection was treated using clarithromycin and amoxicillin for 7 days and a proton-pump inhibitor. The patient’s symptoms improved the day after treatment initiation. In week 33, an EGD was performed to evaluate the therapeutic effect. The duodenal ulcer had healed, and scarring was observed .
+The FC level remained high despite improvement of duodenal ulcer symptoms and endoscopic findings of H. pylori eradication. The patient subsequently developed diarrhea (PUCAI, 10) in week 35 and a UC relapse was considered. Cytomegalovirus antibody, antigenemia, and tuberculosis (T-SPOT assay) tests were negative. Colonoscopy showed small aphthae and edematous mucosa throughout the colon in week 36 . Histopathological examination revealed UC lesions grades 3–5 based on the Matts classification. The patient was diagnosed with a UC relapse, and the 5-ASA dosage was increased to 4,000 mg/day (100 mg/kg/day).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1522_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1522_en.txt
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index 0000000000000000000000000000000000000000..e0ad33c85b464c10ddce0489ee1547db05d5f306
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1522_en.txt
@@ -0,0 +1,4 @@
+A 16-year-old Japanese primipara was urgently transported from a regional maternity clinic to our hospital because of threatened premature labor in the 25th week of pregnancy. There was no medical or family history of note. At that time, there had been extremely powerful earthquakes occurring in the Kumamoto area where she lived, and as a result, she had been forced to stay in an emergency shelter. When she arrived at our hospital, treatment with ritodrine hydrochloride, magnesium sulfate, betamethasone and hydroxyprogesterone was initiated, and her premature uterine contractions were successfully controlled.
+Soon after her admission, considerable polyuria (3000–6000 mL/day), nocturia (5–6 times a night) and polydipsia gradually became obvious . Because she was restricted to bedrest to prevent premature labor, precise diagnosis and treatment of polyuria was necessary. From the 27th to the 28th week of gestation, the amount of urine increased from 4000 to 6000 mL/day . Fasting plasma glucose levels during hospitalization were around 78–88 mg/dL and the results from a 75-g oral glucose tolerance test indicated that she was not diabetic . Although she developed polyuria, serum sodium levels were constant at around 137–140 mEq/L during the clinical course . Serum osmolality was maintained at around 260–265 mOsm/L, while urine osmolality (191–293 mOsm/L) showed below the levels of serum osmolality, indicating that her urine concentration ability had deteriorated . The serum level of AVP was 1.7 pg/mL (0.3–3.5; Table ), which is inconsistent with central DI. At the time of admission, hepatic dysfunction was not observed . A water deprivation test would have been unsuitable for diagnosis in this case because dehydration can deteriorate the maternal-fetus environment. Although a precise diagnosis of GDI was not made at that time, we decided to use oral 1-deamino-8-D-AVP (DDAVP) tablets for diagnostic treatment to determine whether her urine would respond to DDAVP and treat DI, as well as to rule out nephrogenic DI. Thus, the patient was first given 120 μg of oral DDAVP tablets, and then the dose of DDAVP was gradually increased to 360 μg until the amount of urine was less than 2000 mL/day with a urine osmolality of 305–365 mOsm/L . At the 32nd week of gestation, fetal maturation was confirmed and medical support to prevent premature contractions was ceased. Soon after this decision, a male fetus weighing 1660 g and 45 cm was delivered with a one-minute Apgar score of 8/9. Immediately after the normal delivery, DDAVP tablets were no longer necessary to control her polyuria. Daily urine amount decreased to 1300–1600 mL/day . At this point, s-Osm was 268 mOsm/L and u-Osm increased to 540 mOsm/L without DDAVP treatment . Pituitary magnetic resonance imaging (MRI) was performed and confirmed that the normal bright spot in the posterior pituitary on the T1 image was present . After these observations, clinical diagnosis of GDI was confirmed.
+At 2 weeks post-partum, the patient’s sodium, serum and urine osmolality were within normal range. She remained clinically well, and is currently breast-feeding with no complications.
+At 4 weeks post-partum, she developed postpartum destructive thyrotoxicosis with increases of free-T4 and free-T3, and suppressed thyroid stimulating hormone (TSH), with positive thyroglobulin antibody . After 8–12 weeks of follow up with no medications, she had completely recovered thyroid function.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1526_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1526_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..46738ab7a7dada7d53102e3e7b26716d1f3d53ec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1526_en.txt
@@ -0,0 +1,14 @@
+A 22-year-old man presented to our hospital with progressive abdominal distention and nausea. A VPS had been placed 21 years earlier to treat hydrocephalus secondary to spina bifida. Shunt revision was performed only once when he was 10 months old, and no other abdominal surgery was performed after this. He had no history of malignancy or pancreatic or liver disease. Physical examination revealed a large elastic palpable mass in the upper abdomen. No neurological change was observed. His white blood cell count and amylase serum levels were normal. The patient underwent supine abdominal radiography and unenhanced abdominal computed tomography (CT).
+Supine abdominal radiography revealed the VPS in the left upper quadrant and a soft-tissue mass in the upper abdomen (Figure ). Abdominal CT revealed homogeneous low-density fluid collection. The VPS catheter tip was adjacent to the fluid collection, suggesting a giant cystic lesion around the shunt catheter (Figure A,B). The cystic mass was independent of the pancreas.
+Thus, a peritoneal pseudocyst around the VPS causing stomach obstruction was suspected and emergency laparotomy was performed. The large mass was localized in the left upper abdomen between the stomach and transverse colon mesentery, exactly at the omental bursa (Figure ). After the diffuse abdominal adhesions were removed, the cystic mass was opened and 1500 ml of clear fluid was drained. A part of the pseudocyst wall, consisting of the posterior wall of the stomach and colonic mesentery, was resected completely to open the pseudocyst (Figure ). The distal end of the VPS was placed inside the mass. Thus, pseudocyst as a complication of VPS was diagnosed. After examination of the cerebrospinal fluid from the tip of VPS catheter, we replaced the VPS catheter to another position in the abdomen. Histopathological examination of the resected specimen revealed fibrous tissue with inflammatory cell infiltration. After surgery, his appetite recovered and was discharged on the 8th postoperative day in a good condition. The postoperative course has been uneventful for 4 months after his last surgery.
+The findings of fluid analysis were similar to those of cerebrospinal fluid analysis, with negative cultures and absence of microbial flora.
+VPS is the most common treatment procedure for hydrocephalus; however, it is not free of complication. Abdominal cerebrospinal fluid pseudocyst is a rare, but potentially life-threatening complication of VPS placement. It is seen as a thin-walled cystic mass around the shunt tip, which is filled with cerebrospinal fluid. The wall is composed of fibrous tissue without epithelial lining. The underlying mechanisms involved in the formation of the cerebrospinal fluid pseudocyst remain unknown; however, inflammation, either sterile or infectious, is usually regarded as the main causative factor
+. In our case, there was diffuse abdominal adhesion, suggesting a history of previous abdominal infection.
+The symptoms of abdominal cerebrospinal fluid pseudocysts in adult patients are abdominal pain, distention, and a palpable abdominal mass. Thus, adults predominantly present with abdominal signs only. On the other hand, in pediatric patients, symptoms of shunt malfunction, such as headache, nausea, and vomiting are more common
+.
+CT indicates a definitive diagnosis of abdominal cerebrospinal fluid pseudocyst, revealing a large fluid-filled collection delimited by a thin wall adjacent to the catheter tip. Differential diagnoses of an abdominal cystic mass include abdominal abscess, lymphocele, seroma, cystic lymphangioma, cystic mesothelioma, mesenteric cyst, benign cystic teratoma, cystic spindle-cell tumor, pancreatic pseudocyst, and duplication cyst
+. In our case, the absence of infectious symptoms and lack of any inflammatory changes in surrounding tissues makes the diagnosis of the abscess highly unlikely. Furthermore, the absence of a history of pancreatic disease makes diagnosis of pancreatic pseudocyst unlikely. The preoperative diagnosis of pseudocyst around the VPS was made considering the clinical setting and the relationship of the cyst with VPS.
+The time between the last VPS surgery and collection of abdominal cerebrospinal fluid has been reported to range from 3 weeks to 10 years
+. Recently, both Pernas et al. and Sena et al. reported a case of abdominal pseudocyst formation 15 years after VPS placement, both of which seem to be the longest period reported previously in the English literature. In our case, the last VPS surgery was performed 21 years before the beginning of current symptoms, and no other abdominal surgery was performed during that period. This appears to be the longest period reported until date in the English literature.
+Treatment of abdominal cerebrospinal fluid seems controversial. Therefore, many treatment algorithms have been described, such as laparotomy with wide excision of cystic walls, paracentesis and aspiration of the cystic fluid, CT-guided or ultrasound-guided aspiration of the pseudocyst. In the present case, exploratory laparotomy and excision of the cystic walls with fluid drainage was performed. Recently, laparosopic management, which is a useful tool, has been reported
+; however, in our case, it seemed impossible to use this tool because of diffuse abdominal adhesion.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1527_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1527_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..81431d1eb6989beb057040e5b6a8b46bc4413bda
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1527_en.txt
@@ -0,0 +1,5 @@
+A man in his 50s was transferred by ambulance to a nearby physician because of rupture of gastric varices. At that time, he was diagnosed as having cirrhosis after chronic type B hepatitis and had been followed up with by the physician afterward. He was suspected to have developed HCC based on the imaging examination in December 2014, and he was referred to our hospital in March 2015 for further examination and treatment.
+At the time of the first visit, his consciousness was clear, but he had a flapping tremor. He presented with notable conjunctival yellowing. His abdomen was flat and soft without tenderness. Laboratory test results indicated pancytopenia, a prolonged prothrombin time-international normalized ratio, hypoalbuminemia, and jaundice. The result of the indocyanine green retention test was as high as 36.5%. The alpha-fetoprotein level was within the normal range of 2.8 ng/mL, but the protein induced by vitamin K absence/antagonist-II (PIVKA-II) level was as high as 163 mAU/mL. He had cirrhosis after chronic type B hepatitis. The nucleotide analog (entecavir) was already prescribed by the previous physician, and the serological test result was positive for hepatitis B virus DNA . Abdominal dynamic computed tomography (CT) showed that the liver edge was blunt, and the surface was irregular. A 39-mm nodule, which was enhanced in the arterial phase and slightly washed out in the equilibrium phase, was located in segment 8 of the liver. Moreover, prominent splenomegaly, collateral circulation, and a small amount of ascites in the pelvis were confirmed . In gadolinium-ethoxybenzyl-diethilene-triamine-pentaacetic acid-enhanced dynamic magnetic resonance imaging, the 39-mm nodule, which was enhanced in the early phase and had a low signal in the hepatocyte phase, was also observed in segment 8 of the liver. Aside from this tumor, a small nodule measuring 9 mm in diameter showed the same contrast pattern in segment 8 of the liver . CT during arterial portography showed perfusion defects in the 2 HCCs, and CT during arteriography showed hypervascular tumors in the early phase and peripheral enhancement in the late phase, which was consistent with typical HCC contrast patterns . These HCCs were enhanced simultaneously during arteriography of A8, and obvious vascular invasion was not observed . No other lesions suspected of HCC were found in the liver. Upper gastrointestinal endoscopy revealed high-risk esophageal varices (Lm, F2, Cb, RC-sign [+]).
+On the basis of these findings, we diagnosed the patient as having HCCs (cT3N0M0, clinical stage III) with severe liver damage. Regarding liver damage, the Child-Turcotte-Pugh classification was class C (11 points), and the Model for End-Stage Liver Disease score was 16 points, suggesting that he was a candidate for liver transplantation. Although there were 2 HCCs, one of them had a diameter exceeding 3 cm, which deviated from the Milan criteria. When applying the HCC therapy algorithm in Japan to this patient's comprehensive disease condition, only palliative care was recommended. Therefore, to determine treatment other than palliative care, we consulted with a transplant surgeon. As both HCCs were perfused with A8, locoregional therapy could be conducted to downstage HCC and maintain the liver reserve. Moreover, since this patient was relatively young, and his performance status was good, we considered liver transplantation as a curative treatment for HCC and sever liver damage. After confirming the wishes of the patient and his family, we decided to perform TACE following radical liver transplantation. Before these treatments, endoscopic varicocele ligation was performed for the esophageal varices. After confirming the disappearance of varices, lipiodol TACE was performed in segment 8 of the liver with 20 mg of epirubicin and gelatin sponges. There were neither postoperative complications nor changes in the Child-Turcotte-Pugh score. The PIVKA-II level decreased from 163 to 33 mAU/mL after TACE.
+Abdominal dynamic CT on day 60 after TACE showed sufficient lipiodol deposition in the 2 HCCs in segment 8, but a tiny lipiodol deposit-free area remained . On the basis of these findings, we determined that the progress of HCCs was successfully downstaged within the Milan criteria, and this patient underwent liver transplantation 110 days after TACE. Surgery was performed using a left lobe graft (graft weight, 298 g; graft-to-standard liver volume ratio, 25.8%). The operative time was 13 h and 53 min, and the bleeding volume was 7,885 mL.
+Pathologically, most of the tumor was successfully treated by TACE, except for the small remaining HCC where lipiodol deposition was insufficient. The smaller HCC which was 9 mm before TACE was completed . Postoperatively, hyperbilirubinemia and ascetic accumulation due to small-for-size syndrome were temporarily observed but gradually improved after enlargement of the graft volume. This patient was discharged on day 35 after liver transplantation. Two and half years after transplantation, he remains alive without HCC recurrence or liver deterioration.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1531_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1531_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc924024fd0fe6d5c4125ff81f6fb71b97aed501
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1531_en.txt
@@ -0,0 +1,4 @@
+A 36-year-old African American female with significant medical history of obesity and hypertension presented to the emergency department with headache, altered level of consciousness, fever, and severe neck stiffness. The patient was previously evaluated by multiple providers in the emergency department (urgent care) and was diagnosed with chronic allergic sinusitis. She was prescribed multiple courses of antibiotics with supportive care and sent home. She had recent animal exposure to a stray cat and consumed deli meats regularly. There was no history of recent travel. She denied any mosquito or tick bites.
+On physical exam, the patient was febrile, tachycardic, tachypneic, and disoriented to place and time with inappropriate responses to questioning, and nuchal rigidity was present. Complete blood cell count revealed a white blood cell count of 16.88 × 109 per liter with 80% band forms and 14% segmented neutrophils. Comprehensive metabolic panel showed no electrolyte abnormalities or renal or liver dysfunction. Urine analysis was within normal limits. CSF analysis revealed WBC count of 7810 cells/μL with 83% neutrophils, red blood cells count of 22 cells/μL, protein of 267 mg/dL, and glucose of 27 mg/100 mL. Gram stain, West Nile Virus antibody titer, and Coccidioides antibody were negative. Serum lactate was within normal limits. Unfortunately, the patient had received intravenous (IV) antibiotics prior to lumbar puncture and the CSF cultures remained negative. The CSF was not sent for detection of bacterial antigens.
+Despite the negative gram stain and cultures of the CSF, the clinical presentation and results of lumbar puncture were consistent with bacterial meningitis. In the emergency department, the patient was started on broad-spectrum antibiotics and antivirals with vancomycin, piperacillin/tazobactam, and acyclovir. On the medicine service, antibiotics and antivirals were transitioned to standard therapy for bacterial meningitis with ceftriaxone and vancomycin. The patient had resolution in her altered level of consciousness by the following day and was able to answer questions.
+Upon further questioning, she endorsed persistent unilateral clear nasal drainage lasting months and postural headache that was worse when standing or sitting and relieved by laying down. At this time, there was high clinical suspicion of CSF rhinorrhea. Computerized tomography (CT) scan of the sinuses initially indicated findings consistent with chronic sinusitis. However, the patient continued to have copious unilateral clear nasal discharge. Magnetic resonance imaging (MRI) of the orbits was completed which showed findings consistent with CSF rhinorrhea and bony defect of the basal skull . Additionally, her nasal discharge was positive for beta-2 transferrin. Otolaryngology was consulted for further evaluation. The patient was taken to surgery and intraoperative findings were consistent with CSF rhinorrhea of the left sphenoid sinus. The mucosal defect was repaired with free septal mucosal graft and tissue seal. The patient recovered without complications and was discharged home to complete a course of IV antibiotics.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1532_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1532_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea2793dea1210ab745a413bc069bdb0b39e8fbbd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1532_en.txt
@@ -0,0 +1,7 @@
+A 76-year old male presented to emergency department with generalized weakness and encephalopathy.
+His generalized weakness gradually started over a few months and recently he was getting weaker and also confused for a few days.
+His past medical history was significant for hypertension, diabetes and old ischemic stroke with residual right sided weakness.
+He was a non-smoker and non-drinker, and he lived in a house.
+He was somnolent but arousable. He had dry mucous membranes and mild right hemiparesis which was his baseline.
+Laboratory results were significant for serum potassium 6.7 mmol/L, serum creatinine 10.76 mg/dL, and serum creatine kinase 40673 U/L.
+Computed tomography of the brain without contrast showed no acute changes. Electrocardiography did not show any classic changes associated with hyperkalemia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_153_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_153_en.txt
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index 0000000000000000000000000000000000000000..4158b668ce2260d7eba5825829fe5dd437e2e794
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_153_en.txt
@@ -0,0 +1,5 @@
+A 72-year-old woman was referred to our clinic with a complaint of decreased visual acuity for 1 wk following cataract surgery performed in the left eye 2 wk ago.
+The patient underwent an uneventful phacoemulsification cataract surgery for the left eye at our department 2 wk ago, and a rotationally asymmetric refractive multifocal IOL (SBL-3, Lenstec, Inc.) was chosen and implanted with the near segments placed inferonasally. The first day post-surgery, uncorrected distance visual acuity (UDVA) was 0.0 logMAR (20/20 Snellen) and uncorrected near visual acuity (UNVA) was 0.1 logMAR (20/25 Snellen). Preoperative biometric data are given in Table .
+The patient had bilateral primary angle closure glaucoma treated by laser peripheral iridectomy before at a local hospital, bilateral intraocular pressure was normal with no glaucoma medication before cataract surgery, and she had no history of allergies, trauma, surgery, or systemic disease.
+The patient was married and had two sons. She had no family history of ocular disease.
+The patient presented to our clinic for reexamination with deterioration in the UDVA to 1.0 logMAR (20/200 Snellen) and in the corrected distant visual acuity of 1.0 logMAR (20/200 Snellen). Using a slit lamp, the swelling of the corneal endothelium and proliferation of lens epithelial cells crawling over the surface of the IOL could be clearly seen. Meanwhile, the IOL was in positive position, without any tilt or decentration, and the near segment was located in inferonasal orientation .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1541_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1541_en.txt
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index 0000000000000000000000000000000000000000..faae5f14cb042f1f53a70c0da9aba8eb3e550d67
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1541_en.txt
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+A 2 months old male infant was taken to Emergency Department Soebandi Hospital with abdominal distention and bilious vomiting. The symptoms were present after the left inguinal hernia appear and could not be reduced for 12 h before. A left inguinal hernia was present from two weeks old and could be reduced spontaneously before. An early banana diet was given to the patient one day before the symptoms appear. No other food was given except breast milk.
+From the physical examination, we found abdominal distention with hypertympanic and increasing bowel sound as a sign of intestinal obstruction . We also found a sign of dehydration. Radiology examination found an obstructed bowel with caecum visualized at left inguinal hernia .
+Fluid resuscitation and nasogastric tube decompression were performing followed by broad-spectrum antibiotics. Then the patient planned to a herniotomy. During the operation, we found left-side incarcerated Amyand’s hernia with appendicitis and erythematous caecum. No perforation was performed. We also found sticky banana mass to support the suggestion of early banana diet as a predisposing factor .
+Then we perform an appendectomy, reposition of the caecum to the abdomen, and ligation of the sac. It has a good result. There was no postoperative complication. It has a good functional bowel and the patient could take oral breast milk gradually increase. The patient’s parent was satisfied with this treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1545_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1545_en.txt
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index 0000000000000000000000000000000000000000..672f0841640f954bc07eb4a4f1e86dc884db7857
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1545_en.txt
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+A 51-year-old Japanese woman presented to our facility for her regular physical examination. Chest radiographs showed pleural wall thickening on the right side of the apex and upper lung field, which had been seen for several years on her annual regular examinations . She had had a mild dry cough for two weeks without symptoms of a common cold such as sore throat and fever. She was a smoker (20 cigarettes per day for 20 years). She had no history of lung disease, such as bacterial pneumonia or pulmonary tuberculosis.
+A chest high-resolution CT scan was performed for detailed examination and showed multiple nodular lesions (mostly GGOs) throughout the lung fields, approximately 1cm or less in diameter, which were not detected on chest radiographs . No cystic lesions, pleural effusions, or mediastinal lymph node swellings were observed. Bone sclerosis lesions were detected at Th3, Th6, and the first costal bone . The findings seen on the right side of the upper lung fields on chest radiographs were evaluated as old inflammatory changes based on the chest CT scan; their etiology seemed to be different from the multiple nodular GGOs (data not shown).
+Our patient was referred to our hospital for further investigation and treatment. The differential diagnoses of the lung GGOs were atypical adenomatous hyperplasia (AAH), highly differentiated adenocarcinoma in situ (AIS), lymphoproliferative disease, and MMPH. Her physical findings were normal. Breath sounds were normal, and no rales were heard on chest auscultation. No skin lesions such as facial angiofibroma and hypomelanotic macules were observed. A neurological examination showed no abnormalities. She had no intellectual disability and no history of epilepsy or other diseases. There was no family history of TSC. There were no abnormal laboratory test results at the time of her first visit to our hospital. Arterial blood gas analysis results were also normal. Pulmonary function tests were normal except for a mild decrease in diffusing capacity for carbon monoxide (DLCO).
+To further investigate the multiple nodular lung lesions, video-assisted thoracoscopic biopsies of the left upper lobe (S5) and the left lower lobe (S9) were performed. The lesions were found to be tinged white on macroscopic examination . Microscopically, the nodules were well demarcated and consisted of papillary growths of hyperplastic type II pneumocytes accompanied with nuclear inclusion bodies and fibrous thickening of alveolar septa accompanied with increased elastic fibers, resulting in the collapse of the alveolar space . Elastica van Gieson staining revealed increased elastic tissue fibers in the lesions . No cystic lesions were detected. Human Melanoma Black (HMB)-45-positive cells, a characteristic feature of LAM, were not observed on immunohistochemical staining (data not shown). These histological findings were consistent with MMPH.
+A subsequent CT scan suggested that there were bilateral renal angiomyolipomas . Brain magnetic resonance imaging (MRI) demonstrated multiple high intensity areas of cortical and subcortical tubers . All of these findings, including bone, kidney, and brain manifestations, are typical features of TSC , and the latter two findings are major diagnostic criteria for TSC .
+Finally, from the comprehensive assessment including the histological findings of lung nodular lesions and the CT and MRI findings of TSC, such as renal angiomyolipoma, cortical and subcortical tubers, and vertebral bone sclerosis, our patient was diagnosed as having TSC with MMPH, though she had no typical classical manifestations of TSC such as seizures, mental retardation, skin lesions, or a family history of TSC. Our patient is now under routine follow-up with no medication, and is asymptomatic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1572_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1572_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..89941fa5388f15bfe6aeeeb96109c7f95da01de6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1572_en.txt
@@ -0,0 +1 @@
+A 38-year-old man (height, 172 cm; body weight, 120 kg; body mass index, 37) experienced chest discomfort 3 weeks ago, which improved within few days. However, after that episode, he was admitted with rapidly deteriorating severe breathlessness in a preshock state with acute heart failure. The patient had a smoking habit and hyperlipidemia. Electrocardiography revealed abnormal Q waves and slight ST elevation in the aVl, V1, V2, and V3 leads. However, laboratory findings demonstrated creatine kinase (CK) and CK-MB levels within the normal range. Echocardiography revealed aneurysmal enlargement in the anterior wall and moderate-to-massive pericardial effusion, and severely reduced wall motion of LV. Emergency coronary angiography demonstrated an occluded left anterior descending artery (LAD; Fig. ). Circulatory support with an intra-aortic balloon pumping (IABP) catheter was started because of unstable hemodynamics. Enhanced computed tomography showed extensive aneurysm formation on the anterior LV wall and contrast from the inner cavity to the LV myocardium, with moderately accumulated pericardial effusion . Emergency surgery was performed, and his blood pressure ranged 80 to 90 / 50 to 60 mmHg, with 40 mmHg for PA and 20 mmHg for CVP. After the median sternotomy, bloody pericardial effusion (400 ml) was drained, and cardiac tamponade was relieved. A large aneurysmal formation was noted on the anterior LV wall, slightly attached to the pericardium . Cardiopulmonary bypass (CPB) was established with an ascending aorta and bicaval cannulation. After dissecting the pericardium, a 5-mm, slit-like LV rupture site was found in the aneurysm, which caused cardiac tamponade . Following cardiac arrest by antegrade cardioplegia, the middle aneurysm portion was dissected parallel to the LAD. The anterior myocardium comprised intramyocardial heavy and flesh hematoma and necrotic myocardium . Of note, the anterior and posterior papillary muscles were not involved. After removing the hematoma and debriding the necrotic tissue, the anterior wall defect measured 10 × 7 cm. Traction sutures were placed at each anticipated closing line. Then, two sheets of bovine pericardial patch were tailored to the anterior wall defect shape, which was 5 cm × 10 cm. The LV defect was closed using the patch with transmural interrupted mattress sutures to avoid excessive reduction in the ventricular volume . Subsequently, the ventricular edge was closed with interrupted sutures using two Teflon felt strips to reinforce the suture from the outside . A second running suture was used to ensure a secure left ventriculotomy closure, and another Teflon felt strip was placed in the middle of the edge . Cardiopulmonary bypass was easily weaned. He was extubated the following day, and the IABP was smoothly removed. Postoperative echocardiography revealed an improvement in LV function (LVEF:40%), without mitral regurgitation. Postoperative cardiac magnetic resonance image revealed a well-reconstructed LV. He was discharged without any complication 3 weeks postoperatively. The LV aneurysmal rupture site specimen was sent for pathological study . Pathological findings showed myocardial necrotic tissue with cellular infiltration within the aneurysmal wall, consistent with a pseudo-false aneurysm, which was contained by the elements of the ventricular wall .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1595_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1595_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d291770f874bc6d267687b3cce0bd85b0d82e818
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1595_en.txt
@@ -0,0 +1,4 @@
+In May 2019, a 27-year-old man visited our hospital complaining of a palpable periumbilical mass that had been presented for longer than 4 months. Enhanced computer tomography (CT) of the abdomen showed multiple masses in the pelvic and abdominal cavities that involved the intestine, liver, and ureter. Multiple lymph node metastases were also identified with moderate ascites . CT-guided biopsy suggested by multiple disciplinary team was performed and revealed DSRCT and immunohistochemistry test showed Des (+), CD56 (+), EMA (−), CK7 (−), SMA (−), S-100 (−), Ki-67/MIB-1(+, 20%), supporting the diagnosis of IADSRCT . As complete resection could not be obtained due to the extensive metastasis, systemic therapy was recommended by a multidisciplinary team (MDT).
+Combined chemotherapy (vincristine 2 mg D1, epirubicin 100 mg D1, ifosfamide 2000 mg D1-5 and mesna 400 mg t.i.d D1-5, q3w) was started in July 2019. The patient also received anlotinib at an initial dosage of 12 mg, once daily, 2-week on/1-week off. After two active cycles, abdominal CT indicated a partial response (PR) (according to the RECIST version 1.1) as multiple masses were largely reduced . However, the patient suffered grade 3 treatment-related adverse events (TRAE) including hematochezia . Anlotinib was discontinued due to concerns relating to the safety profile. Meanwhile, patient received oral carbazochrome sodium sulfonate, loperamide hydrochloride, as well as Chinese medicine, Yunnan Baiyao. With these active managements, hematochezia stopped 3 days later and continuous fecal occult blood tests were negative .
+Considering the regression and necrosis of the tumor, as well as the anti-VEGFR effect of anlotinib that may have led to hematochezia, the dose of anlotinib was adjusted to 8 mg, once daily, 2-week on/1-week off and re-started in the third cycle. After the dose adjustment, hematochezia disappeared and the combined treatment was well tolerated. A total of 6 cycles were administrated and a follow-up CT scan indicated continuous PR (according to the RECIST version 1.1) .
+Aggressive surgery requiring colostomy and ureterostomy was recommended by the MDT which has a serious impact on quality of life (QOL). The young man refused surgical resection and received anlotinib as maintenance therapy. During maintenance therapy, the most common grade 3 TRAE (according to the CTCAE version 5) were proteinuria and hypertension, especially on the first 14-days of the continuous dose schedule. Notably, when anlotinib was discontinued for 7 days, the symptoms regressed. Based on this response, a 1-week on/1-week off regimen was adopted (8 mg, once daily). The dose reduction and active management of toxicities resulted in the maintenance therapy being well-tolerated. A follow-up abdominal CT in August 2020 indicated continuous PR (according to the RECIST version 1.1). Treatment with anlotinib was continued without grade 3 or 4 TRAE. However, the latest abdominal CT in June 2021 suggested progressive disease (PD) (according to the RECIST version 1.1). As the patient refused to restart chemotherapy, immunotherapy combined with anlotinib was recommended.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_15_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_15_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1349910bad4f80ffbf0d58dacd3e205e583cea1e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_15_en.txt
@@ -0,0 +1,7 @@
+In November 2018, a 51-year-old Caucasian male presented with worsening dyspnoea over 6 months, and lower leg oedema, orthopnoea, and paroxysmal nocturnal dyspnoea. His exercise tolerance was limited to 40–50 m. He denied any chest or abdominal pain, palpitations, or syncope. He did not report history of smoking, excessive alcohol consumption, or drug use including marijuana, cocaine, and amphetamines.
+His past history included urosepsis nine years prior (March/April 2009) and a cerebrovascular event 6 months prior (April 2018). In March 2009, the patient presented with right upper quadrant pain, abdominal distension, and worsening dyspnoea. He was subsequently diagnosed with pyelonephritis. A CT scan identified a 4 mm calculus within the bladder near the left vesicoureteric junction. Notably, this CT scan did not show any cardiac changes. It was complicated by renal failure which required short-term haemofiltration. His serial blood films showed neutrophilia and a leucoerythroblastic appearance with marked left shift. A follow-up CT scan in April 2009 showed cardiomegaly, moderate pericardial effusion, and unusual diffuse LV mid-myocardial calcification. His transthoracic echocardiogram showed mildly dilated LV and moderate systolic dysfunction without significant pericardial effusion; LV ejection fraction (LVEF) was not objectively quantified. Due to preoccupation to attend his urosepsis during the admission, the abnormal cardiac findings were not followed up. He had no cardiac symptoms until he presented with a cerebrovascular event in April 2018. A large LV apical thrombus was detected on his transthoracic echocardiography.
+His main abnormal physical examination finding during his heart failure presentation in November 2018 was bilateral below-knee pitting oedema. There were signs of respiratory distress. He had a heart rate of 80 beats/min, blood pressure of 140/90 mmHg, respiratory rate of 18 breaths/minute, SpO2 98% on room air, temperature of 37.0°C. He was not overweight. There were no peripheral signs of infective endocarditis, respiratory disease, or hepatic disease. His praecordial examination revealed a non-displaced apex beat, with no palpable thrills or right ventricular heave. His auscultation revealed S1 and S2 heart sounds, with no added sounds, murmurs, or lung crepitations.
+His electrocardiogram (ECG) on admission showed evidence of left atrial enlargement, pathological inferior Q waves, and no acute T wave or ST segment changes. It was unchanged compared to his earlier ECG in April 2018 . The serial cardiac troponin levels were normal. His cardiac CT showed signs of mild coronary artery disease without significant stenosis, but diffuse LV mid-wall myocardial calcification. His LVEF was quantified at 20% based on his transthoracic echocardiogram.
+Secondary causes of non-ischaemic cardiomyopathy were investigated for and were found to be normal. Serological tests for sarcoidosis showed normal serum angiotensin converting enzyme level, calcium, and phosphate levels. Serological screens for autoimmune pathologies with known cardiac complications were normal. These include extractable nuclear antigens, antineutrophil cytoplasmic antibodies, lupus, and anticardiolipin antibodies. Investigations for microbes including Legionella pneumophila/longbeachae antibodies, Mycoplasma pneumoniae antibodies, Chlamydia antibodies, hepatitis B virus (HBsAg), hepatitis C virus (HCV antibodies), HIV antibody/antigen combo were negative.
+The patient was diagnosed with non-ischaemic cardiomyopathy and commenced on valsartan/sacubitril 24.3/25.7 mg BD, spironolactone 12.5 mg OD, frusemide 40 mg BD, atorvastatin 40 mg OD, bisoprolol 5 mg OD, and warfarin. His subsequent CMRI in October 2019 showed LVEF of 34% and diffuse LV mid-myocardial late gadolinium enhancement suggestive of scarring in the corresponding wall with myocardial calcification as visualized on his CT images from March/April 2009 .
+Since the November 2018 admission, he has adhered to appropriate antifailure medical therapy and maintained New York Heart Association class II functional status. In April 2020, he still maintains New York Heart Association class II functional status, and because of his persistent reduced LVEF, he received a prophylactic implantable cardioverter-defibrillator.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1608_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1608_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fda61d041307f2c6701dacda2f1e902c728b9a36
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1608_en.txt
@@ -0,0 +1,5 @@
+A 62-year-old woman was confirmed to have liver dysfunction due to HCV in other hospitals and was referred to our hospital for the treatment of HCV. Here, she was treated by interferon/ribavirin therapy for 24 weeks and achieved a SVR. Two years after SVR, a liver nodule that was not pointed out previously was detected in routine abdominal ultrasonography, and the size of the nodule was 11.9 × 6.1 mm. Six months later, the nodule size grew to 12.5 × 7.8 mm, as detected using ultrasonography. Laboratory data on liver function were nearly normal, and the levels of tumor markers such as alpha-fetoprotein, prothrombin induced by vitamin K absence or antagonist II, carcinoembryonic antigen, and carbohydrate antigen 19-9 were also normal. HCV-RNA remained negative.
+Computed tomography (CT) showed a small tumor in the left lobe of the liver. The tumor size was approximately 1.5 cm in diameter , and the tumor showed low density on conventional CT . Dynamic CT revealed early marked enhancement at the periphery of the tumor . From portal to late phase, the tumor showed prolonged enhancement at the periphery and gradual enhancement inside the tumor, revealing slightly lower density relative to the normal parenchyma . Furthermore, 18F-fluorodeoxyglucose positron emission tomography (FDG-PET) showed FDG accumulation inside the tumor and the standardized uptake value maximum (SUV max) was 4.7. Capsule formation and vessel penetration within the tumor were not evident. In addition, there were no findings of lymph node swelling and distant metastasis.
+With magnetic resonance imaging (MRI), the tumor exhibited low and high intensities in T1- and T2-weighted images, respectively . On the other hand, diffusion-weighted (DW) imaging showed remarkably high intensity, and the apparent diffusion coefficient (ADC) value was 1.11 × 10− 3 mm2/s (b value = 1000 s/mm2) . Dynamic MRI using the contrast agent gadolinium-ethoxybenzyl-diethylenetriamine penta-acetic acid showed ringed enhancement in the early phase and became lower in intensity gradually relative to the normal parenchyma in the late phase similar to dynamic CT findings . The tumor exhibited defects in enhancement in the hepatobiliary phase .
+On the basis of these findings, we considered that this hepatic nodule was a malignant tumor and diagnosed this tumor as a CCC or HCC that showed atypical imaging findings. Although we discussed the possibility of it being a metastatic liver tumor, there were no findings to suspect malignant tumors in other organs. Then, laparoscopic lateral sectionectomy of the liver was performed.
+The macroscopic findings of the tumor revealed a white color and a maximal diameter of 1.1 cm. Capsule formation was not observed . The tumor was composed of small cuboidal cells with clear nucleoli and showed irregular anastomosis small grand. The inflammatory cells showed remarkable infiltration, and vascular proliferation and ductular reactions were also seen at the peripheral lesion. . Immunohistochemical findings showed that the tumor cells were negative for Hep-par 1 and positive for cytokeratin (CK) 19 and NCAM . Epithelial membrane antigen (EMA) staining was positive for the membranous side of the lumen . According to these pathological findings, the tumor was diagnosed as a CoCC. There were no events after operation, and the patient was discharged on postoperative day 8 and is alive without recurrence at the time of this report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1666_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1666_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..928399f73676d787f92604e2c64ffb6f5759cbb4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1666_en.txt
@@ -0,0 +1,5 @@
+A 40-year-old man was taken to the local hospital by his office supervisor by foot due to concerns over moving a foreign object impaling his chest (A). As soon as the emergency physician noted that an ice pick was penetrating the man’s left chest, we established an intravenous line while preventing the object from moving from its original position, and an ambulance took the patient to our emergency department.
+On examination, the patient’s general condition was not critical (Glasgow Coma Scale score 15, respiratory rate 24 breaths/min, blood pressure 123/79 mmHg, heart rate 76 beats/min, oxygen saturation 100% on 2 L nasal cannula, and body temperature 37.2 °C). The patient would not reveal the actual cause of the injury. An interview with his family disclosed no history of depressive disorder, pharmacological treatment, substance use, or alcohol abuse, but the patient had a history of several pneumothorax injuries, one 10 years prior and two a year prior to this episode. In all episodes, he had been hospitalized for several days for chest drainage and discharged without any complications. Considering his condition, we strongly suspected a self-inflicted injury. However, our patient denied any suicidal ideation, depressive mood, or hopelessness. His family members described him as a quiet and gentle person who did not behave impulsively.
+Cardiovascular auscultation was unremarkable without murmurs or gallops. Chest X ray demonstrated a clear lung field without pneumothorax or hemothorax (B). Emergency echocardiography disclosed a small amount of pericardial effusion without cardiac tamponade. Computed tomography (CT) of the chest showed linear metallic density in the pulmonary trunk and a small amount of pericardial fluid (A–D). Pneumothorax or bulla was not seen on chest CT. Based on the diagnosis of penetrating cardiac injury, we transferred the patient to the operating theater after cardiac surgery consultation.
+We placed the patient in the supine position. After performing a full median sternotomy, the pericardium was opened. There was a small amount of pericardial effusion that seemed to be mixed with blood. The ice pick had been stuck in the main pulmonary artery (MPA) through the pericardium without any injury to the left lung or internal thoracic artery. Heparin was given and cardiopulmonary bypass (CPB) was commenced with ascending aortic and bicaval cannulation. The patient was cooled down to 32 ° Celsius. After aortic cross clamping, the cardioplegia was infused into the aortic root to obtain cardiac arrest. A longitudinal incision was made in the MPA, and we carefully removed the foreign body, which was lodged through the MPA from the anterior to posterior wall near the annulus of the pulmonary valve without injury to the left main coronary trunk. The holes made by the ice pick were closed using 5-0 polypropylene suture. The MPA was closed using 4-0 polypropylene over and over running suture. After rewarming and deairing, the aortic clamp was removed. The patient’s sinus rhythm came back spontaneously. CPB weaning was smooth, and protamine was given. The chest was closed in a normal fashion. Postoperative recovery was uneventful.
+A police investigation showed no criminal events associated with the injury. Although the patient denied stabbing himself with the ice pick, we strongly suspected the penetrating cardiac injury was self-inflicted and consulted the psychiatric department on day 7 to closely monitor the patient during hospitalization. During the psychiatric counseling sessions after the surgery, the patient continued to stubbornly deny a suicide attempt. At 16 days POD, the patient was discharged to home without psychiatric follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1682_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1682_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b441c9acda783924e87129658613bfa74dbd526
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1682_en.txt
@@ -0,0 +1,3 @@
+A 21-year-old male patient was admitted with 1 month history of intermittent high grade fever. He also complained of weight loss, loss of appetite, generalized body weakness and hair loss. He was not on any long term drug treatment. On clinical examination, he appeared unwell, was febrile at 38.5ºC with mild pallor.
+He also had a painful oral ulcer with bilateral cervical and right axillary nontender lymphadenopathy but there was no hepatosplenomegaly or bone tenderness. Other system examinations were unremarkable. Laboratory evaluation revealed normochromic normocytic anaemia (hemoglobin 9.9g/dl, RBC 3.9×1012/L), leucopenia (white cell count 2.06×109/L) and thrombocytopenia (platelet 75×109/L). Aspartate transaminase was 64.2 U/L, alanine transaminase 86.7 U/L, GGT 244.4 U/L (normal range 15–55 U/L) and lactate dehydrogenase was 757U/L (230-460 U/L). Alkaline phosphatase, serum albumin and bilirubin levels were normal. Erythrocyte sedimentation rate (ESR) was 55mm in 1st hour and C-reactive protein (CRP) was 3.8mg/L (<6).
+Serum ferritin increased at 1174.36ng/mL (20–159 ng/mL). Coagulation profile was normal. Urea, creatinine and urinalysis were normal. Infection screen for Epstein-Barr, cytomegalovirus, hepatitis B, hepatitis C and HIV viruses was negative. Toxoplasma gondii IgG antibody was positive with negative IgM. Blood and urine cultures were negative. Malarial parasites were not detected. Mantoux test was negative. The autoimmune profile revealed increased levels of double stranded (ds)-DNA antibody 133.3 IU/L (>46.1 IU/L is positive), C3 level was 46.1 mg/dL (normal range 90-180 mg/dL). Anti-nuclear antibody (ANA) was positive. Chest x-ray, electrocardiogram, echocardiogram and abdominal ultrasound were normal. Cervical lymph node biopsy revealed chronic reactive lymphadenopathy without neoplastic lymphoid cell proliferation. There was a reactive bone marrow. The diagnosis of SLE was made according to the American Collage of Rheumatology (ACR) diagnostic criteria, as he fulfilled four criteria including hematological involvement, oral ulcer, positive ANA and ds-DNA antibody. He was started on oral prednisolone 1mg/kg daily treatment. He made a dramatic clinical and biochemical improvement within one week and was discharged. He was reviewed at medical clinic regularly and corticosteroids were tailed off gradually. Currently, three months after the diagnosis, he is being managed with low-dose prednisolone, hydroxychloroquine and osteoporosis prophylaxis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1727_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1727_en.txt
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index 0000000000000000000000000000000000000000..346a701f457ca6ed78251ca0be141767af4b2116
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1727_en.txt
@@ -0,0 +1,2 @@
+A 69-year-old man was hospitalized with transient loss of consciousness due to severe anemia and melena. He had previously suffered from thromboangitis obliterans and had undergone revascularization of his lower extremities. Upper gastrointestinal endoscopy showed two lesions. One 15 mm-sized depressed lesion was present in the lesser curvature of the cardia . Biopsy diagnosed poor differentiated tubular adenocarcinoma. As evaluated by endoscopic ultrasound, the tumor had invaded the submucosa and surgery was necessary. The other lesion was present on the posterior wall of the body in the stomach, and a biopsy of this ulcer scar was diagnosed as suspected gastric cancer . Lower gastrointestinal endoscopy revealed a circumferential type 2 tumor in the sigmoid colon . The tumor was 38 cm from the anal verge. Biopsy revealed moderately differentiated tubular adenocarcinoma. The lumen was narrowed by this tumor, but the scope managed to pass. Preoperative computed tomography (CT) showed no swollen lymph nodes around the gastric lesions. The sigmoid colon had thickened walls and increased concentration of surrounding adipose tissue, but no swollen lymph nodes around the sigmoid colon lesion in preoperative CT . There was no distant metastasis to the gastric cancer or sigmoid colon cancer. Preoperative diagnosis was T1N0M0 Stage I (UICC 8th Edition) for two gastric cancers and T4aN0M0 Stage II B(UICC 8th Edition) for sigmoid colon cancer. The lesion in the body of the stomach was an intramucosal lesion and was singled out for endoscopic treatment, but preoperative treatment was not performed because of a lack of time. The symptoms of sigmoid colon lesions began to appear. We have had a policy of total gastrectomy for removing two gastric cancers.
+Preoperative CT and blood vessel construction using 3D image analysis software SYNAPSE VINCENT® (Fujifilm, Tokyo) showed artificial blood vessels under the skin . There was a bypass vessel from the left axillary artery to the left femoral artery under the skin on the left side of thoracoabdominal region. Furthermore, there were three bypass vessels from the left external iliac artery to the right femoral artery under the skin of the lower abdomen. Two of the three bypasses were occluded. In the blood flow to the intestinal tract, the inferior mesenteric artery was already occluded. Peripheral blood flow in the common iliac artery depended on blood flow from the artificial blood vessel, and blood flow from the internal iliac artery to the rectum was poor. Blood flow in the anal intestinal tract after excision seemed to be poor, and anastomosis was judged to be at a high risk of leakage. We have a policy of using laparoscopic Hartmann’s surgery. Port and stoma sites were decided by heeding the position of the artificial blood vessels. The port sites on the left were located more inside than usual. First, the stomach was resected, and the stump was evaluated pathologically. There was no tumor residue on the stump. Next, the sigmoid colon was resected before reconstruction . And then stomach reconstruction was performed by Roux-en-Y reconstruction. The jejunum was lifted anterior transverse colon pathway. Finally, the stoma was made in the lower left abdomen. The operation time was 11 h and 24 min. The blood loss volume was 74 ml. Postoperatively, fever was observed at 9 days after the operation, and CT showed pancreatic fistula (grade B). The patient improved with antibiotics. He was discharged at 21 days after the operation. The pathological diagnosis showed that there was another lesion in the stomach. It was unknown before the operation. In the end, there were three lesions. One was a submucosal invasion, and the others were intramucosal cancers. All were Stage I. Sigmoid colon cancer was T3N0M0 Stage II A. Two years have passed since the operation and there has been no recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1755_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1755_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7986d6a765ee0e39a5aa189412a5615115a72b1e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1755_en.txt
@@ -0,0 +1,4 @@
+A 62-year-old woman was found to have an elevated serum CA125 level of 50 U/ml (normal < 35 U/ml) at a local hospital in November 2018. Her serum CEA and CA19-9 levels were within normal limits, and no obvious abnormalities were found on transvaginal ultrasound (TUS). In November 2019, at the same hospital, her CA125 level had increased to 75 U/ml. TUS performed at the local hospital revealed a large pelvic mass.
+She was then referred to our hospital for further diagnosis and treatment. Laboratory test results, including assessment of tumour markers, routine reproductive hormone examination and routine blood tests, were within the standard levels. The patient was asymptomatic, and a physical examination revealed no abdominal mass. The patient’s family history indicated that the patient’s mother died from ovarian cancer.
+Abdominal computed tomography (CT) revealed a right adnexal well-circumscribed hypodense mass . On a contrast-enhanced CT scan, slight enhancement of the mass was noted and a fluid–fluid level sign was observed. Routine and contrast-enhanced MRI demonstrated well-defined lobulated cystic mass in the right pelvic cavity that was approximately 4.9 × 4.8 cm in size . The mass was of mixed signal on T2-weighted imaging (T2WI) and T1-weighted imaging (T1WI). Nodular hypointensity on both T1WI and T2WI was observed within the lesion. Diffusion weighted imaging (DWI) showed severe hyperintensity. A fluid–fluid level sign was also observed in the cystic mass. The patient was suspected of having a chocolate cyst according to the clinical CT and MRI results. Routine preoperational TUS showed a right adnexal mass with a size of approximately 5.6 × 4.4 × 5.5 cm. Conventional ultrasound showed a well-defined cystic mass with mural and septal nodules. The largest size of internal papillary excrescences was 3.0 × 1.4 × 1.7 cm. Doppler flow could be detected in the internal septation, cystic wall and papillary excrescences. The resistive index of the cyst wall was 0.9. The right ovary was visible. There was no ascites. Considering the appearance and features on TUS, a primary diagnosis of malignant neoplasm was made. To further clarify the nature of the lesion, the patient underwent a CEUS examination, during which 2.4 ml of ultrasound contrast agent (SonoVue; Bracco SpA, Milan, Italy) was injected from the peripheral vein by bolus injection. Hyperenhancement of cystic wall, septations, and papillary excrescences were observed in the arterial phase on CEUS. The mass becomes hypo-enhancement in the late phase. The mural-nodule-like solid component measured approximately 1.7 × 1.7 cm and the smaller one 0.5 × 0.5 cm . Based on the contrast ultrasound results, the diagnosis of cystadenocarcinoma was first considered.
+Surgical resection of the retroperitoneal mass was performed. During the operation, a mass approximately 5 cm in diameter was found in the Douglas cul-de-sac. It was soft and had no obvious adhesion to surrounding tissues. The tumour was cystic and solid, the cyst wall was thick, and the cyst contained solid tissue. Both ovaries and fallopian tubes are normal. Frozen biopsy showed (pelvic) adenocarcinoma, mainly with papillary growth. Da Vinci robot-assisted laparoscopic pelvic tumour resection was conducted. Expert pathologists with more than 10 years of experience determined the pathologic results. Grossly, the tumour was multi-cystic, well-encapsulated and filled with serous fluid. The inner surface contained several papillary nodules protruding into the cavity. Under microscopic examination, the tumour tissues were arranged in a papillary shape; a glandular tube, invasive growth, haemorrhage and necrosis were observed. The tumour cells were abnormally shaped, nuclear division was visible, and nucleoli were obvious. The immunohistochemistry results were as follows: CK20(−), CK7(−), p53(+), CA125(+), CDX2(−), PAX-8(+), ER (+), PR(−), WT(+), calretinin CR(−) and vimentin(+) . The final pathological finding was high-grade serous adenocarcinoma. The patient’s serum CA125 levels decreased after the operation, but the level was slightly higher than the normal range (< 35 U/ml). The patient was treated with a combination of adjuvant carboplatin and paclitaxel (544 mg carboplatin and 268 mg paclitaxel intravenously every 3 weeks) at 3-week intervals for eight cycles. After two cycles of chemotherapy, her serum CA125 level decreased to a normal level. The patient has completed all chemotherapy cycles and is now in good condition. Her serum CA125 level has remained within the normal range as of publication of this report. Written consent was obtained from the patient for publication of the case.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1775_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1775_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..61c63d616ff7afa7c529338ec370cadc2e6dd293
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1775_en.txt
@@ -0,0 +1,3 @@
+A 5-year-old girl initially presented to our department due to worsening pain in the left proximal thigh. Osteosarcoma was suspected radiographically . Open biopsy revealed a high-grade conventional osteosarcoma. The tumor was initially staged as IIB (T2b N0 M0), and neoadjuvant chemotherapy was commenced in accordance with the NECO-95J protocol . After three cycles of neoadjuvant chemotherapy, the pain was alleviated, the extra-osseous mass was dramatically reduced, and limb-salvage surgery was planned. As the tumor had already invaded the epiphyseal plate and epiphysis of the left distal femur at initial presentation, osteo-articular resection was thought necessary so as to obtain a negative surgical margin. At 6 years and 2 months old, distal femoral resection and temporary spacer insertion was performed . Both medial and lateral meniscuses were preserved. The spacer was hand-made, using an intramedullary nail of 7 mm in diameter and molded polymethylmethacrylate (PMMA). Because there were no commercially available molds fitting the distal femur of such a young child, we made the spacer by hand, imitating the original distal femur of the patient that had been just removed. After surgery, the left leg was externally fixed in a cast for 4 weeks. Partial weight bearing on the affected leg, supported by a hinged knee brace, was thereafter commenced ; however, the spacer was dislocated at 7 months post-operatively, preventing the patient from bearing weight and leading to bone atrophy in the left leg .
+At 7 years and 8 months old, secondary surgery was performed with the aim of enabling weight bearing on the affected leg. In order to stabilize the spacer against the tibia, a custom-made ceramic spacer (Kyocera Corp., Japan) with a smooth straight stem of 8 mm in diameter had been ordered 3 months prior to the surgery . Intra-operatively, after the removal of the initial spacer, a 1-cm length of the distal edge of the residual femur was removed, but the periosteum and reactive membrane around the molded PMMA was preserved. The junction between the residual femur and the ceramic spacer was fixed with PMMA, and then covered with the preserved periosteum and membrane . After surgery, the left leg was placed in a cast for 4 weeks, after which the patient re-started partial weight bearing using a hinged knee brace as with the first spacer. The bone atrophy in the left leg was gradually resolved. At 18 months after the second surgery, the cortexes of the femur and tibia had thickened sufficiently for expandable mega-prosthesis; however, loosening of the stem and varus deformity was observed . A third surgical intervention was, therefore, planned.
+At 9 years and 7 months old, the second spacer was removed, and the knee joint was reconstructed using a custom-made growing femoral prosthesis (Stryker Corp., Germany) with a curved porous stem of 8.5 mm in diameter fixed to the residual femur with two screws . Intra-operatively, the PMMA around the junction was already loosened, and the stem was easily removed. The residual femur was carefully reamed, and the stem was inserted. Cancellous bone chips from the proximal tibial epiphysis were grafted around the bone-prosthesis junction and then wrapped with the preserved periosteum and pseudo-periosteum membrane. The proximal surface of the tibia was also replaced, but the growth plate was preserved. Immediately after surgery, range of motion (ROM) exercise was started. Six weeks after surgery, partial weight bearing was permitted. Ten months after the third surgery, the patient was able to walk unsupported, and a radiograph showed further thickening of the cortex of the residual femur . At 10 years and 7 months old, the growing femoral prosthesis was extended by 1.1 cm. At the latest follow-up, at 11 years and 1 month old, the patient was 143 cm in height with a limb length discrepancy (LLD) of 5 cm and was able to walk unsupported using a 2.5 cm shoe lift (Video ). The Musculoskeletal Tumor Society (MSTS) score was 24 out of 30 points . The muscle strength of quadriceps recovered to manual muscle test (MMT) level 3, and active straight leg raising became possible without extension lag. The ROM of the left knee was 0–90°. The patient was receiving a second extension of growing femoral prosthesis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_177_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_177_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec9ec17881c77c2011c9bff5ee488ac02a4e7d7b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_177_en.txt
@@ -0,0 +1,3 @@
+Six years after an uncomplicated cesarean delivery of a first child and one year after being diagnosed with CML, a 37-year-old woman presented to our institution at 36 weeks of gestation with worsening fatigue associated with abdominal discomfort.
+The couple had rejected the option for medical-assisted abortion during the first trimester and, due to her low risk of CML progression determined by an European Treatment and Outcome Study (EUTOS) score of 86 , her hematologist opted for imatinib cessation, which was given initially at a dose of 400 mg per day, during the first and second trimester. She received interferon-α in the later half of pregnancy. Response to treatment was assessed regularly and at the end of 35 weeks she was found to have a palpable spleen (increased from 4 cm to 8 cm below the lower left costal margin) and leukocytosis at 245,000WBC/mm3 including 32% blast cells. Platelet count and hemoglobin concentration were within normal ranges. Bone marrow aspiration was performed and the patient was diagnosed with CML in acute phase. Cytogenetic analysis of the bone marrow cells by using the Giemsa Banding technique revealed the karyotype 46,XX,t(9,22)(q34;q11.2) in 100% of the analyzed cells without any additional abnormality. FISH analysis was not performed.
+Due to the significant deterioration and urgent need for chemotherapy initiation, cesarean delivery was planned for the end of 36 weeks, which was uneventful under general anesthesia. The rate of circulating blasts made the choice of general anesthesia mandatory and judicious rather than a risky perimedullary anesthetic technique. The newborn was healthy and did not require any medical interventions. Postoperatively, she received a multimodal analgesia and an effective thromboprophylaxis. Afterwards, she was started on treatment with imatinib, 800 mg daily, without any satisfactory response. Because of disease progression, the patient received hydroxyurea as palliative treatment with partial response.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1806_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1806_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..26715fcd6ad0f06a3561499f52338074b366924f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1806_en.txt
@@ -0,0 +1,5 @@
+A 40-year-old female presented with chronic headache with infrequent exacerbations. She presents with worsening headache for three months with associated vertigo, nausea, and vomiting not responding to analgesics or vestibular sedatives. Her symptoms initially started twelve years ago as a diffused mild headache, which persisted through the day. Gradually, the headache worsened to a severe headache episodically associated with vertigo, nausea, and vomiting. These episodes lasted for two to three days and got resolved. She was treated with flunarizine for suspected basilar migraine but did not show any response. From the last year, she had monthly exacerbations of headache associated with distressing vertigo, unsteadiness of gait, and right-sided body numbness. In between these episodes, she had a significant dull diffuse headache not responding to simple analgesia. She did not complain of fever or night sweats but had constitutional symptoms lasting for several months. All of these symptoms severely affected her daily activities and functionality.
+During the last 17 years, she had repeated episodes of neurological deficits. Even before the headache appeared, she has presented with visual impairment of the right eye and right lateral rectus palsy and was treated as retrobulbar neuritis with good response to methylprednisolone. One year later, she developed left-sided visual impairment, which fully responded to methylprednisolone. MRI imaging at that time revealed normal results. Few months after this event, she got admitted with right hemisensory loss with hemiplegia, and a demyelination disease or hemiplegic migraine was suspected. Second MRI was performed at this admission, and no abnormalities were detected again. Eight years ago, she had developed a left lower motor type facial nerve palsy, which was attributed to Bell's palsy. Within the last year, she was diagnosed to have depression and anxiety for which she was treated for few months. Other than the first two instances, she was not treated with steroids thereafter. She did not complain of weight loss and did not have constitutional symptoms or chest symptoms during these periods.
+On examination, she is an averagely built female with a BMI of 23 kg/m2. She is afebrile, pale, and did not have lymphadenopathy. Her GCS was 15/15, and she was conscious and rational with normal pupillary response, visual acuity, visual field examination, and fundoscopy. There was no neck rigidity, and she had residual left lower motor VII palsy. She had an ataxic broad-based gait with unsteadiness. Upper and lower limb examination is clinically normal. Her respiratory, cardiovascular, and abdomen examinations were unremarkable.
+Investigations revealed a hemoglobin count of 9 g/dL with normal white cells and platelets. ESR was elevated to 86 mm/1st hour. Renal- and liver-related biochemical investigations were normal with an alkaline phosphatase within the normal range. Initial MRI scans of the brain done 10 years ago did not reveal any abnormalities such as demyelination, optic nerve enhancement of focal lesions in the cerebrum, or cerebellum. CSF examination revealed an elevated protein level of 55 mg/dl with normal glucose and cells with negative oligoclonal bands or TB-PCR. Vasculitis investigations including ANA, ANCA (ELISA and Immunofluorescence), and RF were negative. Syphilis serology and HIV testing were also negative. Chest radiograph, ultrasound abdomen, and CT scan of chest and abdomen did not reveal any mediastinal lymphadenopathy or focal lesions in visceral organ or evidence of any malignancy. Serum ACE levels (19 µ/l) and ionized calcium levels were normal. We performed a new MRI scan of the brain with contrast, which revealed a diffuse and patchy meningeal thickening and enhancement mainly in the right frontoparietal and left occipital regions with a minor enhancement of bilateral optic sheaths . Her NMO antibodies were normal, and the MRI did not show any areas of demyelination. Therefore, she underwent a dural biopsy from the thickened dura, which revealed large areas of caseous necrosis surrounded by epithelioid histiocytes and lymphoid cells with a few isolated giant cells in the adjacent vicinity . There were no features of vasculitis or sarcoidosis. TB-PCR of tissue and acid-fast bacilli were negative. Final conclusion was necrotizing granulomatous inflammation suggestive of dural tuberculosis. This diagnosis was presumed by the presence of necrotizing granulomatous necrosis with caseation with a strongly positive Mantoux test of 25 mm , and later was supported by a marked response to antituberculous medication.
+We initiated her on antituberculous therapy (all four drugs for 3 months and 9 months of rifampicin and isoniazid) without streptomycin as she is already having vestibular symptoms. Steroids were added concurrently (1 mg/kg) and was continued for 6 weeks and was tailed off over a month. She experienced a marked improvement of her headache, and she could do her daily activities normally. After a year of anti-TB medication and follow-up, she did not complain of any worsening of symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1810_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1810_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..30a141aadd0c576925dad75977230e940861294e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1810_en.txt
@@ -0,0 +1,3 @@
+It was a second pregnancy of 34-year-old women with obesity and primary hypertension. High blood pressure of maximum values 170/100 mmHg was treated with methyldopa in increasing doses, trimetazidinie, dihydrochloride and low dosage acetylic acid. Ultrasound exam at the 13th week of gestation was normal with NT 2,2 mm, and at 20 weeks of gestation there was reported normal fetal biometry and normal heart anatomy. At the age of 34th week of pregnancy, woman was admitted to hospital because of high blood pressure and abnormal Doppler flow in fetus. No echocardiography exam was available. Antenatal corticosteroids were given once three days before birth with magnesium sulfate for fetal neuroprotection and lung development stimulation.
+In a district hospital, a male neonate was born at 34 weeks of gestational age by C-section because of increased risk for birth asphyxia, based on abnormal cardiotocography (CTG) tracing .
+The preterm boy had birth weight 2600 g and had head circumference and length in normal values range of 50–90 centiles. Due to respiratory distress syndrome, nasal Duo positive airway pressure was performed for the first two days of postnatal life. The chest x-ray excluded pneumonitis, the heart size was in normal values. Laboratory findings show increasing C-reactive protein concentrations in the following days. A third day at the physical exam, his heart rate was 220/bpm. ECG has shown the supraventricular tachycardia with a narrow QRS atrial rate (AR) was equal to ventricular (VR) and was 220/min. Adenosine was administered twice- first dose 0,15 mg/kg, second dose 0,25 mg/kg. But arrhythmia remained resistant to these therapies. However, ECG detected for a short time atrial tachycardia (atrial rate 420/min, ventricular rate 45-65-70/min). Therefore, amiodarone therapy was started- 5 mg/kg. Echocardiography revealed patent foramen ovale, tricuspid valve regurgitation with a 29 mmHg gradient and mild mitral regurgitation. The ejection fraction (EF) was 62%. Because of unsuccessful treatment, the newborn was transferred from the district hospital to hospital with a Paediatric Cardiology Department on day 3. Next ECG demonstrated supraventricular tachycardia with narrow QRS (220/min) . The administration of adenosine (0,1 mg/kg) resulted in the obvious appearance of “sawtooth wave” typical for AFL . After a while, ECG demonstrated supraventricular tachycardia (SVT), exactly 3:1 atrioventricular conduction AFL (atrial rate 500/bpm, ventricular rate 250/bpm). Due to the recurrence of AFL, cardioversion was performed with 1 J/kg and the rhythm converted to normal. Amiodarone therapy with a dosage of 15 mg/kg/day was started as a prophylaxis against recurrent arrhythmia attacks. After 24 h without the AFL attack, intravenous amiodarone therapy was replaced with oral treatment. SVT did not occur and the infant was discharged on the 23rd day of life in a good general state with amiodarone oral therapy. AFL did not repeat in the 1-year follow up and corrected QT (QTc), Holter ECG and echocardiography (ECHO) were all found to be normal. Therefore, therapy was stopped.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1818_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1818_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d6f7fb9e0477ee9481fecb6726bd3b8a2478957a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1818_en.txt
@@ -0,0 +1,3 @@
+A 59-year-old man with no related medical history presented to the emergency room with chest pain and syncope. On admission, he showed signs of hypovolemic shock with paleness, sweating, low blood pressure (BP) of 62/36 mmHg, poor peripheral perfusion, and acutely deteriorating anemia (blood level of 12.3 d/dL on first check and 9.5 d/dL on the second) check; he was alert at this time.
+Electrocardiography and chest radiography showed no significant findings. After fluid resuscitation, contrast-enhanced computed tomography (CT) showed that the middle and distal third of the splenic artery were fully replaced by an aneurysm (10 cm in maximum diameter), with active contrast extravasation into the aneurysm. It was packed into the posterior wall of the stomach. The stomach showed significant expansion with mud fluid . Subsequently, we suspected a splenic artery pseudoaneurysm that had ruptured into the stomach. A nasogastric tube was inserted to aid in the prevention of vomiting and aspiration because we suspected UGI bleeding. Bright red blood (300 mL) was drawn using the tube. At that time, he lost consciousness showing a rapid drop in BP of 54/37 mmHg, HR70 again. In total, 4 units of red blood cells (RBCs) and 2 units of fresh frozen plasma (FFP) were administered, and while preparing to move the patient to the operating room, the systolic BP stabilized to > 100 mmHg. Laparotomy was performed immediately. The aneurysm was located in the distal part of the splenic artery, adhering to the body of the pancreas. Its wall densely adhered to the posterior wall of the stomach covered with necrotic slough around that was the ruptured root of the splenic aneurysm to the stomach . The pancreas was mobilized along with the splenic artery from the retroperitoneum, and a tape was passed around the body of the pancreas to enable bleeding control and the ligation of the splenic artery. After dissecting the body–tail of the pancreas, we performed a distal splenopancreatectomy including the aneurysm and partial gastric resection . The total durations required for the surgery and general anesthesia were 212 min and 292 min, respectively. The intraoperative fluid balance was + 440 mL with an estimated blood loss of 1950 mL, including gastric clots and the urine output of 340 mL. Intraoperatively, 6 units of RBCs and 2 units of FFP were transfused.
+The postoperative vitals of the patient stabilized immediately and his general condition improved quickly. He was discharged from the hospital on the 42nd postoperative day, after waiting for decrease in the pancreatic fistula output and the removal of the drainage tube. The pathology of the resected specimen showed a splenic artery aneurysmal sac eroding into the gastric mucosa. The surrounding gastric mucosa did not show any malignant evidence, but exhibited the destruction of the elastic fibers of the vessel wall, suggesting pseudoaneurysm of the splenic artery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1842_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1842_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..be15ee283f8d49757e82934a7b573b9d9b757b17
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1842_en.txt
@@ -0,0 +1,9 @@
+A 47-year-old man, with a history of appendicectomy as a child and a severe trauma of the left hemithorax, left hypochondrium and left flank three years from the current presentation was admitted in the Department of Gastroenterology for nausea, repeated vomiting, epigastric pain, and intermittent constipation for over a month. He also had acid regurgitation and pyrosis, as well as loss of appetite and a significant weight loss in the past six months. Physical examination revealed a firm, palpable abdominal mass in the left hypochondrium and left flank.
+Laboratory tests showed low iron serum level (46 μg/dL) and leukocytosis. Upper endoscopy described a deformed stomach with an extrinsic compression especially on the antrum, which made difficult the passage through the pylorus. There was no significant distention of the gastric body on insufflation and no mucosal abnormality.
+We performed an abdominal ultrasound (US) and highlighted a heterogeneous mass with tissular and cystic components, extended from left hepatic lobe (LHL) to the spleen’s hilum. Contrast-enhanced ultrasonography (CEUS) pointed out that the tissular component of the tumor was enhanced in arterial phase and presented a wash-out phenomenon in the late phase. The cystic and necrotic components were unenhanced .
+Since we could not define the point of origin, we scheduled a contrast-enhanced abdominal computed tomography (CT). The CT scan described a heterogeneous tumor of 17×15×14 cm containing numerous necrosis and cystic areas with origin in the fundus and greater curvature of the stomach, with extraluminal development . The tumor was causing a mass effect on the stomach, spleen, splenic vein, and enveloping the body and pancreatic tail. Thus, we suspected it was a GIST with necrotic areas.
+Due to tumor size and gastric outlet obstruction symptoms, we proposed the patient for surgery. A xypho-umbilical approach was chosen, and the peritoneal cavity was opened. The giant tumor occupied most of the upper abdominal cavity with adherence to the gastric wall. After the gastro-colic ligament was sectioned, tumor appurtenance of the great gastric wall, and infiltration of the tail of the pancreas and splenic pedicle were confirmed. No hepatic or peritoneal metastases were found, and the rest of the abdominal organs seemed macroscopically normal. En bloc surgical removal of the tumor was decided including with adjacent lymph nodes, spleen, and pancreas tail. The pancreas tail was sectioned 5 cm proximal from the splenic pedicle. The tumor block included the greater curvature of the stomach, which was consecutively sealed with a linear stapler.
+Macroscopically, the resected piece measured 23×17×10 cm, while the tumor had 22×10 cm with many cystic and necrotic areas. For HP examination, tumor fragments were embedded in 10% formalin for 24 hours and included in paraffin according to current protocols. Classical staining with Hematoxylin–Eosin (HE) described similar characteristics of a mesenchymal tumor, with spindle-shaped cells with high mitotic rate [over 5 mitoses/50 high-power fields (HPFs)], with an 86% risk of progression (PT4Nx).
+In the thickness of the muscular tunic of the gastric wall, a partially encapsulated tumor proliferation was noted, with a pseudonodular appearance, composed of fusiform cells, with hypertrophic nuclei, with unevenly arranged chromatin with karyorrhexes and mitoses. The cells were arranged in a fasciculate pattern, with myxoid, hemorrhage, and necrosis areas . Neoplastic proliferation invaded only the submucosa, did not affect the gastric mucosa, and did not invade adjacent splenic or pancreatic parenchyma. The mitotic rate was high, >5 mitoses/50 HPFs. Free margins (R0), no evidence of perineural invasion, lymph node, or peritoneal metastasis was noted.
+For IHC, we used an antibody algorithm by the labeled Streptavidin–Biotin and horseradish peroxidase (HRP) methods . IHC staining revealed that tumor cells were strongly diffuse positive for CD117/c-kit , CD34 , and DOG1 . SMA and neuron-specific enolase (NSE) were variable focal positives in tumor proliferation . The Ki67 proliferation rate was positive in more than 5% of the tumor cells in 50 HPFs and the S100 protein was negative.
+The patient was successfully discharged and underwent oncology follow-up with Imatinib, with no relapse a year after surgical resection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1861_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1861_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..362c7ed9f1c254476367ad3335e6bf009a30e71b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1861_en.txt
@@ -0,0 +1,6 @@
+This study was conducted under the approval of the ethics committee of the Third Hospital of Hebei Medical University, and the protocol accorded with its standards.
+This patient was a 52-year-old man who was admitted to our hospital due to low back pain 2 weeks ago. The symptom of low back pain did not improve after bed rest. He was a chronic smoker for the past 20 years and quit smoking for 5 years. Twenty-nine months previously, he underwent right radical nephrectomy not followed by local radiotherapy. Histopathology of the nephrectomy specimen revealed a CCRCC. No recurrence or distant conversion was found in intermittent reexamination. A routine physical examination revealed a body mass index = 19.27 kg/m2 (reference <25) with significant conjuctival pallor but no organomegaly. His blood pressure, pulse rate, respiratory rate, and body temperature were all in the normal range. He had no hypertension, heart disease, diabetes, any infectious disease, or drug allergy history.
+Six months ago, he fell down accidentally during work and later developed lumbar pain. He went to the local hospital for computed tomography (CT) examination, which showed lumbar compression fracture, and received local physical therapy. Later, he felt that his symptoms were better than before. However, he had low backache for the last 2 weeks without cause. At day 1 after admission, the lumbar CT revealed expansive bone destruction in the vertebrae and appendages of the 11th thoracic vertebra and the first lumbar vertebra, bone cortex thinning, and local continuity interruption, accompanied by soft tissue mass formation and vertebral canal compression . Multiple spotty abnormal signals were seen in the cervical vertebra, thoracic vertebra, lumbar vertebra, and sacrum by magnetic resonance imaging (MRI), which were both low signal on T1-weighted imaging and high signal on T2-weighted imaging, accompanied by mass formation in the 11th thoracic and first lumbar vertebrae and appendages . Diffusion weighted imaging (DWI) of vertebral showed scattered high signals, and they were low signals on the corresponding apparent diffusion coefficient (ADC) imaging . Pathological fractures were seen on multiple vertebrae suggestive of metastasis of bone or MM.
+A routine laboratory examination showed that red blood cells and hemoglobin were decreased. Leukocyte and platelet count were normal. Total protein and globulin increased, while albumin decreased. His serum β 2-microglobulin was 4.59 µg/mL (ref. 0.9–2.7), M protein was 45.79 g/L, and IL-6 was 28.871 pg/mL (ref. <10). Five items of myeloma detection showed that IgG (70 g/L, ref. 7.51–15.6) and immunoglobulin k light chain (KAPPA, 94 g/L, ref. 6.29–13.5) were increased, and immunoglobulin A (IgA; 0.515 g/L, ref. 0.82–4.53), immunoglobulin M (IgM, 0.253 g/L, ref. 0.4–2.74), and immunoglobulin M light chain (LAMBDA, 1.16 g/L, ref. 3.13–7.23) were decreased. Immunotyping of lymphoma (including plasma cell tumor) was abnormal. Serum-free light chain assay showed that elevated serum free kappa was 832.5 mg/L (ref. 3.3–19.4). Blood calcium was reduced, and blood phosphorus was normal. Bone marrow aspiration was MM. Alkaline phosphatase (ALP) was normal .
+The patient had symptoms of lumbar nerve compression, and surgery was the first choice in clinical practice to relieve the symptoms of nerve compression, but he had anemia. Before surgery, anemia must be corrected and immunotherapy and targeted systemic therapy must be performed. According to the above results, bone marrow aspiration and CT-guided vertebral biopsy were performed to make a definite diagnosis. Pathological examination showed the coexistence of myeloma with CCRCC in hematoxylin and eosin (HE) staining . There were monomorphic cells with clear cytoplasm and an intricate network of capillary vasculature in the CCRCC site. The variegated areas of atypical plasma cells infiltrated in CCRCC. There was no clear distinction between the two components. The CCRCC cells were positive for carbonic anhydrase IX (CA-IX), cytokeratin-8, and paired box gene 8 (Pax8); however, the myeloma cells were positive for CD38, CD138, multiple myeloma oncogene 1 (MUM1), and kappa and negative for lambda.
+He received radiotherapy and immunotherapy and acquired a satisfying outcome. The patient recovered well after treatment and was followed up for 12 months during the whole treatment course. The symptom of back pain was significantly relieved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1864_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1864_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2522173aea63030e1dd1394de1146e64e4fef1c6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1864_en.txt
@@ -0,0 +1,9 @@
+The index patient was a 16-year-old girl in the second year of junior middle school in Zhejiang Province, China, who has experienced persistent cough and expectoration for 37 days since 1 March 2014. She tested positive for smear pulmonary TB and extrapulmonary TB (TB of the cervical lymph nodes) on 8 April 2014 (see Table ). She was subsequently suspended from school and treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z) since 9 April 2014, with the dosages of these medications dependent on patient’s weight (see Table ). During the treatment period (9 April 2014–8 November 2015), the index patient visited the local TB-designated hospital for further consultation every month and was followed up once a month by the local community health service center. However, the Mycobacterium tuberculosis isolate was resistant to H/R/E/S based on the results of the drug susceptibility test (DST) on 1 May 2014.
+On 19 May 2014, the index patient was treated with regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide (see Table ). On 17 July 2014, as she experienced heel pain, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide. On 1 January 2015, the chemotherapy program was adjusted to regimens of propylthioisonicotinamide, pyrazinamide, and pasiniazide.
+On 14 November 2016, she was subsequently cured according to the results of the laboratory smear and X-ray examination. During the treatment period, the sputum smear test results were negative in June, September, and October 2014.
+Based on the interview conducted on the index patient, her classmates and teachers were her primary close contacts. Local health authorities conducted a contact investigation in April 2014. All potential contacts were screened by performing the tuberculin skin test (TST), and close contacts with positive TST results and with induration larger than 5 mm were diagnosed with MDR-TB . The index patient’s two family members all had negative TST and X-ray examination results. There was no history of TB in her family. All 54 (49 classmates and five teachers) individuals with close contact with the index patient in the same class were screened during 12–15 April 2014, and five of these contacts had positive TST results. However, these five individuals refused to receive preventive anti-TB treatment. The five TST-positive contacts in our investigation had been consistently followed up, and based on the follow-up result, TB infection was no longer observed in the next two years in these five patients.
+In April 2016, two student patients (P1 and P2) tested positive for smear pulmonary TB in different high schools. P1 has persistently experienced the symptoms of cough and expectoration since 15 January 2016 and has left school because of winter vacation since 21 January 2016. P1 tested positive for smear pulmonary TB on 2 April 2016 and experienced hemoptysis, with multiple cavities in the lung parenchyma. His M. tuberculosis isolate was resistant to H/R/E/S based on the results of his DST on 22 June 2016. P2 has persistently experienced the symptoms of cough and expectoration since 12 March 2016, and she tested positive for smear pulmonary TB on 5 April 2016. She also experienced hemoptysis during that time. The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 19 June 2016. They were suspended from school since 3 April 2016 and 6 April 2016, respectively, and were initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z), with the dosages of medications dependent on the patient’s weight. Subsequently, the chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to their DST results. All 56 (50 classmates and six teachers) individuals who were in close contact with P1 were screened through X-ray examination and TST during 6–8 April 2016. Moreover, all 58 individuals (52 classmates and six teachers) who were in close contact with P2 were screened during 7–11 April 2016. No other cases of TB or infection were observed.
+On 2 February 2017, one student (P3) from another high school tested positive for smear pulmonary TB. P3 had persistently experienced symptoms of cough and expectoration since 1 December 2016. The M. tuberculosis isolate was resistant to H/R/E/S based on the results of her DST on 20 May 2017. She was also suspended from school since 22 February 2017 and was initially treated with chemotherapy comprising isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z), with the medication dosages dependent on the patient’s weight. Subsequently, the chemotherapy program was adjusted to regimens of moxifloxacin, propylthioisonicotinamide, amikacin, pyrazinamide, and pasiniazide according to the patient’s DST results. All 51 (46 classmates and five teachers) individuals with close contact with the patient were screened through X-ray examination and TST during 22–24 February 2017, and 14 of these 51 patients had positive TST results.
+Through a retrospective epidemiological investigation by local health authorities, there were no histories of TB in the patients’ families, although three student (P1, P2, and P3) patients clinically diagnosed with MDR-TB were from three different high schools in Lanxi City. However, they attended the same junior middle school and the same class as the index patient. Furthermore, they sat together in the classroom. The index patient sat in the middle of them, P1 was in the front of her, and P2, P3 were on her right and left side. Moreover, two of these patients (P2 and P3) lived with the index patient in the same dormitory , and their exposure time to the index patient was approximately 37 days. Although they all had negative TST and negative X-ray examination results at that time, the drug resistance patterns of the four patients diagnosed with pulmonary TB were identical (resistant to H/R/E/S). Their average discovery delay was 55 days.
+After further retrospective epidemiological investigation, we learned that the index patient had evident risk factors for MDR-TB transmission. Epidemiological links were categorized into neighborhood environments. The neighbors (N1, N2, and N3) living around the index patient were all diagnosed with TB in 2011, 2012, and 2013, respectively . N4, who was the wife of N2, was diagnosed with TB in July 2015. Four neighbors of the index patient experienced treatment failure due to irregular treatment, and three of them did not undergo further DST investigation. All neighbors were initially treated with regimens of isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z). Only N2 was diagnosed with MDR-TB and treated with regimens of moxifloxacin, propylthioisonicotinamide, ethambutol, pyrazinamide, and pasiniazide according to the patient’s DST results (resistant to H/R/E/S). However, he still experienced treatment failure due to the adverse effects of the medications and the heavy economic cost of treatment.
+Isolated strains from four patients (index patient, P1, P2, P3) were sent to Zhejiang Provincial Center for Disease Prevention and Control for repeat drug sensitivity tests and gene typing tests . Variable-number tandem repeats of mycobacterial interspersed repetitive unit loci were used to genotype the strains. When 15 site combinations were used, the TB strains of four patients were clustered. The results showed that four patients had homologous transmission (see Fig. ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1883_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1883_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4cf0be028c21cbc4de9f98c0d5973f71f38c59b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1883_en.txt
@@ -0,0 +1,5 @@
+A 32-year-old Iranian man with an unremarkable medical history presented with the chief complaint of a lump on the dorsal ulnar side of his right hand and wrist. He first noticed his symptoms approximately one month earlier. The patient reported that the mass had been there for one month and had been growing steadily over the previous month. There was no prior trauma history or constitutional symptoms, and his past medical, and family history was otherwise unremarkable. He noted some swelling in the left dorsal area but no fever, chills, or pain. Furthermore, in part of his social history, he did not abuse alcohol, drugs, or cigarettes. Also, at the time of admission, his vital signs were in normal range (pulse rate = 75, blood pressure = 118/83, temperature = 36.7, O2 saturation = 98%). In addition, as Table depict all patient’s laboratory findings except 25-Hydroxy Vitamin D3 were normal. Thus, for his low level of 25-Hydroxy Vitamin D3, supplement medication (a tablet of Vitamin D3 1000 mg daily) was started.
+Standard hand-wrist radiographs were taken to rule out any foreign body or fracture.
+There was no evidence of bone involvement, and no foreign bodies or breaks in any cortical margins were noted. The primary physician clinically suspected the case as a ganglion cyst during that period. After receiving conservative treatment (a tablet of Naproxen 500 mg when he suffers from pain) for 2 months, the size of the lesion gradually increased. On clinical examination, a mass of size 30 × 20 mm was found between the second and third metacarpal bones of the dorsal surface of the left hand, extending up to the proximal of the metacarpal bones and the distal part of the wrist joint. Moreover, in terms of neurovascular examination patient did not have any significant abnormalities, despite the tumor size. The patient could flex and extend his wrist suitably. His deep tendon reflex was normal. Moreover, his sensation and precipitation were literally acceptable. As well, his muscle power was 5 out of 5. In addition, Magnetic Resonance Imaging (MRI) was performed, and the image was reviewed by a radiologist. The image revealed a hypersignal lesion in T2 that was iso to a hypersignal lesion in T1 in the deep soft tissue of the middle and medial side of the hand in the 3rd and 4th web with encasement of the 4th metacarpal bone. The lesion was suggestive of a cystic structure with fine internal septation and heterogeneous signal intensity. A deviation of the flexor tendon was observed due to the mass effect of this lesion. Additionally, displacement of the extensor tendon of the hand was observed in the 3rd, 4th, and 5th fingers .
+With the patient under local anesthesia, an excisional biopsy was performed, which revealed a gray gelatinous, loose mass adhering to the lumbrical and interosseous muscles and invading the carpometacarpal joint. The mass was excised in total and sent to the pathology laboratory for review.
+Unfortunately, the patient had poor follow-up and did not return to the clinic after 2 months when he reported a recurrent lesion at the same location . Furthermore, in that follow-up, he brought the pathology report which revealed synovial sarcoma (biphasic). Considering the pathology report, abdominal—pelvic, and thoracic CT scans were requested for him and the result of the aforementioned images was literally normal. The patient was referred to an orthopedic oncologist. As a part of patient treatment, amputation was also suggested to the patient However, the patient refused to start his treatment and had no more follow-ups.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1903_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1903_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..04965de0aa258f5abaae70286165c4b266f9d35d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1903_en.txt
@@ -0,0 +1,6 @@
+A 56-year-old woman came to medical observation in our Hospital in September 2016 on the grounds of heartburn, nausea, vomiting, muscle weakness, and profuse fatigue for 3 weeks.
+The patient’s medical history included iron deficiency anemia, hypertension, menopause for 4 years, and chronic autoimmune thyroiditis. Multiple sclerosis, first diagnosed in 1989, had been treated with Azathioprine, Betaferon, Natalizumab with disappointing results. Over time, her disease had progressively more frequent relapses, necessitating repeated courses of steroids. Owing to the poor efficacy of the treatment, our patient adhered to a non-conventional management schedule based on oral supra-physiological cholecalciferol dosages (the Coimbra protocol).
+In January 2015, before starting vitamin D integration, serum levels of calcium (2.38 mmol/L) and phosphorus (1.06 mmol/L) were normal, while 25OH-vitamin D levels were very low (12.25 nmol/L) . Concurrently, there were high levels of intact parathyroid hormone (PTH) (108 pg/mL) with normal renal function (creatinine 61.61 µmol/L, estimated glomerular function rate (eGFR)> 60 mL/min), which suggested hyperparathyroidism secondary to vitamin D deficiency . Cholecalciferol supplementation was started with an initial oral dose of 70,000 UI/day. In March 2015, normal calcium-phosphorus metabolism and renal function were documented, while 25OH-vitamin D serum concentrations were already above the upper limit of the normal range (>375 nmol/L) after only 2 months of therapy, with a cumulative dose of 4,200,000 UI of cholecalciferol. Although serum vitamin D levels were above the normal range, the dosage of cholecalciferol supplementation was progressively increased as follows: 100,000 UI/day from March 2015 to July 2015, then 140,000 UI/day to April 2016, and finally up to 160,000 UI/day. At subsequent examinations performed during 20 months of treatment, the biochemical pattern remained quite stable, except for a progressive reduction of PTH, until September 2016, when she entered our inpatient Clinic .
+At admission, the patient had normal vital signs, diffuse abdominal pain, and dehydration of mucous membranes and skin. Heart rhythm was normal. Hypercalcemia (3.23 mmol/L) and acute renal injury (serum creatinine 220.05 µmol/L, eGFR 20 mL/min) were identified. The suspicion of vitamin D intoxication was confirmed by the very high levels of 25OH-vitamin D (920 nmol/L) assessed by a chemiluminescence assay (Diasorin, Inc., Stillwater, MN). Accordingly, PTH was below the normal range (6.7 pg/mL, normal range 15-88 pg/mL). Routine chest and abdomen X-rays were negative. Moreover, bone mineral density (BMD) was evaluated upon intoxication by Dual-Energy-X-ray-Absorptiometry (DXA) (DXA, Hologic-QDR-2000 densitometer, Inc., Waltham, MA). According to the World Health Organization (WHO) criteria , T-scores at the lumbar spine (L1 to L4) and total hip were defined as normal (i.e. T-score > -1.0), and BMD did not significantly differ over time compared to a previous DXA performed in 2014, before the start of vitamin D integration.
+Vitamin D integration was immediately stopped and high-flow hydration (physiological solution 170 cc/hour), intravenous diuretics (furosemide 40 mg/day), and steroids (hydrocortisone 200-300 mg/day) were administered. Serum calcium returned to normal in a week and renal function gradually improved.
+In April 2017, i.e. six months after the discontinuation of cholecalciferol, serum calcium remained within the normal range (2.43 mmol/L), renal function returned to normal (creatinine 79.22 µmol/L, eGFR >60 mL/min) and PTH levels increased (46.7 pg/mL), while 25OH-vitamin D levels were still high (787.50 nmol/L). It took about 18 additional months to observe 25OH-vitamin D concentrations below the intoxication threshold of 250 nmol/L in May 2018 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1904_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1904_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e8225d1d59e12671247e44eb542016d447c3c847
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1904_en.txt
@@ -0,0 +1,4 @@
+The present case is a 71-year-old male patient who had a laparoscopic radical cystoprostatectomy and ileal conduit for muscle-invasive bladder cancer (pathological stage T4aN2Mx). During the perioperative period, a foley catheter was used as traction and as a drain through the urethral route, and the catheter was removed on the 4th postoperative day. The patient’s past medical history does not reveal chronic disease, including diabetes. Also, his renal function test and other laboratory parameters were within normal limits. The preoperative clinical lymph node status was N0. The intraoperative blood loss was minimal, and no blood transfusion was needed. Enoxapirin was used for one month postoperatively. Two weeks postoperatively, the patient presented with yellow-white discharge from the meatus and bruising in the glans around the meatus . Physical examination revealed glandular necrosis. Appropriate antimicrobial therapy (Meropenem + Teicoplanin + clindamycin ) was initiated after the patient’s admission. Initial laboratory investigation revealed an elevated white blood cell count (12,420ng/dl), and CRP (19.9), while other parameters were within normal limits.
+The urethral discharge culture showed an E.coli, Klebsiella pneumonia, and Enterococcus faecium. Colistin and Tigecycline antimicrobial therapy were started after infectious disease consultation.
+Surgical exploration was planned for the patient, as there was no improvement on the 9th day of the antibiotic therapy. During the procedure, it was observed that the necrosis was not limited to the glans. The necrosis had spread to the entire penile urethra and corpus spongiosum, and an excision of approximately 14 cm of corpus spongiosum was performed .
+The postoperative period was uneventful, and the patient was discharged on the 6th postoperative day . The pathology findings reported no malignancy and showed dıffuse hemorrhage and necrosıs of the urethra and extendıng to the surrounding tıssues. Glans necrosıs, ulceratıon, hemorrhage and chronıc ınflammatıon were also reported.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_190_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_190_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc2f9a87376bf1e86d14e12314c64be994c51d41
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_190_en.txt
@@ -0,0 +1,5 @@
+Ms XF is a 31 year old Caucasian female who has a diagnosis of uncontrolled asthma which has required repeated admissions over approximately ten years . She is otherwise well with no significant co-morbidities.
+Her usual medications are inhaled Salbutamol, Fluticasone accuhaler, nebulised Salbutamol, Salmeterol, Monteleucast 10 mg, Theophylline 300 mg bd, Vitamin D3 and Lansoprazole.
+The patient was admitted with a history of cough with green sputum, wheezing and shortness of breath over three days. Initially she treated herself with Salbutamol inhalers and nebulised bronchodilators without improvement. She continued to deteriorate and in A&E she was treated with "back to back" salbutamol nebulisers and transferred to ITU. On admission she had no evidence of hypoxia, infection and hypovolemia as evidenced by clinical examination along with invasive monitoring and investigations such as blood gases, FBC, CRP, and CXR.
+In ITU she complained of worsening breathlessness, despite an objective improvement in peak expiratory flow rate and wheeze. Her arterial blood gases at that time showed a compensated metabolic acidosis with high lactate. We excluded all common causes of a metabolic acidosis in this clinical setting including hypoxia, hypovolemia and sepsis. We suspected that the lactic acidosis may have been secondary to nebulised salbutamol, and consequently reduced the dosing interval. This resulted in a reduction in the serum lactic acid level. When the nebulised salbutamol was subsequently stopped the lactic acidosis promptly reversed . The patient was transferred to the ward and discharged home uneventfully.
+In this particular patient, salbutamol and its resultant metabolic acidosis caused us difficulty in assessment and management of her asthma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1921_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1921_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f852bc99f95df1fe5243fae699280555f559dcd7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1921_en.txt
@@ -0,0 +1,7 @@
+A 70-year-old female patient was admitted to the Department of Cardiology due to complaints of repeated dizziness over a 10-year period and shortness of breath and cough for 1 year. These symptoms progressed over a 1-mo period.
+The patient was transferred from the Cardiology Department to the Respiratory Department due to recurrent cough, fever, and multiple lesions identified on computed tomography (CT) in both lungs. Physicians recommended fiberoptic bronchoscopy for further diagnosis. Two hours after completion of the operation, the patient complained of exacerbation of left arm numbness and weakness. The skin of the left upper extremity was found to be cyanotic, muscle strength decreased to grade 3, and the left brachial artery pulsation was not detectable. B-mode ultrasound examination of the blood vessels revealed hyperechoic material in the left subclavian artery, axillary artery, brachial artery, and parallel veins . Based on the patient’s symptoms, history of rheumatic heart disease, and ultrasound images, we diagnosed embolism in the left upper extremity. As our hospital has no vascular surgery capability, the patient was transferred on the same day to a specialized hospital for an emergency thrombectomy. A tracking investigation found that the patient’s conditions improved after successful thrombectomy. The numbness in the left upper limb disappeared, and muscle strength and skin color returned to normal.
+The patient had a history of rheumatic heart disease at age 10 years with hypertension as high as 160/110 mmHg, which was well controlled through oral amlodipine tablets.
+The patient had no pertinent family history.
+Vital signs of the patient appeared stable during bronchoscopy, except for minor coughing. Blood pressure was 128/80 mmHg, heart rate was 80–105 beats/min with signs of AF, peripheral capillary oxygen saturation (SpO2) was 95%–98%, respiratory rate was 20 breaths/min, and temperature was 36.5°C, 2 h after the examination. The patient complained of numbness in the left arm and difficulty stretching the fingers of her left hand. Her skin in the left upper extremity was cyanotic; muscle strength decreased to grade 3; and the left brachial artery pulsation was not detectable.
+Five coagulation tests on the first day of admission revealed a prothrombin time (PT) of 13.6 s, an activated partial thromboplastin time (APTT) of 23.4 s, a thrombin time (TT) of 16.6 s, an international normalized ratio (INR) of 1.19, and fibrinogen (FIB) levels of 5.12 g/L. Emergency coagulation tests after bronchoscopy showed a PT of 12.3 s, an APTT of 22.7 s, a TT of 17.2 s, and an INR of 0.89. The FIB concentration was 6 g/L (reference range 2–4 g/L), D-dimer was 8.13 mg/L (reference range 0-0.55 g/L), te potassium level was 3.36 mmol/L (reference range 3.5–5.3 mmol/L), lactate dehydrogenase was 439 U/L (reference range 90–250 U/L), and troponin I was 0.216 g/L (reference range 0.006–0.06 g/L).
+Color doppler ultrasound indicated the presence of rheumatic heart disease, moderate mitral valve stenosis, and moderate insufficiency, left atrium enlargement, decreased left ventricular diastolic and systolic function, moderate tricuspid valve regurgitation, severe pulmonary hypertension, and minor pericardial effusion. Chest CT detected multiple nodules and exudative lesions in both lungs, as well as local swelling of the left upper lung lobe. The bronchoscopy examination detected branch stenosis in the anterior segment of the right upper lobe, chronic inflammation in the right upper lobe, and inflammatory infiltration in the upper apicoposterior segment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1927_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1927_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..121c3c0b28818d48e2417027647e0d6b4bba86ed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1927_en.txt
@@ -0,0 +1,2 @@
+A 28-year-old fit male soldier was brought by his family to Emergency Department (ED) with a history of severe headache, neck pain, nausea, and vomiting, which were associated with behavioral changes in the past 2 days. His symptoms started 2 months ago after lifting a heavy object when he developed neck pain associated with a severe headache that increased in severity over time. He has visited the ED twice before this time, and he was only investigated by a cervical spine X-ray with no brain images; then, he was discharged on analgesia and an outpatient department clinic appointment. As his symptoms did not improve with time, he went to an uncertified chiropractor for neck pain, asking for a neck therapy session, after which his symptoms increased in severity. As the headache became unbearable after the therapy session, he went to a hospital and did a brain computerized tomography (CT) which showed bilateral SDH [ and ]. There was no history of trauma, loss of consciousness, or seizure. He was not on any chronic medications, anticoagulants, or antiplatelets. The patient had a negative history of bleeding tendency, no constitutional symptoms, and an unremarkable systemic review. He was a nonsmoker with no history of alcohol or drug abuse. He had a negative family history of a brain aneurysm and bleeding disorders. On assessment, he was vitally stable, afebrile, conscious, alert, and oriented; however, he looked depressed and agitated. He had an abnormal involuntary repetitive extension movement involving his little fingers bilaterally that started 2 days ago. The rest of the neurological examination was unremarkable. All laboratory investigations were normal. CT angiography, magnetic resonance angiography, and whole spine magnetic resonance imaging did not reveal any identifiable cause that would explain the SDH [, and ]. The patient underwent bilateral mini craniotomies with bilateral subdural drains . A specimen of the SDH external membrane was sent for a histopathology examination, which revealed typical histological findings of the external membrane of the hematoma. The surgery went successfully with no complications or abnormal bleeding. His symptoms improved immediately after the surgery. During his hospital stay, further blood investigations (Blood smear,
+Factor VIII and XIII, and vWF cofactor and Antigen) were done and came within normal ranges. The psychiatry team was consulted, and he was diagnosed with major depressive disorder. Eventually, the patient was discharged home in stable condition and completely resolved symptoms on the 6th-day post-surgery. After 8 months, a follow-up brain CT scan was done, and it showed an interval resolution of the bilateral SDH with no signs of recurrence . The patient had no recurrence of the clinical symptoms and was discharged from the clinic.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1931_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1931_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..12b720f59fc5e7d868ac213f44f88f7ae0ca7f3e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1931_en.txt
@@ -0,0 +1,4 @@
+A 20-year-old woman, gravida 7 para 0060, at 14+3/7 weeks gestation by 8-week ultrasonography with history of depression and bipolar disorder presented to the emergency department (ED) complaining of unremitting nausea and vomiting, exacerbated by oral intake, for the past several weeks. She also reported intermittent hematemesis, epigastric abdominal pain, and mild diarrhea. However, she denied headache, fever, chills, chest pain, shortness of breath, palpitations, or dizziness. She also denied vaginal bleeding and discharge, vaginal bleeding, leakage of fluid, contractions, suprapubic or pelvic pain. She was given IV hydration, ondansetron, famotidine, and metoclopramide but continued to vomit without visible blood. She had mild hypokalemia, which was replaced with intravenous (IV) and oral potassium. She slowly improved throughout her hospital course and was able to tolerate oral intake by hospital day 6. The patient had a two-year history of multiple ED visits for the same issue, for which she was diagnosed with hyperemesis gravidarum and managed with hydration and antiemetics.
+During the following month, the patient returned several times with the same complaints. She was treated again with IV hydration and antiemetics (oral ondansetron and promethazine suppositories), which resolved her symptoms. She was instructed to continue her home doxylamine succinate-pyridoxine hydrochloride and prescribed ondansetron and promethazine prophylactically.
+At 22+4/7 weeks gestation, the patient presented to labor and delivery again with complaint of nausea and vomiting. She reported that she remained free of symptoms for approximately a month with home medications but began vomiting again with inability to keep fluids or solids down for the past 12 hours following consumption of contaminated food. She denied any fever, chills, diarrhea, headache, or blurred vision. She reported good fetal movement and no vaginal bleeding or discharge or contractions. While on the labor and delivery, she continued to vomit with antiemetics (IV ondansetron and promethazine). On the hospital day 2, patient was found in the shower and reported that warm showers are the only relieving factor for nausea and vomiting—concerning for CHS. Urine drug screening (UDS) was performed and was positive for cannabinoids. The patient was informed that this was possibly related to her cannabis exposure. She remained abstinent throughout the hospital stay and was continued on IV fluids and antiemetics. On the hospital day 3, she noted vast improvement and was able to tolerate regular diet. Patient was discharged home with promethazine, ondansetron, and doxylamine succinate-pyridoxine hydrochloride. Patient was counseled on completely discontinuing all exposure to cannabis and voiced understanding. UDS remained negative at subsequent prenatal visits.
+At 40+1/7 weeks gestation, the patient delivered vaginally a live female infant weighing 3.19 kg with APGAR score of 8/9 without any complications. The mother and baby were discharged home on the second postpartum day.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1943_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1943_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e7896213b73bd93a4e2a1286ed120d74ff1a2476
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1943_en.txt
@@ -0,0 +1,4 @@
+A 16-year-old boy was admitted to the local health center for evaluation of dyspnea, cough, chest pain and a body temperature of 39°C. He was normotensive with a heart rate of 115 beats per minute and a respiratory rate of 25 breaths per minute. The complete blood count revealed elevated white blood cells (15.130/μl) and an erythrocyte sedimentation rate of 105 mm. Serum electrolytes, hepatic and renal function tests were normal.
+He reported that the symptoms had occurred after attending a party for teenagers, during which he had consumed a large quantity of alcohol and had an episode of vomiting. He also reported that he had practiced a fire-eating performance during the party using liquid paraffin, without knowledge of inhaling any of it. A chest radiograph showed infiltration in the right middle lobe which was diagnosed as aspiration pneumonia, and he was treated at the local health center with a combination of antibiotics (a macrolide and a second-generation cephalosporin). After 5 days of treatment, because of clinical deterioration, he was referred to a pulmonary clinic.
+Spirometry revealed severe restriction of lung function (a forced vital capacity 68% of the normal value). Arterial blood gas measurements were within normal ranges: pH = 7.38, pCO2 = 36.3 mmHg, pO2 = 98.5 mmHg and sO2 = 97.4%. A chest computed tomography scan was performed, which showed consolidation with an air bronchogram in the right middle lobe, and areas of atelectasis and ground glass opacities in the middle and lower right lobes .
+Bronchoscopy presented inflamed, hyperemic mucosa, especially on the right side. Bronchoalveolar lavage fluid was hemorrhagic and revealed cytoplasmic vacuolation of the macrophages, lipid-laden alveolar macrophages detected by lipid staining and oil-red-O stain, and neutrophilia (23%; Figure ). Owing to the bronchoalveolar lavage fluid findings and the history of fire-eating, the patient was diagnosed with hydrocarbon pneumonitis and was treated with systemic steroids (intravenous prednisolone 25 mg × 2) and intravenous antibiotics. Steroids were prescribed for 21 days: 6 days during the patient's hospitalization followed by tapering doses over the next 15 days. There was significant clinical and radiologic resolution 6 days after treatment was initiated .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1966_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1966_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8abe078c0bea8556d14d893ae257579d11e4be03
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1966_en.txt
@@ -0,0 +1,3 @@
+A 74-year-old Japanese woman gradually developed general malaise and loss of appetite. In addition, arthralgia and pitting edema in her feet appeared. Her laboratory findings revealed an elevated white blood cell (WBC) count and C-reactive protein (CRP). She was admitted to our hospital for further examination. She had an operation for endometrial cancer at the age of 72 and had no family history.
+On admission, her blood pressure was 129/76 mmHg, heart rate was 101/minute, respiratory rate was 18/minute, and body temperature was 39.1 °C. A physical examination revealed pitting edema on the dorsum of her hands and feet. Her neurological examination was unremarkable. However, she had difficulty with squatting and walking because of arthralgia in her proximal lower limbs. Laboratory testing showed a WBC of 11700/μL, CRP of 6.7 mg/dL, erythrocyte sedimentation rate of 44 mm/hour, total protein of 5.8 g/dL, and albumin of 2.3 g/dL. Rheumatoid factor, anti Ro/SSA antibody, anti La/SSB antibody, anti Scleroderma 70 antibody, and anti cyclic citrullinated peptide antibody were negative. Serum interleukin-6 (IL-6) and vascular endothelial growth factor (VEGF) were markedly increased to 285 pg/mL (normal; <2 pg/mL) and 1820 pg/mL (normal; 262±228 pg/mL) , respectively. Her human leukocyte antigen (HLA) typing included B7. A chest X-ray revealed mild pleural effusion on the right side. Electrocardiography showed a complete right bundle branch block without ST-T change. Echocardiography revealed a slight pericardial effusion surrounding her entire heart.
+She had a high fever, general malaise, and muscle weakness, and her laboratory tests revealed elevated inflammatory markers including WBC, CRP, and erythrocyte sedimentation rate. Because infectious disease was suspected, tazobactam-piperacillin 13.5 mg/day was started. On day 2, atrial fibrillation appeared on the electrocardiography monitor. A chest X-ray showed that the pleural effusion had increased in both lungs. Furthermore, echocardiography demonstrated increased pericardial effusion around her heart. On day 3, she developed respiratory failure, and oxygen administration was started by nasal cannula at a dose of 3 L/minute. Enhanced chest-abdominal computed tomography (CT) showed marked bilateral pleural and pericardial effusions without neoplastic lesions . Analysis of the pleural effusion revealed exudate with an increased protein level and neutrophils, but cytological evaluation of the pleural effusion revealed no evidence of malignancy. Cultures of blood and pleural effusion were all negative. Our patient fulfilled the diagnostic criteria of RS3PE syndrome including: 1) pitting edema of the hands and feet; 2) sudden onset of polyarthritis; 3) onset at age 50 years or older; and 4) negative serology for rheumatoid factors . From day 6, she was treated with methylprednisolone administered intravenously at a dose of 1000 mg/day for 3 days. After steroid therapy, her fever rapidly improved, and blood tests revealed a decrease in CRP to 1.71 mg/dL. The pleural and pericardial effusions on chest CT decreased . When the pericardial effusion decreased, her atrial fibrillation disappeared. After steroid pulse therapy, oral prednisolone administration at a dose of 15 mg/day was started. Her respiratory failure immediately improved, and then she no longer required oxygen administration. A chest CT performed on day 38 revealed that the pleural and pericardial effusions had disappeared . On day 45, she was discharged. One year later, the prednisolone dosage was decreased to 8 mg/day, but the patient experienced no recurrence of symptoms. At the 1-year examination, no malignancy was found. Serum IL-6 and VEGF were significantly decreased to 1.3 pg/mL and 562 pg/mL, respectively.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1993_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1993_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ff35f8df19705b1439f2be89d4c1cee35adca890
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1993_en.txt
@@ -0,0 +1,3 @@
+A 14-year-old girl had pain in the left epigastrium for more than 10 d, with no tarry stool, hematemesis, or coma history. She normally liked squatting, and her activity tolerance was low. She was normally developed without positive signs.
+The results of laboratory examinations were as follows: routine blood examination: red blood cell 4.64 × 109/L, white blood cell 4.83 × 109/L, blood platelet 218 × 109/L; blood biochemistry: alanine aminotransferase 36.9 μ/L, aspartate aminotransferase 30.6 μ/L, serum albumin 41.9 g/L, total bilirubin 21.7 μmol/L, direct bilirubin 8.0 μmol/L, PT 12.8 s, international normalized ratio 1.13. Blood ammonia 22.4 μmol/L, lactic acid 3.28 mmol/L. No abnormality was observed in arterial blood gas parameters at resting state.
+CT suggested congenital extrahepatic portacaval diversion (Type Ib Abernethy deformation). The superior mesenteric vein and splenic vein joined to form a short extra-hepatic portal vein that drained into a postcava with left hepatic vein, associated with double pulmonary congestion and pulmonary arterial hypertension. There were multiple space-occupying lesions in the liver, and the size of the relatively large tumor was approximately 50 mm. To exclude malignant tumor transformation, positron emission tomography-CT examination was performed . The results indicated nodules and mass imaging with multiple increased glycometabolism in the liver parenchyma and increased 11C-choline metabolism in some lesions. Multiple focal nodular hyperplasia combined with partial malignant transformation was highly possible. Echocardiography suggested the mean pressure of pulmonary artery at 36 mmHg and light pulmonary arterial hypertension. Pulmonary function examination indicated severe diffusion impairment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1998_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1998_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2b8f1000f45b67046193546ecba8ab842898e7fa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1998_en.txt
@@ -0,0 +1,3 @@
+A 55-year-old female patient who had a 4-year history of type 2 diabetes was admitted to our hospital due to paroxysmal general weakness and acro-anesthesia for one year. Since her diagnosis with type 2 diabetes, she was advised on a low-carbohydrate diet and was prescribed an oral hypoglycemic agent regularly (Repaglinide, 3.0 mg/day). She was then followed up averagely twice a month with fasting plasma glucose (FPG) levels 6.0 ~ 7.0 mmol/L and HbA1c around 7.0% (53 mmol/mol). She denied any prolonged use of laxatives or diuretics, or any episodes of diarrhea or vomiting in recent weeks. Blood pressure and body mass index (BMI) of the patient were 90/70 mmHg and 23.6 kg/m2, respectively. The muscle strength of upper limbs was grade 4, and that of the lower limbs was grade 3. Deep tendon reflexes were weakened. Laboratory findings revealed hypokalemia, hypomagnesemia, metabolic alkalosis. Urinary analysis showed alkaline urine with renal wasting of potassium, sodium and chloride, as well as significantly decreased excretion of calcium (urinary calcium/creatinine ratio 0.04 mol/mol). There was neither haematuria nor proteinuria, while the concentrations of plasma aldosterone and renin activity were both elevated. According to the clinical features and biochemical parameters, the patient was suspected with Gitelman syndrome (GS) and concurrent of type 2 diabetes.
+According to the clinical features and biochemical parameters, the patient was suspected with Gitelman syndrome (GS) and concurrent of type 2 diabetes. After obtaining written informed consent from the patient and her family, Sanger sequencing of SLC12A3 gene was performed. As described in our previous study [, ], twenty-three pairs of oligonucleotide primers were synthesized to amplify all 26 exons and flanking intronic regions of the SLC12A3 gene . Her results demonstrated the patient was a compound heterozygote for a recurrent mutation c.179C > T and a novel deletion c.1740delC , which were predicted as a missense variant p. Thr60Met and a frame-shift variant p.(Met581fs) in protein level respectively. Validation of the two mutations by Sanger sequencing in all family members revealed that heterozygous p. Thr60Met and p. (Met581fs) was present in her son and daughter respectively. Accordingly, the patient was genetically diagnosed with GS.
+One-week of treatment with potassium chloride (3.0 g/d) and magnesium chloride (element magnesium 350 mg/d), her serum potassium and magnesium levels fluctuated around 3.91 mmol/L and 0.65 mmol/L, respectively. General weakness and acro-anesthesia also disappeared and quickly she was discharged. Since then, she was repeatedly sent to local hospital due to hypoglycemic coma (blood glucose 2.2 ~ 2.60 mmol/l). However, both her serum potassium and magnesium levels were normal (3.6 ~ 3.9 mmol/l and 0.7 ~ 0.8 mmol/l, respectively). She denied any change of behaviors including eating habit and physical excise, as well as smoking and drinking. Then, she was admitted to our hospital and the OGTT was performed again , which showed increased insulin secretion level (evaluated by the homeostasis model assessment for β cells (HOMA-β)) and markedly improved insulin sensitivity (evaluated by the homeostasis model assessment for insulin resistance (HOMA-IR)). Although hypokalemia and hypomagnesemia both have effects on blood glucose, we also consider the side effects of hypoglycemia of repaglinide after the magnesium and potassium supplementation. Then the patient was recommended to change the hypoglycemic agent to a dipeptidyl peptidase-4 (DPP-4) inhibitor (Trajenta 5 mg/d). Her blood glucose level was maintained at 6 to 9 mmol/L during the follow-up of two years.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_19_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_19_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fa491f84732630cf6970455fd1af16bbdf65ad39
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_19_en.txt
@@ -0,0 +1,2 @@
+Our patient a 29-year-old right hand dominant male, who presented late, about 25 days after trauma following a motor vehicle accident, had been to multiple hospitals previously and then came to this institute. On examination, he had frank swelling and deformity over the wrist. There was marked tenderness over carpals and the anatomical snuff box. He was unable to move the wrist however retained limited flexion and extension of the fingers. There was no associated open wound and no distal neurovascular compromise and no other skeletal injury. After presenting to the emergency room, his fresh anteroposterior, lateral, and oblique view radiographs of the wrist were done which showed the dislocation of the lunate volarly with the classical spilled tea-cup sign suggestive of volar PLD. An attempt for closed reduction under analgesia and local anesthesia was given in the emergency room itself, however, was deemed unsuccessful. The patient was applied a long arm cast and was subjected to further investigations before being posted for surgery. CT of the right wrist was done which was suggestive of volar displacement of the lunate with undisplaced fracture of waist of scaphoid. After routine investigations, pre-anesthesia evaluation and taking informed consent patient was posted for surgery.
+Patient was posted for open reduction and reduction was achieved through dorsal approach. Incision was taken over the dorsal aspect of wrist and after retracting the extensor tendons and cutting through the extensor retinaculum, the wrist joint capsule was visualized. The joint capsule was cut open and the lunate bone was identified under C arm. Traction and manipulation were done and after manipulation with the help of k wire, the lunate was reduced to its original place. Reduction was confirmed under C arm and was deemed acceptable. The fracture of the scaphoid was identified and two percutaneous Kirschner’s wires were passed across the fracture site to hold the fragments in place after confirming the reduction, ligament repair was done. After confirming the reduction and the joint stability, the joint capsule was closed, retinaculum was sutured back, and closure was done. The k wires were cut and pin tract dressing was done and along arm thumb spica cast was applied. Two weeks later, the sutures were removed and the cast was removed and the cast was changed with a short arm thumb spica cast. At 8 weeks, the k wires were removed and the patient was started with rigorous hand physiotherapy. At 1-year follow-up, the active range of motion for active flexion was 75° and active extension up to 65° with a decrease in pronation and supination to 55°. Modified mayo wrist score of 76 indicates a good outcome.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2008_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2008_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c02f9989e5ec4ec50a194a9530f49a243f34a23b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2008_en.txt
@@ -0,0 +1,4 @@
+A 32-year-old woman, gravida 2 and para1, withregular menstruation, detected a small lump of 2 × 1.5 cm in her left breast upon self-examination in July 2010. The breast ultrasound confirmed the presence of a 1.8 × 1.2 cm lump of low echo-levels in August 2010. In January 2011, the position emission tomography-computer tomography (PET-CT) of the whole body revealed that there were metabolism-elevating occupying lesions in the left breast, left kidney, and two lungs. Computed tomography (CT) confirmed the occupying lesions in the lung and left kidney . The core needle biopsy in the left breast was performed, but no cancer cells were detected. The levels of human chorionic gonadotropin (HCG) was 22,931 U/L (normal values: 0–5 U/L). In February 2011, the breast excisional biopsy was performed and a diagnosis of breast infiltrating ductal carcinoma was made. In the chemotherapy regimen, one cycle was 21 days. Two cycles of docetaxel (75 mg/m2, once per cycle) combined with epirubicin (75 mg/m2, once per cycle) reduced the lesions in the lungs and kidney and the HCG level (5,773 U/L at the end of the first cycle but 9,026 U/L at the end of the second cycle), while new lesions appeared in the lungs. The chemotherapy regimen was then changed to two cycles of docetaxel (75 mg/m2, once per cycle) and cisplatin (75 mg/m2, once per cycle), and the lesions in the lungs remained stable; the HCG level continued to decrease to 1,490 U/L at the end of the regimen. During this regimen, resection of the left kidney was performed due to rupture and bleeding. The left kidney excisional biopsy was also performed and a diagnosis of high-level infiltrating renal carcinoma (breast cancer metastatic to the kidney) was made. The chemotherapy regimen was changed to one cycle of docetaxel (75 mg/m2, once per cycle) and lobaplatin (35 mg/m2, once per cycle), and the HCG level continued to decrease to 57.86 U/L at the end of the regimen. Due to the severe marrow depression of docetaxel and lobaplatin, the chemotherapy regimen was changed to three cycles of docetaxel (75 mg/m2, once per cycle) and capecitabine (2 g/m2) (one cycle means once-daily administration for 2 weeks followed by 1 week of rest). At the end of the regimen, the HCG level continued to decrease to 17.64 U/L and the lesions in the lungs remained stable. A single capecitabine was then used instead of docetaxel and capecitabine. After two cycles of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest), the HCG level continued to decrease to 0.12 U/L as didthe lesions in the lungs. The excised breast cancer and breast cancer metastatic to the kidney were retrospectively analyzed using HCG immunohistochemistry (IHC) staining. The IHC results demonstrated that all the cancer cells strongly expressed HCG, and the final pathological diagnosis was corrected to BCCF and BCCF metastatic to the kidney . After a further 9 cycles of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest), the HCG level returned to normal values and the lesions in the lungs disappeared . At this time, the patient was still alive (the survival was 37 months), and was undergoing her 26th cycle of capecitabine (2 g/m2, one cycle means once-daily administration for 2 weeks followed by 1 week of rest) with no additional treatment.
+Grossly, the left breast of the patient was normal and BCCF did not protrude through the skin surface. The BCCF was 3.2 × 3.2 × 1.8 cm in size, and was a solid, well-circumscribed, and dark red mass, with extensive necrosis and hemorrhage in the lesion. The BCCF metastatic to the kidney was 5 × 3.5 × 2 cm in size, and was a solid, well-circumscribed, and chromatic mass, with extensive necrosis and hemorrhage in the lesion.Histologically, the BCCF showed well-demarcated borders with extensive hemorrhage, and no infiltrating ductal carcinoma and ductal carcinoma in situ could be found . At high magnification, a sheet-like arrangement of oval-shaped epithelial cells with prominent nucleoli was seen. Multinucleated giant cells with oval nuclei, prominent multiple nucleoli, and irregular chromatin clumping resembling syncytiotrophoblastic cells could also be seen . The BCCF metastatic to the kidney showed a very similar pattern in histology . The cancer (presented as a thin border of intact choriocarcinoma) was well-circumscribed and cystic, surrounded by normal renal tissue, with extensive hemorrhage around it . In the background of hemorrhage, giant cells with prominent pleomorphic nuclei, and abundant acidophilic and vacuolated cytoplasm resembling cytotrophoblastic cells could be seen . In all, the BCCF and BCCF metastatic to the kidney were made up of proliferation of large sized cells with high nucleus/cytoplasm ratio and increased nuclear chromatin. Multinucleated or mononucleated giant cells resembling syncytiotrophoblastic and cytotrophoblastic cells could be seen. This finding was similar to choriocarcinoma originating from genital tract. No subtypes of breast infiltrating ductal carcinoma or ductal carcinoma were identified in the cancer. No lymphovascular invasion was identified.
+IHC staining was performed on paraffin-embedded tissue sections, using a standard avidin-biotin-peroxidase complex method. The IHC staining demonstrated that all the cancer cells strongly expressed HCG in the BCCF and BCCF metastatic to the kidney . In BCCF, other IHC markers were described as follows: HER-1 (++); HER-2 (-); p53(-); Cyclin D1 (-); ER (-); Ki-67 (+ >75%); PR (-); Top-IIα (+50% to 75%); p120 (++); CK5 (-); CK7 (+); CK20 (-); CK (+); EMA (+); and GCDFP-15 (+). In BCCF metastatic to the kidney, other IHC markers were described as follows: HER-2 (-); ER (-); Ki-67 (+ >75%); PR (-); CK (+); CK7 (+); CK20 (-); EMA (+); p63 (-); Vimentin (-), and PLAP (-).
+According to the IHC study findings, the diagnosis of BCCF and BCCF metastatic to the kidney was confirmed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2014_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2014_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4371ae057f3685448f603cd9cb40863a9a86aca2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2014_en.txt
@@ -0,0 +1,8 @@
+This 16-year-old girl was admitted to the pediatric intensive care unit (ICU) with severe dystonic storm which had started after a tooth extraction under general anesthesia. She had a history of markedly delayed development since infancy. Seizures started during the first months of life, and she also developed episodes of varying intensity of dystonic movements of her arms and legs and later involving also the trunk. Initially, she had a diagnosis of cerebral palsy. She never learned to speak, but developed understanding of language, and she was later able to communicate with a talking device. She could not walk independently and was mobilized with a wheelchair and a walking frame. Further symptoms included hypersalivation and multiple contractures and luxations of her extremities which needed surgical correction.
+Over the years, she had several episodes of dystonic storm, occasionally associated with rhabdomyolysis and renal impairment which were managed conservatively. Genetic analysis revealed a de novo heterozygous variant in the GNAO1 gene (c.626G > T; p.(Arg209Leu)). MR imaging of her brain was unremarkable .
+After admission to the ICU at age 16, treatment was started with infusions of clonidine, midazolam, and morphine. Thereafter, continuous infusions of hydromorphone (6 µg/kg/h) and clonidine (1.2 µg/kg/h) were given which yielded little improvement of the dystonic storm. Additional treatment with clobazam, tetrabenazine, and gabapentin was ineffective.
+Subsequently, hyperkalemia (6.9 mmol/l) and rhabdomyolysis (creatine kinase > 100.00 U/l) developed. Sedation with chloral hydrate resulted in improvement of dystonic storm; however, upon reduction of medication, dystonic storm reemerged over a period of 3 weeks. In the following, her state was further complicated by the development of acute colitis and pneumatosis hepatis.
+With regard to her deteriorating condition, she was scheduled for emergency DBS surgery under general anesthesia. Quadripolar DBS electrodes (Vercise Cartesia Directional, Boston Scientific) were implanted bilaterally into the posteroventral lateral globus pallidus internus with CT stereotactic guidance supplemented by preoperative MR imaging and microelectrode recording as described in detail elsewhere [, ].
+Subsequently, the electrodes were connected to an implantable pulse generator (Vercise PC, Boston Scientific). Postoperative stereotactic CT-imaging demonstrated appropriate electrode placement in the target bilaterally . Pallidal stimulation was started directly after completion of the surgery with the following settings: amplitude 2 mA, frequency 130 Hz, and triple monopolar electrode montage on both sides.
+The dystonic movements improved rapidly after weaning from general anesthesia. On the second day after implantation of the electrodes, the medication with midazolam, clonidine, and hydromorphone could be reduced and was completely stopped over the next few days. The stimulation amplitude was increased in parallel to 2.9 mA. The rhabdomyolysis ceased, and the colitis subsided. The patient was discharged from the hospital 17 days after DBS surgery.
+At 3-month follow-up, there was sustained marked improvement. No further episodes of dystonic storm had occurred. The patient could participate in daily activities again. She lived at home with her parents who were very satisfied with the result. At 2-year follow-up, she was in a stable condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2076_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2076_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9073c1cfa7e340efaacbe49d225473fe5d6f42aa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2076_en.txt
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+A 51-year-old Caucasian left-handed housewife lady (weight 61 kg, height 159 cm) was admitted to our institution because of severe sudden onset headache followed by transient loss of consciousness and vomiting. On examination she was fully conscious and oriented and complained of severe headache. Nuchal rigidity was evident. No focal neurological deficit was found. Temperature was 38°C and other vital signs were stable. Past medical history was negative and she did not consume any medication.
+CT scan of the head revealed acute subarachnoid hemorrhage prominently occupying the right sylvian fissure. CT angiography was performed . The cerebral vasculature was found to harbor three saccular aneurysms at: (1) right MCA trifurcation, (2) left ICA bifurcation, and (3) distal basilar artery. The right MCA aneurysm was presumed to be the ruptured aneurysm due to location of subarachnoid clot and irregular shape of the aneurysm.
+A right pterional craniotomy was performed with the patient in the supine position and head rotated 30 degrees to left. After elevation of the craniotomy flap, the sphenoid ridge was drilled flush with the orbital roof to facilitate exposure of the basilar tip aneurysm. After duratomy, gentle frontal lobe retraction allowed CSF drainage from the optic and carotid cisterns. Right optic nerve and right ICA were identified and the Sylvian fissure was opened from medial to lateral, following the bifurcation of right ICA to MCA trifurcation. A saccular aneurysm was found in the MCA trifurcation projecting inferolaterally. After dissection of the neck it was clipped. Next, opening the membrane of Liliequist, let to the distal basilar aneurysm from the corridor between the right optic nerve and right ICA. The aneurysm was located between the right PCA and right SCA with a wide neck, and its dome projected laterally to right. Successful clipping was achieved. The left ICA bifurcation aneurysm was identified after following the right A1, anterior communicating and left A1 arteries with minimal brain retraction, and gaining benefit from favorable neuroanesthesia. The aneurysm projected superiorly and was also clipped .
+The patient experienced an uneventful post-operative period and was discharge within 5 days of surgery. A follow-up CT angiography confirmed successful obliteration of all lesions and preservation of normal cerebral vasculature .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2087_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2087_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..26e918d7a46ad7fd4c685cdb2013e81bd1623207
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2087_en.txt
@@ -0,0 +1,6 @@
+A 40-year-old Caucasian man presented to our cardiologic outpatient department for regular cardiac evaluation. Dyspnoea or other cardiologic symptoms were negated by the patient. AA amyloidosis and associated end-stage chronic renal failure with need for constant dialysis due to highly active Ankylosing spondylitis was diagnosed 7 years ago and confirmed on kidney biopsy. At initial echocardiographic examination 4 years ago typical left ventricular wall thickening (19 mm) and ‘apical sparing’ with abnormal longitudinal function was stated, suspicion of CA was raised. Left ventricular ejection fraction (LVEF) was normal (60%). Yet, no aortic or mitral dysfunction was stated. No additional cardiac diagnostic modalities were done because of potential contrast agent side effects in absence of expected further therapeutic consequences. The patient continued his regular visits at the nephrology department. Due to arterial hypertension and LVH, regular antihypertensive and heart insufficiency medication was initiated (ramipril 5 mg b.i.d.; lercanidipine 10 mg b.i.d.). Anti-inflammatory therapy for ankylosing spondylitis consisted of 15 mg Prednisolone daily. Despite our recommendations no echocardiographic follow-up was performed in the following 4 years till the present visit.
+In the present echo exam, the patient showed no change in LVH or LVEF. Surprisingly, while any cardiac symptoms were negated, the patient now showed severe aortic valve stenosis and mitral valve stenosis, the valves showing signs of massive calcification (see , , Video S1) (left ventricular end-diastolic volume: 51 mm, left ventricular end-systolic volume: 36 mm, no pericardial/pleural effusion, no left ventricular outflow tract obstruction, no systolic anterior movement, aortic valve mean pressure gradient: 30.56 mmHg, aortic valve Vmax: 3.8 m/s, aortic valve area: 1.1cm2, mitral valve mean pressure gradient: 13.92 mmHg, mitral valve area: 1.7cm2, no relevant aortic, mitral, or tricuspid valve regurgitation). N-terminal prohormone of brain natriuretic peptide was >70 000 ng/dL. Electrocardiogram showed regular sinus rhythm, without any conduction abnormalities. Clinical examination of the patient showed normal blood pressure (128/68 mmHg), normal heart rate (58 b.p.m.), rhythmic pulse and normal SpO2 (98%) by pulse oximetry. Auscultation revealed a 3/6 systolic, crescendo-decrescendo murmur, heard loudest at the 2nd right intercostal space. No peripheral oedema or increased jugular vein pulse was present. No hepatic or splenomegaly was present. Physical examination showed overheated and swollen knee joints. Due to suspicion of progressive systemic amyloidosis and ankylosing spondylitis a therapy with interleukin-6-receptor monoclonal human antibody (Tocilizumab) was initiated.
+Following discussion in the multidisciplinary cardiology meeting, the decision for surgical valve replacement of the aortic and mitral valve, due to fast progression, was made. A coronary angiography for preoperative evaluation showed no relevant coronary stenosis. Despite the high surgical risk in this patient, transcatheter aortic valve implantation was rejected by the Heart Team due to the young age and accompanying severe surgically treatable mitral valve disease in compliance with the current European Society of Cardiology (ESC) guidelines for the management of valvular heart disease.
+Surgical replacement of the aortic and mitral valve was conducted 8 weeks after severe aortic valve stenosis and mitral valve stenosis was diagnosed [23 mm Trifecta GT Aortic Valve (St. Jude Medical Abbott, St. Paul, MN, USA)/mitral valve prosthesis: 29 mm Hancock II (Medtronic, Dublin, Ireland)]. Macroscopic examination of the valves revealed significant calcification and were sent to our pathologic department for further examination. Both valve prosthetic devices showed normal function as well as a normal LVEF in initial post-operative transoesophageal echocardiography.
+Histopathological examination of the removed aortic and mitral valve showed severe calcification and the high presence of amyloid by Congo-red staining and immunohistological staining for AA-Amyloid (see ).
+Post-operatively the patient suffered from severe systemic inflammatory response syndrome (SIRS) with prolonged weaning, recurrent respiratory and abdominal septic shocks, cardiogenic shock due to cardiac arrhythmias and multiple further complications. Respiratory weaning was complicated by recurrent hospital-acquired pneumonia with proof of Citrobacter koseri and Stenotrophomonas maltophilia in bronchoalveolar lavage. Weaning remained without progress despite surgical tracheotomy and anti-infective treatment (Tazobactam/Piperacillin/Ciprofloxacin). Furthermore, the patient suffered from retractory Clostridium difficile enteritis, treated with vancomycine/fidaxomicine. A rectoscopy in suspicion of gastrointestinal bleeding (decrease in haemoglobin, peranal haemorrhage) revealed a defect of distal rectum with tissue necrosis. Aetiology of the defect remained unclear. An endosponge was inserted by laparoscopy and a protective ileostomy was placed, local peritonitis was seen intraoperatively. Two days after bowel surgery, the patient’s condition worsened with increasing demand of catecholamines in suspicion of abdominal septic shock. Additionally, the patient showed repeated ventricular arrhythmias with necessity of 10 min of reanimation and multiple defibrillations. The patient died 3 months after surgical valve replacement due to intractable multiorgan failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_210_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_210_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..afc38eb5b59fabc45de1ecc35c6a4adcb3547382
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_210_en.txt
@@ -0,0 +1,6 @@
+“Mr. L” was a 54-year-old single, jobless man. He had treatment-resistant chronic schizophrenia with eight previous psychiatric hospitalizations, mostly in recent 2 years prior to this admission in 2012, and had been received electroconvulsive therapy (ECT) twice. He also had type 2 diabetes mellitus under medical control. There were no other systemic diseases.
+After completing military service, Mr. L worked as a carpenter for several years. At age 28, unstable mood and violent behavior were first noted by his family. He was hospitalized and diagnosed with schizophrenia, presented with delusion of persecution, misidentification, delusion of reference, and auditory hallucination. Under medications, he could keep daily function and housework, but he never returned to his baseline functionality.
+One year prior to this admission, Mr. L could not keep housework and self-care due to aggravated delusion of persecution, reference, and auditory hallucination. He had a suicide attempt by trying to explode a gas tank, and then he became one of the recurrently readmitted inpatient psychiatric patients. He had poor response to high dosages of risperidone, zotepine, quetiapine, olanzapine, paliperidone, haloperidol, and even flupenthixol with another oral antipsychotic medication combination trial. He was ever prescribed clozapine in other hospitals for short period of time, but discontinued without blood dyscrasias. After two times of ECT, he showed more stationary condition so he was transferred to our psychiatric chronic ward. However, medication refusal and aggravated hallucinatory behavior were noted 2 months after last ECT was done. He would shout, follow a specific female worker, and have self-harm behaviors such as slapping and kowtowing due to commanding auditory hallucination.
+After admission, a trial of clozapine was started with initial dose of 100 mg/day, and gradually titrated to 200 mg/day, with concomitant treatment of flupenthixol 40 mg intramuscular injection every 2 weeks, benzodiazepines, laxatives, and one oral hypoglycemic agent. Moderate drooling was observed but did not influence his intake. He experienced notable improvement after 2 weeks with decreased auditory hallucinations and no more self-harm behaviors, but he also developed eosinophilia, with a count of 1.4 × 109/l, 15.5% of the total WBC count (9.3 × 109/l). Eosinophilia persisted 4 days later, with a count of 3.8 × 109/l, 32% of the total WBC count (12.0 × 109/l).
+Before deciding whether to continue the clozapine treatment, we reviewed the published literature about eosinophilia after clozapine use , and successful rechallenge had been reported. A medical workup was performed, including cardiac enzymes, an electrocardiography, liver function tests, blood creatine level, blood urea nitrogen, levels of amylase, lipase, erythrocyte sedimentation rate, and C-reactive protein, none of which showed evidence of myocarditis, hepatitis, nephritis, pancreatitis or other inflammatory conditions. Given several failed antipsychotic medication trials before, and positive response to clozapine, Mr. L, his brother, and his psychiatrist agreed that the known benefits of clozapine to the patient outweighed the potential risks as long as close monitoring of blood parameters. Mr. L’s brother, who was his health care proxy, was involved in extensive discussions about the risks of clozapine, and Mr. L agreed to the trial.
+The recommendation of the hematology service was to continue clozapine treatment with close monitoring of complete blood count with differential test to track his eosinophil count even with the current level of eosinophilia since the patient was not showing signs of end-organ involvement. Figure illustrates the course of Mr. L’s clozapine dosage and eosinophil counts throughout the clozapine trial and beyond. Over the next 3 weeks, clozapine was titrated slowly. Mr. L’s eosinophilia reached a peak of 4.0 × 109/l, 34% of the total WBC count (11.8 × 109/l), at a clozapine dosage of 250 mg/day, but decreased then and remained within normal limits 3 weeks later. The dosage was gradually raised as high as 400 mg/day. His psychotic symptoms got partial remission and continued to show no signs of end-organ inflammation at the time of discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2120_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2120_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6bf74b8062730c6d3f103499337fd1c328cd13c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2120_en.txt
@@ -0,0 +1,13 @@
+A 36-year-old woman presented at our hospital with a palpable mass at the external left breast quadrants in December 2011. The patient underwent breast ultrasound and breast magnetic resonance imaging (MRI) that confirmed the presence of a nodular formation of about 5 cm. In addition, at least three lymphadenopathies with eccentric hilum were identified in the left axillary cable, and remote staging tests were negative. In January 2012, breast biopsy diagnosed an infiltrating ductal carcinoma of the breast, grade 3, estrogen receptor (ER)-positive (90%), progesterone receptor (PR)-positive (36%), HER2-positive (3+ by IHC), and MIB-1 36%. The pathological nature of lymphadenopathies was confirmed by fine-needle aspiration.
+From January 2012 to April 2012, the patient received neoadjuvant chemotherapy with docetaxel (100 mg/m2) and trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) every three weeks for four cycles followed by cyclophosphamide (600 mg/m2) and doxorubicin (60 mg/m2) every three weeks for four cycles. The second cycle of chemotherapy was delayed due to hypertransaminasemia grade 2 (according to common terminology criteria for adverse events (CTCAE) version 5.0), treated with glutathione and prednisone 25 mg/die for five days. Treatment with docetaxel was resumed at 25% reduced dose, reporting only grade 1 hypertransaminasemia during subsequent cycles. In August 2012, the patient underwent bilateral mastectomy and axillary node resection with a partial response to neoadjuvant chemotherapy (ypT1c ypN1 Mx).
+From October 2012 to April 2013, the patient continued adjuvant therapy with trastuzumab administered subcutaneously (600 mg) every three weeks to complete one year of treatment and hormone therapy with tamoxifene plus luteinizing hormone-releasing hormone (LHRH) inhibitor since September 2012.
+In January 2014, after the finding of thickening of the subcutaneous areola, the patient underwent surgical radical removal of the nipple and left areola. The diagnosis was intraductal carcinoma of cribriform type in galactophore ducts of high-grade sec. WHO 2012 and Paget’s disease, ER 90% PgR negative.
+She continued regular clinico-radiological follow-up, negative for locoregional and distance recurrence, until January 2016 when a total body contrast-enhanced computed tomography (CECT) scan and an 18-fluor-fluorodeoxyglucose positron emission tomography-computed tomography (18F-FDG PET/CT) confirmed the presence of bilateral pulmonary, mediastinal pathological lymph nodes and bone metastases. According to the disease stage, biomolecular tumor characteristics, and clinical conditions (PS 0 sec. ECOG), in January 2016, the patient started first-line therapy with pertuzumab plus trastuzumab and docetaxel every three weeks at standard doses. She reassumed the same regimen up to four courses and then she continued with dual HER2-blockage for a further three cycles. The CECT scan after three courses of treatment showed a partial response, but after the second cycle the patient showed grade 2 mucositis and grade 3 hypertransaminasemia, treated with glutathione and prednisone 25 mg/die for five days, and the third cycle was delayed. Antigens of hepatitis were tested and resulted negative.
+In August 2016, an 18F-FDG PET/CT revealed lymph node and bone progression disease. Thus, she started second-line therapy with T-DM1 at 3.6 mg/kg every three weeks with concurrent denosumab every four weeks. From August 2016 to April 2018, she received 28 cycles. After the ninth cycle, due to the occurrence of grade 2 hypertransaminasemia, glutathione was introduced in chemotherapy regimens with the resolution of toxicity.
+In April 2018, due to a lymph node and lung disease progression, the patient was enrolled in the phase III clinical trial SOPHIA (NCT02492711) and randomized to the control arm. The screening laboratory findings showed a grade 3 hypertransaminasemia that was treated with glutathione infusion. At the resolution of toxicity, since the patient had been randomized into the control arm, she began treatment with trastuzumab (8 mg/kg loading dose, followed by 6 mg/kg) and navelbine (25 mg/mq d1–8 every three weeks). The treatment was poorly tolerated with grade 4 neutropenia and grade 2 anemia after the first cycle and grade 4 neutropenia after the second cycle with 50% dose reduction and secondary prophylaxis with granulocyte colony-stimulating factor (G-CSF). Due to hematological toxicities, she continued treatment without navelbine, and she received four courses with trastuzumab.
+In October 2018, a further lymph node and lung disease progression was detected, and then she started fourth line with capecitabine (1000 mg/mq bid d1–14) plus lapatinib (1250 mg once daily) every three weeks. The patient received IX cycle from November 2018 to June 2019. After the first cycle, she presented grade 1 hypertransaminasemia, which was resolved with glutathione infusion.
+After a further lymph node and lung disease progression, she received fifth-line therapy with nab-paclitaxel 260 mg/m2 and trastuzumab every three weeks with primary prophylaxis with G-CSF. She received nine courses from July 2019 to December 2019, and she presented only grade 1 hypertransaminasemia.
+Due to the evidence of complete response and the patient’s preference to discontinue alopecitizing chemotherapy, she continued treatment with trastuzumab alone until March 2020, when an 18F-FDG PET/CT revealed lymph node and lung relapse. Then, in April 2020, she started sixth-line therapy with gemcitabine 1000 mg/m2·d1, d8 plus trastuzumab 6 mg/kg every three weeks. After the first cycle, she presented grade 2 hypertransaminasemia and grade 2 thrombocytopenia, so she stopped the treatment; due to the occurrence of pain in the left arm (VAS 8), we prescribed oxycodone plus naloxone. At the fourth cycle, she showed grade 3 hypertransaminasemia, and we decided to reduce gemcitabine dose, but the toxicity persisted. Therefore, liver virology was tested again. Moreover, at this time point , since the new technology for DDGI had become available at our center, we evaluated her genomic polymorphisms, including genes encoding for the main drug metabolism enzymes, and simultaneously analyzed all her clinical, biochemical, and genomic data by using the new Drug-PIN system comprehensive approach ( (accessed on 31 March 2020)) In particular, for the SNP analysis, the patient’s DNA was extracted from samples of 5 mL of peripheral blood, using the automatic QIAsymphony system for the extraction of nucleic acid (Qiagen, Hilden, Germany), and then the latter was processed using a next-generation sequencing platform Ion Chef/Ion S5 system (Thermo Fisher Scientific, Waltham, MA, USA) according to the manufacturer’s instructions.
+Due to the results of the analysis , we decided to maintain the reduced dose of gemcitabine and to introduce glutathione as part of cancer treatment from the sixth cycle of chemotherapy.
+From August to December 2020, the patient received 25% reduced dose gemcitabine with four vials of glutathione, and she showed maximum grade 2 liver toxicity.
+In December 2020, an 18F-FDG PET/CT evaluation revealed oligometastatic lymph node and bone progression; therefore, we decided to treat with local radiotherapy on sternal dumbbell and left later-cervical, supraclavicular, and retro-pectoral lymph nodes, maintaining the same chemotherapy regimen. Today, the treatment with gemcitabine and trastuzumab is still ongoing, and the patient has reported an overall survival (OS) of 111 months from first diagnosis and of 50 months from recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2131_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2131_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d940e3a74cdc142ee74e2087eb289f72e3c5dd9e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2131_en.txt
@@ -0,0 +1,2 @@
+A 62-year-old Thai man presented to our facility with a generalized erythematous maculopapular rash on his trunk and extremities. Our patient had been diagnosed as having pulmonary tuberculosis two weeks earlier. He had long-standing hypertension and diabetes mellitus; his treatment for this included daily amlodipine 5mg, metformin 500mg and glipizide 5mg daily. When tuberculosis was diagnosed, anti-tuberculosis therapy of isoniazid 300mg, rifampicin 450mg and ethambutol 800mg daily was administered. After two weeks of anti-tuberculosis medication, a generalized exanthematous rash appeared on his trunk and extremities . All anti-tuberculosis drugs were stopped after his admission due to a clinical suspicion of drug-induced adverse cutaneous reactions. The exanthematous rash resolved within three days of admission, leaving post-inflammatory hyperpigmentation. One day later, multiple well-defined, non-blanchable, erythematous-to-purplish macules and papules, some of which showed an annular arrangement, were noticed . He had no history of drug allergy and a review of systems was unremarkable.
+Laboratory study findings were as follows: leukocytes, 12.8×103 cells/mm3 (neutrophils 86 percent, lymphocytes 9 percent, monocytes 2 percent, eosinophils 2 percent, basophils 1 percent); hemoglobin, 7.9g/dL; platelet count, 215×103 cells/mm3; creatinine, 1.2mg/dL; aspartate aminotransferase, 31U/L; alanine aminotransferase, 34U/L; alkaline phosphatase, 582U/L; γ-glutamyl transferase, 393U/L; total bilirubin, 9.6mg/dL; direct bilirubin, 8.4mg/dL; hepatitis B surface antigen, anti-hepatitis C virus and anti-human immunodeficiency virus (HIV) test results were all negative. Anti-nuclear antibody and anti-neutrophil cytoplasmic antibody test results were also negative. Urine analysis results showed no evidence of proteinuria or hematuria. The findings from an abdominal ultrasound were unremarkable. A skin biopsy from a purpuric annular lesion on his leg showed peri-vascular and interstitial infiltration of neutrophils with extravasation of erythrocytes and fibrin deposition , characteristic of LCV. A direct immunofluorescence (DIF) study was positive for IgA, IgM and C3 along superficial dermal blood vessels, consistent with cutaneous small vessel vasculitis . These findings were diagnostic for annular LCV associated with anti-tuberculosis drugs and drug-induced cholestasis. Our patient was treated with an oral antihistamine and topical corticosteroids. The skin eruption cleared within one week without hyperpigmentation and liver function test results returned to normal limits three weeks after the anti-tuberculosis drugs were withdrawn. Streptomycin (750mg per day), ethambutol (800mg per day) and ofloxacin (400mg per day) were subsequently administered as second-line anti-tuberculosis therapy during the hospitalization. No adverse reactions were observed. Therefore, he was subsequently treated with ethambutol, ofloxacin and streptomycin without recurrence of the skin rash.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2153_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2153_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..712e03132079c5d6a1c4a3226fa4c98dad6edce8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2153_en.txt
@@ -0,0 +1,7 @@
+A 27-year-old man with recurrent fever, fatigue for more than 2 mo, and unconsciousness for 1 day was admitted to our emergency department.
+During the previous 2 mo, the patient had visited our outpatient department twice for fever and fatigue, his highest documented temperature having been 40.0°C. A chest computed tomography (CT) 6 wk prior to admission had shown bilateral lung infection . Routine blood testing revealed the following: White blood cell (WBC) count: 14.63 × 109/L, red blood cell (RBC) count: 3.35 × 1012/L, hemoglobin: 107.00 g/L, platelet count: 98 × 109/L, and C-reactive protein (CRP): 47.63 mg/L. Because the patient refused admission, the attending physician prescribed the antibiotic moxifloxacin (0.4 g daily) and asked him to attend the outpatient department for follow-up.
+The patient had no notable history of past illness.
+The patient had no notable personal or family history.
+The patient’s temperature was 38.5°C, pulse rate 129 beats/min, respiratory rate 42 beats/min, transcutaneous saturation of oxygen 65%, and blood pressure 85/55 mmHg (11.33/7.33 kPa) on admission. His blood pressure increased to 113/78 mmHg (15.029/10.374 kPa) with infusion of 1 µg/kg/min norepinephrine. He was intubated and placed on mechanical ventilation in synchronous intermittent mandatory ventilation mode with the following settings: Fraction of inspired oxygen: 80%, positive end-expiratory pressure: 10 cm H2O, and pressure support: 15 cm H2O. His breathing was shallow with obvious moist crackles. No other abnormalities were detected on physical examination.
+Routine blood testing 6 wk before admission revealed a high WBC count [14.63 × 109/L (normal range 3.5–9.5)], high CRP concentration [47.63 mg/L (< 8.0)], low RBC count [3.35 × 1012/L (4.30–5.80)], low hemoglobin [107.00 g/L (130–175)] and low platelet count [98 × 109/L (125–350)], indicating that he had inflammation and was anemic. Blood gas analysis on admission revealed anoxia and hyperventilation with a low partial pressures of oxygen [46.8 mmHg (80–100)] and carbon dioxide [24.3 mmHg (35–45)], pH: 7.516 (7.35–7.45), and transcutaneous oxygen saturation 75%. Routine blood testing on admission revealed a higher WBC count (34.45 × 109/L) and CRP concentration (80.78 mg/L) than 6 wk previously, together with a lower hemoglobin (90.00 g/L) and platelet count (80.78 mg/L) than previously, indicating that his inflammation and anemia had progressed. Additionally, his RBC count was 3.36 × 1012/L, mean corpuscular volume 120.1 fL (82.0–100.0), and mean corpuscular hemoglobin 40.8 pg (27.0–34.0). His erythrocyte sedimentation rate [106 mm/h (0–15)] and ferritin [> 1500.00 ng/mL (15–200)] provided further evidence of inflammation.
+Chest CT 6 wk before admission had shown multiple patchy shadows with ill-defined boundaries and local consolidation in both lungs, indicating that he had bilateral pneumonia . On admission, CT showed more severe multiple patchy shadows in both lungs and consolidation, indicating that his pneumonia had worsened . B-mode ultrasonography of the liver and spleen on admission showed no obvious abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_215_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_215_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da6ecf77a5b16331113acde6599804ca51ce2659
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_215_en.txt
@@ -0,0 +1,3 @@
+On 27th July 2020, a 47-year-old woman, working as a ceramic dental technician since November 2018, required a medical examination at our Occupational Health Dept., as in the previous months she was affected by dry and irritating cough, especially related to intense work activity. She also suffered some episodes of low-grade fever and fatigue and dyspnea on efforts. In March 2020, chest CT showed lung nodules characterized by net margins and oval shape, in peripheral or subpleural site, especially in the inferior lobes. The biggest nodule, 9 mm, with polygonal shape, was in the anterior basal segment of the righ inferior lobe .
+Pulmonary function tests were in the normality range and revealed a normal diffusing capacity, albeit at the lower limits of the normal (DLCO/VA 73%); autoimmunity markers were in the normal range. Then, she underwent fibro-bronchoscopy with bronchoalveolar lavage (BAL) and bronchial aspirate (BAS). BAL differential cell count showed macrophages (79%), lymphocytes (18%), neutrophil granulocytes (3%), and a CD4/CD8 lymphocyte ratio of 7.8. In both BAL and BAS, several macrophages with numerous intracytoplasmic exogenous metallic material and reflective dust were seen at optical microscopy. Owing to the SARS-CoV2 pandemic, she was absent from workplace from March to August 2020 and in such period her symptoms ameliorated. At work, the woman was involved in milling and polishing monolithic zirconia structures, then layered with ceramic. She described workplace as dusty, lacking aspiration hoods hence she was concerned about workplace safety. She used respiratory personal protective equipment (PPE) inconstantly.
+We examined three samples of dust settled nearby her workstation by inductively coupled mass spectrometry (ICP-MS) . Among others, we detected average Cobalt (Co), Tungsten (W), Zirconium (Zr) and Yttrium (Y), a component of dental ceramic) at concentrations of 45, 60, 96 and 176 µg/g, respectively. Apart from Co, the same elements could be detected, always by ICP-MS, on a paraffin-embedded BAS sample. On BAL cytocentrifugated slides, scanning electron microscopy (SEM) coupled to Energy Dispersive X-Ray Analysis (EDX) showed numerous inorganic particles, containing Zr and Aluminum (Al), the latter probably as oxide, within the macrophages . In addition, a signal attributed to W was detected but not localized in a specific image detail. About a month after return at work, we investigated metal concentrations in urine (U) and in exhaled breath condensate (EBC), collected either at the beginning and at the end of a workweek, by ICP-MS. We could demonstrate a 6 times weekly increase of urinary concentrations of W (0.18 µg/L vs. 1.1 µg/L). We concluded for a diagnosis of early work-related pneumoconiosis due to abnormal occupational exposure to metals. We advised periodical chest CT and pulmonologist monitoring (the next after 6 months), along with the prescription to strictly wear respiratory personal protective equipment (PPE) at work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_216_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_216_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6827365b99be246986ec872a8724e7d598f5e14e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_216_en.txt
@@ -0,0 +1,3 @@
+A case of tuberculosis of the cervix presenting as cervical carcinoma is being reported for its rarity.
+A 26-year-old P2L2 Indian lady, housewife by occupation, presented with chief complaints of pain abdomen, irregular bleeding and discharge per vaginum for three years. She had history of post-coital bleeding and inter-menstrual bleeding; and significant weight loss over the last two years. There was no history of genitourinary malignancy or tuberculosis in the past or in the family. The patient was a non-smoker, non-alcoholic and did not have any other significant medical or surgical illness in the past.
+General physical examination was essentially normal with no palpable lymph nodes. Systemic examination did not reveal any abnormality. On per speculum examination, cervix was replaced by an irregular friable growth, which was bleeding on touch . On bimanual examination, same growth was felt. Uterus was anteverted, normal in size and bilateral fornices were free. Per rectal examination did not reveal any induration or nodularity of parametria and rectal mucosa was smooth and freely mobile. Colposcopic examination showed increased vascularity without any acetowhite or iodine negative areas. PAP smear showed epitheloid like cell clusters without any dysplasia. Biopsy taken from the cervical growth revealed granulomatous inflammation with caseous necrosis. Smear from cervix was found positive for acid-fast bacilli. Endometrial biopsy was normal with no AFB . A chest radiograph was normal. Sputum and urine samples were negative for AFB and failed to culture mycobacterium. CECT abdomen showed bulky cervix with evidence of soft tissue streaking in parametrium. HIV 1 and 2 was negative. Patient was started on antitubercular treatment (four drugs: isoniazid, ethambutol, rifampicin and pyrazinamide) and discharged. At six months, the cervix had an almost normal appearance and there was complete relief from symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2192_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2192_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..07a73e6126286a85582fb766c18d4c461daabffe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2192_en.txt
@@ -0,0 +1,5 @@
+A 36-year-old male survived a severe traffic accident but lost his right leg, bilateral testicles and a large area of genital skin, including the foreskin and scrotal skin. Additionally, the penile urethra was damaged, resulting in a urethral defect 6 cm in length, and the meatus had descended to the penoscrotal junction.
+The patient strongly desired to perform standing urination; therefore, we performed a three-stage procedure to repair his penis. In the first stage, skin saving measures and coverage of the skin loss were the most important treatments. Free skin grafts and pedicle flaps were transposed to repair the skin defects. The nude penile shaft was buried beneath the skin of the left anteromedial thigh .
+Twelve months later, the patient underwent the second-stage procedure for penile release and urethral plate expansion . In this stage, the penis was released from the left thigh and was fully covered with skin and subcutaneous fat. The size of the penile dorsal skin was designed to be large enough to wrap the corpus cavernosum and residual urethral plate. Considering the shrinkage of the residual urethral plate, a lingual mucosal graft was harvested to expand the urethral plate. The neourethral plate was designed to be as large as possible due to the expected 20% shrinkage of the oral graft . A protective tie-over dressing was placed to reduce the chance of hematoma collecting under the graft. No focal graft contracture occurred requiring an additional operation to patch the graft, and no donor site complications were observed at the follow-up evaluation (Additional file ).
+At 6 months after the second-stage surgery, a third stage was performed for urethroplasty. In this stage, the patient underwent a urethroplasty procedure utilizing the preset flap and the neourethral plate with a standard Thiersch-Duplay technique (Additional file ). The neourethra was tabularized with 2-layer running subepithelial 6–0 Vicryl sutures. Adequate dissection of the new foreskin, excision of a part of the subcutaneous adipose tissue and Z-plasty led to tension free coverage of the corpus cavernosum and neourethra (Additional file ). The 12-Fr catheter was removed on postoperative day (POD) 21, and no fistula was observed after the urethral catheter was removed.
+At the 2-year follow-up evaluation after the repair, the patient voided satisfactorily (Additional files and ). The maximal flow rates (MFRs) were 27.8 ml/s, 23.3 ml/s, and 22.2 ml/s with no postvoiding residual urine after the third-stage operation and at the 12-month and 24-month follow-up evaluations, respectively. No edema, infection, hemorrhage, or cicatricial retraction were observed. The patient reported penile erectile function and the ability to perform intercourse without penile curvature. A mild reduction of penile hardness and sensitivity were reported during the 2-year follow-up visit. However, his IIEF-5 scores were 22 and 23 at the 12-month and 24-month follow-up evaluations, respectively, as demonstrated by nocturnal penile tumescence (NPT) during postoperative year 2.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_219_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_219_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5b0c14a293d192e4b2577ae8578fa537bb889f1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_219_en.txt
@@ -0,0 +1,3 @@
+A 23-year-old male sedentary worker sustained road traffic accident 1 year back, fall on outstretched hand, while he was driving two-wheeler. Immediately, he noticed inability to adduct the arm, bony mass below the collar bone. He was taken to nearby local hospital manipulated to reduce dislocation. He was immobilized in adducted position. He was asymptomatic till last 2 months when he experienced one more episode of dislocation which he reduced himself, following which seven episode of dislocation following daily routine activities each reduced by patient himself. Pain aggravated in last few days which made him to visit our hospital. On examination, coracoid tenderness present, Neer apprehension test positive, load and shift test positive, anterior draw test was grade 2, with no hyperlaxity. Routine radiographs revealed coracoid fracture. Computed tomography was done to assess glenoid bone loss and avulsion fracture of coracoid . Coracoid fracture belongs to Ogava et al., type II, magnetic resonance imaging confirmed the same . Labrum was deficient anteriorly and there was no associated rotator cuff tear.
+After a discussion with patient, open Laterjet procedure using fractured coracoid process in beach chair position under general anesthesia was decided. An incision of 5 cm made over apparent coracoid made standard deltopectoral approach performed. Clavipectoral fascia incised. Fractured coracoid process identified with its partial coracoacromial ligament and pectoralis minor attachment which was separated. Fractured fragment with conjoint tendon attachment separated from underlying structures . Graft was prepared of size length of 2 cm width of 0.8 mm with good amount of cancellous bed. Two drill holes were made over graft centimeter apart using 3.2 mm drill bit with special graft holding device. Graft recipient site was approached using upper two-third and lower one-third subscapular split and shoulder capsule incised vertically. Humeral head retracted using fakuda retractor. After adequate exposure and preparation of recipient site offset jig used to place graft parallel to glenoid anterior surface. Bi-cortical drilling performed over glenoid for adequate purchase of screws. After confirming the offset of graft two cannulated cancellous titanium screws of size 36 mm were inserted . Adequate stability of graft and tenodesis effect of lowed third subscapularis confirmed. To provide triple tenodesis effect, lateral leaf of capsule was sutured over glenoid lateral surface with double loaded 3.5 mm metal suture anchor as adequate amount of coracohumeral ligament was not present with fractured coracoid process.
+Post-operative rehabilitation includes shoulder immobilizer with chest binder to maintain arm in adducted position. Active elbow wrist exercises, Codman pendular exercises for 2 weeks, following suture removal isometric rotation exercises and shoulder range of motion exercises, were advised as permitted by pain. The patient called for follow-up at 6-week, 4-month, and 6 months for assessment of pain, range . At three and 6 month follow-up, CT scan was performed to assess union of graft and allowed to return to sport activity .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2207_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2207_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7027511d48d7e1688a3a7c4f8fee2f6c05811b56
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2207_en.txt
@@ -0,0 +1,3 @@
+A 78-year-old man was hospitalized to our hospital for a week owing to memory loss and poor responsiveness without obvious precipitating factors. Since the onset, he was in poor appetite and spirit, and occasionally unstable gait. The patient denied headache, dizziness, nausea, or vomiting, but he responded with intermittent headaches in the hospital. He had no ataxia, dystonia, speech disorder, and abnormal immunocompetence. There was also no history of cognitive decline, personality changes, seizures, radiation exposure, systemic infection, or other autoimmune diseases. His family history was unremarkable. Neurological examination did not show focal neurological signs. The patient was diagnosed with prostate cancer 3 years ago and got symptomatic treatment. On further evaluation, a routine blood investigation including HIV was done which was nonreactive.
+The brain computed tomography (CT) disclosed three solid masses with slight hyper-attenuation, non-calcification, and non-cystic components. The biggest one was located in the third ventricle and the others were located in the body and posterior horn of the left lateral ventricle , MRI showed multifocal solid lesions in the same regions. They were slightly hypointense on T1WI and isointense to slightly hypointense on T2WI and T2WI dark-fluid images. While on diffusion-weighted imaging (DWI), the third ventricular lesion was hypointense, and the lateral ventricular lesion was slightly hyperintense, both of them with low apparent diffusion coefficient (ADC) values, all suggesting diffusion restricted. Post-enhanced, the ventricular lesions were significantly enhanced. Furthermore, parenchyma around the third ventricle displayed swelling and hyperintense on T2WI. It did not cause ventricular expansion and hydrocephalus above the lesions . He was diagnosed with intraventricular malignancy and based on his history of prostate cancer, the possibility of metastasis was considered clinically.
+In order to determine the nature of the lesion and ensure smooth cerebrospinal fluid circulation in the third ventricle, the patient underwent a subtotal resection of the third ventricle tumor by transcallosal approach. Analysis of a frozen section was consistent with uncertain PCNSL. Immunohistochemistry revealed the tumor cells were positive for CD10, CD20, Bcl-6, MUM-1, C-MYC(10%), Bcl-2(90%), and Ki-67(80%), and negative for CD3, CD30, cyclin D1, ALK, and EBER in situ hybridization . The P53 was wild-type. Thus, the final diagnosis of the third ventricular tumor was DLBCL with a germinal center subtype. Postoperatively, the patient was in a shallow coma, and in poor overall condition. On day 17, he became critically unwell due to respiratory and circulatory failure and arrhythmia. But the families gave up continued resuscitation and requested to be discharged.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2227_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2227_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5ebc37eb0d1c25d74e3361812c6a37592a1cdcc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2227_en.txt
@@ -0,0 +1,2 @@
+An 11-year-old girl showed proteinuria on a school urinalysis screening. She was taken to a hospital for investigation of upper eyelid edema. She was born at 26 weeks of gestation, with a birth weight of 526 g (standard deviation [SD], -2.7) and birth height of 30 cm (SD, -1.3), and she started growth hormone treatment at the age of 4 years and 5 months for her short stature. There was no medical or family history of kidney disease. She had no infection in the last few months, and her vital signs were normal. Her height was 137 cm, and her weight was 37 kg, which was 7 kg heavier than usual. Physical examination showed that she had marked generalized edema. She had no cutaneous purpura, abdominal pain, or joint pain, suggesting that she did not have IgA vasculitis. Urinalysis and urine chemistry results were as follows: urinary protein, 2165 mg/dL; urinary protein-creatinine ratio, 22 g/gCr; urinary red blood cell count, > 100 /high power field; and urinary β2-microglobulin, 8579 μg/L. The findings of laboratory examinations were as follows: normal complete blood cell count; serum total protein, 3.7 g/dL; serum albumin, 1.3 g/dL; aspartate aminotransferase, 20 IU/L; alanine aminotransferase, 14 IU/L; lactate dehydrogenase, 159 IU/L; alkaline phosphatase, 383 IU/L; total bile acid, 1.1 μmol/L; ammonia, 33 μg/dL; total cholesterol, 666 mg/dL; triglyceride, 268 mg/dL; blood urea nitrogen, 12.9 mg/dL; serum creatinine, 0.54 mg/dL; sodium, 135 mEq/L; potassium, 4.5 mEq/L; chloride, 107 mEq/L; calcium, 7.4 mg/dL; and C-reactive protein, 0.02 mg/dL. Immunological examination revealed serum IgG of 122 mg/dL, serum IgA of 82 mg/dL, C3c of 67 mg/dL (normal range: 73–138 mg/dL), C4 of 14.1 mg/dL (normal range: 11–31 mg/dL), CH50 of 28 U/mL, and antistreptolysin O of 44 IU/mL. Antinuclear, myeloperoxidase, and proteinase 3 antineutrophil cytoplasmic antibodies were negative. Screening for infectious diseases were negative for parvovirus B19 IgM and mycoplasma antibodies. Her physical and laboratory findings suggested no autoimmune diseases or infections. Hepatitis B surface antigen and hepatitis C antibody test results were also negative. Liver disease-related IgA nephropathy was ruled out because ultrasonography and computed tomography revealed ascites in the absence of portosystemic shunt and cryoglobulinemic glomerulonephritis was ruled out because blood tests were negative for cryoglobulin. Based on these results, nephrotic nephritis with hypocomplementemia was suspected, and a renal biopsy was thus performed.
+Light microscopic studies showed mesangial cell proliferation and increased mesangial matrix with lobulation in almost all glomeruli. Endocapillary proliferation in the glomeruli and a few neutrophil infiltrations in the capillaries of the glomeruli were observed . Additionally, periodic acid-methenamine-silver staining showed some double contours of the glomerular basement membrane ; these are all characteristic findings of MPGN. The size of the glomeruli was within the normal range, and there were 2.6 glomeruli per square millimeter. The glomerular density of 13 minimal change nephrotic syndrome patients (mean 11.8 ± 3.6 years) with normal birth weight was 3.6 ± 1.1 / per square millimeter , indicating that the glomerular density of this patient was within the normal range or slightly lower. Immunofluorescent studies showed that deposits of IgA and C3 were dominantly detected in the mesangial regions, and were also slightly detected along the capillary walls. In addition, IgA deposits were stronger than those of C3 . IgA subclass staining revealed stronger staining for IgA2 stains than for IgA1 stains . Electron microscopic studies showed electron-dense deposits in the subendothelial, subepithelial, and paramesangial regions. Mesangial cell interposition was observed . The subepithelial deposits were not hump-like and podocytes were slightly sparse. No disease-specific glomerular deposit structures such as renal amyloidosis or monoclonal immunoglobulin deposition disease were observed on EM . Based on these aforementioned findings, we diagnosed this girl with IgA-dominant MPGN. Hypoalbuminemia was treated by intravenous infusion of albumin, and furosemide was also administered. After the biopsy, the patient was treated with three courses of methylprednisolone pulse therapy (MPT; one course; 30 mg/kg of methylprednisolone for three consecutive days), followed by oral prednisolone (1 mg/kg/day) and mizoribine (MZR). Lisinopril was used to treat hypertension and proteinuria. Although hypocomplementemia improved after the three courses of MPT, nephrotic-range proteinuria and hypoalbuminemia remained; therefore, two courses of MPT were additionally administered, and the immunosuppressant was changed from MZR to cyclosporine (CsA). The dose of CsA was initially started at 2 mg/kg/day. The CsA blood level target for single-point concentration 2 h post-dose was set at 600–700 ng/mL for approximately 2 months, after which the dosage was adjusted to 450–550 ng/mL. Subsequently, the urinary protein-creatinine ratio decreased from 4 to 0.8 g/gCr, and serum albumin tended to increase. She was discharged on the 155th day of hospitalization. The dose of prednisolone was changed every other day and gradually decreased. Decreased urinary protein was detected 13 months after the treatment . A second renal biopsy was performed 22 months after the start of treatment, and improvement in glomerular lesions was found . Cyclosporine nephropathy was not observed. On the second biopsy, positive deposits of IgA were detected mainly in the mesangial regions and also slightly along the capillary walls. Deposits of C3 and IgA1 were not detected, but very slight deposits of IgA2 were present in the mesangial regions and along the capillary walls. . No deterioration of kidney function was observed after almost 2 years of treatment. The levels of C3 improved after three courses of methylprednisolone pulse therapy, and has remained normal since then. Posterior subcapsular cataract was considered as an adverse effect of steroids because no deterioration in visual acuity was observed during the follow-up period.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2229_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2229_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3e13e98122e728ee831e049efe91e74dbb042789
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2229_en.txt
@@ -0,0 +1,2 @@
+A 44 year old Caucasian male was referred by his primary care physician for a recurrent asymptomatic left sided massive pleural effusion. The pleural effusion was first discovered on a chest X-ray obtained to follow-up his left 8th, 9th and 10th rib fractures from an accidental fall. The effusion was recurrent over one and a half month even after drainage with thoracentesis and chest tube placement . The initial chest X-ray immediately after his fall that revealed the acute fractures did not show any pleural effusion or blunting of costophrenic angles . The patient had no significant past medical history, denied recent travel, but admitted to smoking tobacco and consuming alcohol. The patient worked, as a maintenance man, but at the time of presentation was unemployed.
+At presentation the patient had normal vital signs with an oxygen saturation of 93% on room air. Physical examination revealed an average built man in no apparent distress, non-labored breathing, central trachea, absent breath sounds with a stony dull percussion note on the left hemi thorax. Abdomen was soft and non tender with a palpable liver 10 cm below the costal margin. Laboratory investigation revealed mild anemia, hypoalbuminemia (3.1 gm/dL), normal BUN, creatinine, electrolytes and urine analysis. Arterial blood gas (ABG) analysis showed pH 7.48, PaCO2 34 mm Hg, PaO2 63 mm Hg, HCO3 25 mEq/L, oxygen saturation 93% on room air. Pleural fluid study showed lactate dehydrogenase (LDH) 112 U/L, pH 7.80, WBC 76, Polymorphs 40%, Eosinophil 1%, glucose 139 mg/dL, albumin 0.90 gm/dL, RBC 1300/mm3, amylase 169 U/L, pleural fluid – serum LDH ratio was 0.48. Pleural fluid gram stain, cultures (aerobic, anaerobic, AFB, fungal) and cytology were all negative. Computerized tomography of chest showed the massive left-sided unilateral pleural effusion with complete collapse of the left upper and lower lobes, but no pulmonary embolism or malignancy. . Echocardiogram was normal. Ultrasound of abdomen was remarkable for fatty liver, but no ascites. Magnetic resonance cholangio-pancreatography (MRCP) showed normal pancreas and biliary system without ascites. Tuberculin skin test, ANA, ANCA, AMA, ceruloplasmin, TSH, HIV, RPR, and Hepatitis virus serology were normal. Due to frequent massive re-accumulation a diagnostic and therapeutic video assisted thoracoscopy (VATS) procedure was performed, which revealed a 2 cm diaphragmatic hernia with inflamed, friable, incarcerated omentum and small amount of bowel. This inflamed omentum was determined to be the etiology for the recurrent pleural effusion. About 3.5 liters of pleural fluid was removed by VATS. Histopathology was consistent with moderately inflamed omentum. Hernia was repaired and talc-pleurodesis was performed. There was no re-accumulation on follow-up over 2 years .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2253_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2253_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..12bc3be921ad3cc32bcd32bd9d3e644bd8c0accf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2253_en.txt
@@ -0,0 +1 @@
+A 82-year-old man living on the French Riviera presented at the emergency department for fever and chills lasting for 5 days. He complained of severe asthenia. He came back two weeks ago from a travel in New York city, USA with a two days stay on the Long Island countryside. He did not note any insect bite during his travel. Jaundice was noticed on examination as well as slightly enlarged spleen and liver. Blood test showed an abnormal blood cell count with neutropenia (0·5 G/L), lymphopenia (0·3 G/L), thrombocytopenia (30×109/L) and anemia (haemoglobin of 91 g/L) with a low reticulocyte count (45 G/L). Blood test also showed increased C reactive protein (154 mg/L), raised ferritin (5953 ng/ml) and liver enzymes were elevated (ALT 56 UI/L (N<40), AST 68 UI/L (N<53), Alkaline phosphatase 213 UI/L (N<129), total bilirubin 48·9 μmol/L). Haptoglobin was undetectable, LDH levels increased 620 UI/L (N<225) and coagulation tests were in normal range. Routine blood cultures were negative. Bone marrow aspiration was performed because of the severe cytopenias associated with a low reticulocyte count and showed typical hemophagocytosis . Microscopic examination of the blood smear and the bone marrow stained with Giemsa showed intra-eryhtrocytic parasites . The parasitemia was evaluated about 3% of red blood cells. Rapid testing for Plasmodium falciparum by PCR revealed negative. Intravenous treatment for babesiosis with clindamycin and quinine was started. Patient’s clinical status improved with the resolution of the fever after 3 days of treatment. Blood analysis improved after the 10 days treatment course (haemoglobin 104 g/L, platelets 220×109/L, neutrophils 3 G/L, C reactive protein 16 mg/L). PCR testing on blood for babesia was positive . Babesia microti was confirmed by PCR with specific primers (LDH gene amplification) as shown on Figure B. Serology for Borrelia burgdorferi, the agent of Lyme disease, was negative.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_225_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_225_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fb5028f1db373c64ae67b7601f4d32f66a37d593
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_225_en.txt
@@ -0,0 +1,3 @@
+A 74-year-old Japanese female patient with a history of ischemic heart disease, nonvalvular atrial fibrillation, cerebral infarction, chronic kidney disease, and hypothyroidism was brought to the emergency department after a cardiac arrest at home. After a few minutes of manual CPR by her family and paramedics, mechanical CPR was initiated using the Lund University Cardiopulmonary Assist System-2 device (Physio-Control Inc.). The patient was defibrillated twice for ventricular fibrillation. She received multiple doses of epinephrine, and spontaneous circulation returned after 29 min of mechanical CPR. The device was used in its appropriate position.
+However, as pulseless ventricular tachycardia was still observed, cardiac support with venoarterial extracorporeal membrane oxygenation (VA-ECMO) was initiated. Coronary angiography revealed no new lesions in the coronary arteries. A noncontrast CT scan was carried out to investigate the cause of cardiac arrest. This revealed multiple bilateral anterior rib fractures due to the chest compressions, with no evidence of other injuries . The cause of the arrest was considered to be hypokalemia (admission level K = 2.6 mmol/L) induced by multiple diuretic drugs. The patient was admitted to the intensive care unit for continued resuscitation. Furthermore, she received continuous infusions of unfractionated heparin based on active coagulation time. She was given prasugrel and apixaban because of her atrial fibrillation and high risk of stent thrombosis.
+On hospital day 3, her blood pressure gradually decreased, and ECMO flow could not be maintained the following day. The patient had already received more than 20 units of blood products and was on a high-dose vasopressor. Blood examination revealed progressive coagulation abnormalities . The results were as follows: activated partial thromboplastin time, 136 s; prothrombin time activity, 31%; and platelet count, 25 × 109/L. Abdominal ultrasound revealed an echo-free space around the liver and spleen. An emergency laparotomy was carried out due to the massive bloody ascites observed on contrast-enhanced CT . Intraoperatively, a grade 2 splenic injury (according to the American Association for the Surgery of Trauma) was observed with a capsular tear and a 2 cm laceration at the inferior pole. The spleen was adherent to the retroperitoneum and diaphragm. The abdomen was temporarily closed using an open negative-pressure therapy system, ABThera (KCI). The volume of blood loss was greater than 10 L. As the patient was hemodynamically stable the next day, VA-ECMO was discontinued. Her coagulation abnormalities were resolved after management with the interruption of antithrombotic agents, surgical hemostasis, and blood transfusions. Abdominal closure was achieved on day 6. Histopathological examination of the excised splenic tissues was unremarkable. Tracheostomy was carried out on day 15, she was discharged from the intensive care unit on day 26, and transferred to a rehabilitation hospital on day 87 with no neurological deficits.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2275_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2275_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c7ec57465016ea2710e474e13f8c0abbdb09235
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2275_en.txt
@@ -0,0 +1,3 @@
+A 68-year-old Caucasian man was referred to our out-patients clinic following the incidental discovery of a 6 × 8 cm distended iliac vessel whilst having an ultrasound for surveillance of liver cirrhosis. His clinical history revealed a progressive history of right flank pain, worsening right leg claudication and a persistently cold sensation in his right foot. He also complained of progressive breathlessness on exertion, clinically suggestive of deteriorating CCF. There was no history of trauma or previous surgery. Ankle-brachial pressure measurements revealed a reduced index of 0.76 on the right, and a normal index of 1.35 on the left with corresponding toe pressures of 55 mmHg and 143 mmHg respectively. A contrast enhanced computed tomography (CT) scan showed an isolated right common iliac artery (CIA) to right common iliac vein AVF . His aorta was normal in caliber, measuring 19 mm at the aortic bifurcation. The aneurysmal segment began immediately distal to the aortic bifurcation at the origin of the right CIA, with no normal segment of CIA evident. The aneurysm measured 9.4 cm in maximal diameter and extended to within 17 mm of the right iliac bifurcation. It was impossible to differentiate the arterial wall from the venous wall in the aneurysmal segment on either ultrasound or CT scans. His inferior vena cava (IVC) was grossly distended with a uniform diameter of 36 mm in its full course.
+Pre-operative discussions focused on finding an endovascular strategy to solve the problem. As no normal caliber proximal right CIA existed, an isolated iliac covered stent was impossible as no proximal sealing zone existed. This required sealing a proximal stent in his aorta. Bifurcated endografts have been used to seal ilio-iliac fistulae previously . The aortic bifurcation diameter was 19 mm in this case and although some devices have reported success negotiating smaller aortic bifurcations , we felt an aorto-bi-iliac graft would be in danger of being compressed at the bifurcation with a high risk of occlusion. As a result, a hybrid approach with deployment of an aorto-uni-iliac (AUI) device followed by a femoro-femoral bypass was planned. Our patient was operated upon in our endovascular suite (Siemens) under spinal anesthesia. Both common femoral arteries (CFA) were controlled and cannulated with 6Fr sheaths (Johnston & Johnston). His aorta was cannulated with a 0.035 wire Bentson wire (Cook Medical, Bloomington, IN, USA) via each CFA with the assistance of an angled catheter (Kumpe, Cook Medical). A diagnostic flush pigtail catheter was placed in his aorta via the contralateral limb. A stiff 0.035 Amplatz wire (Amplatz Super Stiff, Boston Scientific) was exchanged as access to the ipsilateral limb. Following an angiogram to confirm renal anatomy, an aorto-uni-iliac device (Zenith Renu, Cook Medical) was deployed from immediately below his renal arteries to his mid right external iliac artery, thus occluding his right internal iliac artery. A 14 × 10 mm Amplatzer occlusion device (AGA Medical Corp, MN, USA) was deployed via the contralateral limb to his proximal left CIA. A completion angiogram confirmed exclusion of the ilio-iliac AVF. A right to left femoro-femoral bypass with 8 mm polytetrafluoroethylene (PTFE) was performed to re-establish flow to his left leg as well as providing left internal iliac perfusion.
+On the first postoperative day, the mass was no longer pulsatile and the machinery-like murmur in the right iliac fossa was absent. A CT scan on postoperative day two confirmed a patent AUI endovascular graft and patent femoro-femoral bypass, as well as confirming exclusion of contrast from the right iliocaval system . His right foot no longer felt cool and the postoperative ankle brachial index (ABI) confirmed an index of 1.05 on the right and 0.95 on the left, with corresponding toe pressures of 119 mmHg and 117 mmHg respectively. He was discharged after seven days without complication. At a clinic one month later, his claudication had resolved completely and he no longer had symptoms suggestive of CCF. A duplex ultrasound confirmed exclusion of arterial flow from the iliocaval vessels.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2298_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2298_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..35096e9034067fe2f8d17bb24f4ed64637f6cfc4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2298_en.txt
@@ -0,0 +1,6 @@
+A 43-year-old male patient, a cigarette smoker who works as an office employee, was diagnosed with MG in February 2019. The condition started on December 2018 with weakness in the left side of his face associated with dysarthria that was misdiagnosed as left Bell’s palsy, for which the patient received steroid therapy and physiotherapy with no response to the medication. A few months later, the condition progressed to be associated with diplopia with a blurring of vision, followed by bulbar manifestations in the form of dysphagia with nasal regurgitation to fluid and frequent choking. Within a few days, the patient developed neck muscle weakness, especially flexion, with proximal weakness of the upper and lower limbs. These manifestations had diurnal variation, with increased symptoms at the end of the day and increased with exertion. Till this time, the patient received non-specific treatment.
+The patient sought medical advice, and repetitive nerve stimulation in the frontalis and deltoid muscles was done in February 2019, revealing a positive decrement test for myasthenia. The serum level of the acetylcholine antibody was positive, and the titer was 7.9 nmol/l (negative if < 0.4 nmol/l). The patient was hospitalized and received six sessions of plasmapheresis with complete improvement. During this time, no chest imaging was done to assess the thymus gland status and the patient was managed conservatively and was prescribed acetylcholine esterase inhibitors (pyridostigmine 60 mg) twice daily with azathioprine twice daily and steroids that were gradually tapered, but the patient was incompliant with the treatment and developed recurrent attacks of exacerbations.
+In September 2021, the patient complained of epigastric pain, dysphagia, and repeated food regurgitation and sought medical advice several times. Upper endoscopy revealed only hyperemic edematous mucosa with multiple fundal and pre-pyloric gastric ulcers. The patient was prescribed medical treatment with proton pump inhibitors with no improvement in his gastrointestinal tract (GIT) symptoms (vomiting and dysphagia, described as a sensation of food sticking behind his chest).
+In November 2021, the patient developed worsening of his MG symptoms with a chest infection suggestive of pneumonia and was admitted to the hospital’s intermediate care unit. The patient was investigated for Corona Virus Disease 2019 (COVID-19) infection with a complete metabolic profile, and multislice computed tomography (MSCT) chest were done. The complete metabolic profile was normal, apart from absolute lymphopenia. The MSCT chest with and without contrast showed a ground glass appearance in both lungs suggestive of COVID-19 (CORAD III). Other findings in the MSCT chest included: iso-dense left anterior mediastinal soft tissue mass measuring about 6.7 × 6.7 × 5 cm, with minute foci of calcification. The mass showed homogenous enhancement in the post-contrast study, partially encasing the left innominate vein with no definite infiltration . Also, the distal part of the esophagus was minimally dilated and filled with fluid with no definite mass lesion. At first, the patient was managed for his COVID-19 infection. In January 2022, after controlling the infection, CT guided true cut needle biopsy was done for his left anterior mediastinal mass, which revealed undifferentiated neoplasm for immunohistochemistry.
+A few days later, the patient was transferred to neurology due to his myasthenic crisis. His neurological examination showed bilateral ptosis, diplopia, weakness of muscle of facial expression, neck muscle weakness more in neck flexors, and proximal weakness of both upper and lower limbs (grade 4a according to the medical research council muscle grading system), with unremarkable rest of neurological examination. The patient received five sessions of plasmapheresis with complete improvement apart from unexplained persistent dysphagia and vomiting. The patient was assessed by a cardiothoracic consultant and prepared for elective thymectomy. In March 2022, transsternal extending thymectomy of left thymus mass with partial resection of innominate vein via median sternotomy. The histopathological examination revealed a picture of thymoma type B2, p T1 (cortical thymoma and polygonal cell thymoma). After surgery, the patient was stable because he did not need postoperative mechanical ventilation and did not develop a postoperative myasthenic crisis. The patient was discharged home and received the postoperative treatment (levofloxacin, bronchodilators and anti-inflammatory) and continued MG medication (pyridostigmine 60 mg four times daily).
+In June 2022, another attack of MG exacerbation for which the patient was admitted and received five sessions of plasmapheresis with partial improvement of his symptoms except for persistent vomiting after meals and regurgitation of undigested food with dysphagia. The patient was discharged on medical treatment (pyridostigmine 60 mg three times daily, azathioprine 50 mg twice daily, and steroid with gradual tapering). After gastroenterology consultation for his GIT symptoms and investigations, including upper endoscopy, barium swallow, and high-resolution esophageal manometry (HRM), the diagnosis of achalasia was confirmed. Upper endoscopy showed dilated esophagus with retained fluid and spastic cardia . The barium swallow study showed dilated esophagus with a bird beak appearance, and HRM showed achalasia type II . In July 2022, elective pneumatic balloon dilatation (PBD) was done with successful dilation and remarkable improvement of the patient’s GIT symptoms. The patient is now stable on his MG medical treatment for the sixth month’s follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2318_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2318_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e467763a9ae164a4e438ec9a388a255e7e9c684f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2318_en.txt
@@ -0,0 +1,7 @@
+A 58-year-old woman was referred to our center for further investigation of a cystic lesion in the pancreas. She has a history of repeated resection for brain tumor diagnosed as meningioma in another hospital. The first brain surgery was performed at 31 years of age, and she underwent surgical excision of the recurrent tumor 16 and 26 years after the initial resection. During admission in a community hospital for the treatment of a femoral bone fracture, computed tomography (CT) incidentally detected a 5.5-cm cystic tumor in the pancreas tail.
+The laboratory data on admission in our hospital indicated a slightly elevated level of serum lipase (56 IU/L; normal range, 13–55 IU/L) and gamma-glutamyl transpeptidase (47 IU/L; normal range, 9–32 IU/L). In contrast, the tumor marker levels of carcinoembryonic antigen, carbohydrate antigen 19-9, and DUPAN-2 were within the normal range.
+Endoscopic ultrasonography (EUS) revealed a circumscribed well-encapsulated cystic mass in the pancreas tail with protruding vascularity-rich components inside. A hypervascular area that appeared like collateral vessels was also observed on the surface of the tumor . Dynamic contrast-enhanced CT showed a heterogeneously enhancing mass beside the splenic hilum with a large non-enhancing portion inside. From the arterial to portal phase, strong enhancement was observed both in the rim and the edge of the protruding solid components with the hypoattenuating area inside the solid lesions. During the portal to delay phase, all of these were gradually isoattenuated compared to the surrounding pancreatic parenchyma except for the non-enhancing portion . Magnetic resonance imaging (MRI) confirmed low signal intensity in the solid components on T1-weighted imaging and slightly higher signal intensity on T2-weighted imaging compared with the pancreas parenchyma. Additionally, the large non-enhancing portion on CT appeared as a bright signal on T2-weighted imaging, indicating cystic or necrotic change .
+Based on these findings, we considered pancreatic neuroendocrine neoplasm, solid pseudopapillary neoplasm, and hemangioma in the differential diagnosis. Although its morphological structure is untypical, mucinous cystic neoplasm was also considered given the patient’s sex and tumor location. Invasive carcinoma of the pancreas was excluded from the differential diagnosis. EUS-guided fine-needle aspiration biopsy (EUS-FNA) was not performed considering the risk of cystic puncture and bleeding. We performed distal pancreatectomy with regional lymph node dissection for this disease. The pancreatic parenchyma was resected above the left edge of the superior mesenteric artery. The postoperative course was uneventful, and the patient was discharged on the 15th postoperative day.
+The resected specimen revealed a well-demarcated hemispheric cystic mass projecting from the pancreas tail and measuring 5.6 × 5.4 cm in diameter. The solid components occupied most of the lesion . The pancreatic stump was free of tumor with a margin of approximately 3 cm including the width of the stapler closure. Histopathological examination confirmed that oval and spindle-shaped cells proliferated bluntly with a richly vascular stroma, and they were configured to be a hemangiopericytoma-like structure . Immunohistochemically, the specimen stained positively for CD34, a mesenchymal marker , but negatively for cytokeratin AE1/3, an epithelium marker (data not shown). Furthermore, CD99, Bcl-2, and STAT6 were diffusely positive , whereas beta-catenin, chromogranin, and synaptophysin were all negative (data not shown). Therefore, we diagnosed this tumor as SFT of the pancreas. Further, the tumor showed an increased mitotic rate (ten mitoses per ten high-power fields), indicating its malignant potential.
+Considering the similarity of meningioma, which was the patient’s past disease, to intracranial SFT, we conducted a histopathological review of her brain tumor. We found that it had the same characteristics as the pancreatic tumor and thus determined that the SFT of the pancreas was derived from the central nervous system tumor.
+She underwent no adjuvant therapy, and no recurrence has been observed in the abdominal cavity. However, she developed meningeal dissemination 4 years after the pancreatectomy and is currently undergoing treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2328_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2328_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eb74c27013ca80aea090fb241e213c97cca46948
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2328_en.txt
@@ -0,0 +1,9 @@
+We present a case of acute angle closure due to spontaneous suprachoroidal haemorrhage secondary to loss of anti-coagulation control.
+A 67-year-old man, who recently returned from a holiday abroad, presented with a one-day history of worsening right visual acuity and 4 day history of increasing right retro-bulbar pain not relieved with simple analgesia.
+He had a past medical history of essential tremor managed with Propranolol, Atrial Fibrillation on anticoagulation with Warfarin 4 mg daily – target International Normalised Ratio (INR) 2.5. Possible confusion with his tablets in the week leading up to the start of his symptoms.
+Our patient was also known to have normal tension glaucoma (NTG) managed with Latanoprost. He had Selective Laser Trabeculoplasty (SLT) to the right eye 12 months before to improve his intraocular pressure control. His last recorded visual acuity (VA) was 6/6 in both eyes.
+On examination the patient was found to have reduced VA in the right eye 6/12 with an injected conjunctiva, cloudy cornea and a mid-dilated pupil with a very shallow anterior chamber (AC) and closed irido-corneal angle on gonioscopy . Fundus exam revealed a large supero-nasal suprachoroidal haemorrhage not involving the macula. His right intra-ocular pressure (IOP) was 42 mmHg. The left eye had a VA of 6/6 with a deep AC and IOP of 12 mmHg . He was therefore diagnosed with acute angle closure secondary to spontaneous suprachoroidal haemorrhage. His INR measured at > 8. The patient was given 1 mg of Vitamin K to reverse his INR, which quickly came down to 5.1. Advice was taken from the general physicians’ team and no further Vitamin K doses were given.
+He was started on maximal topical and systemic IOP lowering treatment including G. Apraclonidine 1% TDS, G. Latanoprost 0.005% ON, G. Brinzolamide/Timolol (Azarga®) and Oral Acetaolamide 250 mg QDS as well as cycloplegia with G. Atropine 1% OD.
+After 12 h the IOP was 27 mmHg and INR 3.1. But unfortunately, in the following 12 h, the patient had a second bleed, and his IOP went up to 42 mmHg and VA was down to finger counting. There was no view of the fundus due to corneal edema. B-Scan Ultrasound showed an extension of the suprachoroidal haemorrhage, covering 360 degrees and involving the fovea .
+For the next 7 days the patient’s remained on the same medical treatment and his IOP was stable in the high 20s. A decision was taken to perform a combined phacoemulsification and lens implant, pars-plana vitrectomy and suprachoroidal haematoma drainage under general anesthesia. (Additional file 1).
+Six weeks post operatively the patient had a wide-open angle with a central IOL and a flat retina . Intraocular Pressure without IOP lowering treatment was recorded at 20 mmHg with VA 6/24. He was restarted on IOP lowering topical treatment (G Brinzolamide/Timolol BD).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2335_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2335_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d8690d2d74a9dd96b1037b2d10482df05dd47d43
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2335_en.txt
@@ -0,0 +1,4 @@
+The patient was a 16-year-old female with a past medical history of type 1 diabetes on insulin pump therapy, previous episodes of DKA, and autoimmune hypothyroidism. She presented to the emergency department with altered mental status, severe abdominal pain, and multiple episodes of vomiting. According to her mother, all her symptoms started within the prior 24 hours. The patient was observed to be awake but disoriented with generalized abdominal tenderness to palpation. The insulin pump was taken off by the family just prior to presenting to the hospital. She presented to the hospital via emergency medical services, and her vital signs were normal upon arrival. Initial physical examination revealed a Glasgow Coma Scale (GCS) of 12 (eyes 3, verbal 4, motor 5) and the patient was localizing to pain on palpation of the right lower quadrant, without any other significant exam findings. Monitoring and intravenous (IV) access were established, and blood for laboratory evaluation was collected.
+The patient was started on a lactated Ringer’s infusion. Her vital signs remained stable and upon re-evaluation, her GCS remained unchanged. With her clinical picture and previous history with DKA, initial concern was for DKA, although her initial point-of-care glucose was 109 mg/dL (reference 80–140 mg/dL) Subsequent point-of-care glucose readings showed decreasing levels less than 100 mg/dL (80–140 mg/dl) requiring glucose administration. Because of initial normal point-of-care glucose readings, the treating team pursued other causes of altered mental status. Initial labs were significant for a venous pH of 7.2 (7.35–7.45), bicarbonate of 8 mEq/L (21–28 mEq/L); anion gap of 33 millimoles per liter (mmol/L) (4–12 mmol/L); lactate of 2 mmol/L (0.5–1 mmol/L); sodium 133 mEq/L (135–145 mEq/L); potassium 4.9 mEq/L (3.6–5.2 mEq/L); blood urea nitrogen 19 mg/dL (7–20 mg/dL); creatinine of 0.8 mg/dL (0.84–1.21 mg/dL); beta-hydroxybutyrate of 3.26 mmol/L (0.4–0.5 mmol/L); initial plasma glucose of 108 mg/dL (80–140/mg/dL); and leukocytosis of 20,600 per microliter (4500–11000 per microliter).
+Urine toxicology, salicylate, and acetaminophen screen and pregnancy test were negative. A non-contrast computed tomography (CT) of the brain was unremarkable. She also had an IV contrast-enhanced CT of the abdomen, which was suspicious for possible early appendicitis. With her resulting labs, other causes of elevated gap metabolic acidosis were considered. An endocrine consult was obtained for possible eDKA. Based on the consult and test results, the patient was started on an insulin drip at 0.1units per kilogram per hour as well as an infusion of a dextrose 10% solution.
+Pediatric surgery was consulted, and after exam and review of the CT results recommended that the patient be taken to the operating room for an appendectomy. Surgical findings were noted to be equivocal and the appendix was removed without complication. The patient’s mental status improved post appendectomy. With fluid and insulin therapy her condition improved, laboratory abnormalities normalized within a few days, and she was subsequently discharged home. The consulting teams agreed that the final diagnosis was eDKA likely caused by appendicitis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2339_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2339_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dfc9cf24919652d482a50138c939d39b54499509
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2339_en.txt
@@ -0,0 +1,5 @@
+In October 2011, a 70-year-old Han Chinese woman with Type 2 diabetes (T2D) was admitted to Department of Endocrinology at the Tianjin Medical University General Hospital for uncontrolled hyperglycemia. The patient had a history of T2D for 21 years and received continuous long-term insulin treatment with a dosage of about fifty units per day. On the seventh day after admission, the patient developed symptoms of nausea and vomiting accompanied by left leg radiating pain without diarrhea and fever. She did not present with headache, dizziness, disturbance of consciousness, melana or hematemesis. The medications used in the hospital are listed in Table . The patient had no recent history of using diuretic agents. Serum sodium levels decreased to 112 mmol/l and chloride levels to 81 mmol/l with an effective osmolality at 267 mOsm/kg.H2O (normal range: 280–310 mOsm/kg.H2O). Urinary sodium increased to 85 mmol/l and chloride to 86 mmol/l with an osmolality of 257 mOsm/kg.H2O indicating hypotonicity during normal dietary salt intake. She was clinically normovolemic with no signs of fluid retention. Her hepatic and renal functions were normal with a serum creatinine of 68 (normal range: 44–115) umol/L. Fractional sodium excretion was calculated as 1.56%. Thyroid and adrenal function were measured with ACTH = 59.8 pg/mL(normal range: 0–46), cortisol = 25.6 ug/dL(normal range: 5–25), 24-hour cortisol in urine = 64.4 ug(normal range: 30–110), FT3 = 3.04 pmol/L(normal range: 3.5–6.5), FT4 = 19.76 pmol/L(normal range: 11.5–23.5), TSH = 3.657 uIU/mL(normal range: 0.3–5.0) and rT3 = 1.76 nmol/l (normal range: 0.43–1.15). The magnetic resonance imaging (MRI) of her pituitary gland showed herniation of the suprasellar cistern. Based on the MRI result, our first diagnosis was hypopituitarism, which was treated with intravenous hydrocortisone at 50 mg/day. Both the serum sodium and serum chloride increased from 112 to 116 mmol/l and from 81 to 84 mmol/l, respectively, on the following day.
+After further inquiry, the patient informed us of a past history of Mucosal-associated lymphoid tissue lymphoma (MALT) which had not received further treatment. We also discovered that she was last hospitalized on March 2011 for uncontrolled hyperglycemia without symptoms of nausea and vomiting. Nevertheless, hyponatremia had been noticed with serum sodium of 131 mmol/L and serum chloride of 95 mmol/l. Urinary investigation showed increased levels of sodium (90 mmol/l) and chloride (83 mmol/l) without corresponding osmolality data. Her renal function was normal with a serum creatinine of 63 umol/L. This information led us to believe that SIADH caused the patient’s hyponatremia. Three days after restricting fluid intake to 1000 ml/day, the serum sodium rose to 128 mmol/L from 116 mmol/L. Ten days later, the patient’s serum sodium levels increased to 142 mmol/l, and the symptoms of nausea and vomiting disappeared.
+Since the patient had a past history of MALT, we performed a gastric endoscopy, which indicated the absence of lymphoma. Additionally, the serology result was negative for purified protein derivative (PPD), and the serum and urine protein electrophoresis were also negative for monoclonal gammopathy. Additional laboratory findings were listed in Table . A negative chest computed tomography (CT) scan excluded the possibility of SCLC as the cause of SIADH in this patient. However, we noticed that the patient had obvious pain in the left leg, abdominal distension, and skin itching on a clinical exam and further discovered that her abdomen circumference had increased significantly in the last six months. An abdominal CT scan showed that a mass measuring approximately 49 mm*70 mm*90 mm was located on front lumbar vertebra 1–4 and the surrounding abdominal aorta. A subsequent abdominal enhancement CT revealed that the mass might be lymphoma . As the pathological result was critical for her diagnosis, we conducted a left inguinal lymph node puncture showing no abnormal lymphocytes. Consequently, a whole left inguinal (2 × 1 × 0.5 cm) lymph node was resected. The pathological morphology revealed that the lymph node structure was replaced with substantial amounts of lymphoid tissue and fibrosis. Thus, the diagnosis of Castleman’s disease was established according to the pathological exam .
+Although hyponatremia was corrected, her hemoglobulin levels decreased from 109 g/L to 96 g/L. With her consent, we conducted a biopsy of the enlarged abdominal lymph node by using a celioscope. The pathological exam disclosed diffuse large B-cell lymphoma with an anaplastic subtype .
+After the diagnosis of lymphoma was established, the patient was transferred to the Department of Hematology for further treatment. For the etiology treatment of B-cell lymphoma, the chemotherapy of cyclophosphamide, hydroxydaunorubicin, oncovin and prednisone (CHOP) with rituximab (a monoclonal antibody against the protein CD20) was administered. The patient’s serum sodium level stabilized without fluid restriction.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2348_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2348_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e17d6e797615abe0ed71822f10a7760558de4c35
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2348_en.txt
@@ -0,0 +1,5 @@
+A 73-year-old male presented to the emergency department with complaints of fevers peaking at 104 °F, chills, and rigors for 4–5 days. The patient's past medical history was significant for oropharyngeal squamous cell carcinoma treated with resection and adjuvant radiotherapy, hypopharyngeal squamous cell carcinoma treated with laryngopharyngectomy and neck dissection with tracheostomy, prostate cancer, and melanoma. Per the patient, he did not have any pets and did not have any other zoonotic exposure. The patient resided in the city (urban environment) and had retired from his job as a construction worker 15 years earlier. The patient reported that several days prior to the onset of symptoms, he had started a new chemotherapy regimen for his squamous cell carcinoma. He also reported a chronic intermittent productive cough that was old. The rest of the patient's review of systems was negative.
+The patient's vital signs upon admission were as follows: temperature of 39.2 °C, heart rate of 109 beats/minute, blood pressure of 99/70 mmHg, and respiratory rate of 26 breaths/minute, with a SpO2 of 100%. Physical examination yielded a gentleman who was lying comfortably in bed and was warm to the touch, with a tracheostomy in place. The tracheostomy appeared clean, non-erythematous, and free of discharge. Pulmonary auscultation revealed breath sounds decreased in the right lung, as well as coarse crackles.
+Lab results were as follows: white blood cell count 13.4 K/μL with 88% neutrophils and 9% bands, hemoglobin 12.2 g/dL, platelet count 114 K/μL, albumin 2.9 g/dL, and lactic acid 1.4 mmol/L. A urinalysis was performed, which was unremarkable. A chest x-ray showed a new right mid lung nodule and right basilar opacity suggestive of pneumonia or mass.
+Blood cultures were drawn, and the patient started empiric antibiotic therapy with intravenous cefepime, vancomycin, and metronidazole, which was subsequently switched to ampicillin/sulbactam, for presumed sepsis secondary to pneumonia. Two of the four blood culture bottles grew P. multocida sensitive to amoxicillin/clavulanic acid, tetracycline, and penicillin G. A subsequent computed tomography scan of the chest showed multiple lung masses which were suspicious for metastases. A transthoracic echocardiogram showed no signs of infective endocarditis. After consultation with pulmonology and infectious disease, antibiotics were switched to amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth. Lower respiratory cultures were done which showed gram negative bacteria and later showed Pasteurella. This was considered consistent with blood cultures and the source for infection was considered secondary to obstructive pneumonia due to multiple lung masses. Speciation was not available from the lower respiratory cultures. Nasopharyngeal swab was not done.
+The patient continued to improve, and the repeat blood cultures after 48 h were negative. As the patient did not have any new cardiovascular abnormalities and repeat blood cultures were negative with medical therapy, infectious disease did not recommend a transesophageal echocardiogram. The patient was discharged with amoxicillin/clavulanic acid 875 mg–125 mg twice daily by mouth to complete a 14-day course.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2388_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2388_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2f8a3d32a03ae2900d763c649f8bc31abaf436f3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2388_en.txt
@@ -0,0 +1,13 @@
+The patient is a 28.9-year-old woman, born after a full-term pregnancy from unrelated healthy parents. Maternal age was 44 years and paternal age was 40. Foetal movements were decreased during pregnancy. Caesarean section was necessary because of premature rupture of the membranes. Birth weight was 2450 g. After delivery the patient showed severe muscular hypotonia, weak cry, sleepiness, poor deep tendon reflexes and abnormalities in thermoregulation. Feeding problems were noted due to a poor sucking reflex and the baby required gavage. She was discharged with diagnosis of congenital benign hypotonia. She had a psychomotor delay, non-specific mild dysmorphisms and strabismus. Karyotype was normal (46, XX). Neonatal screening for CH showed normal thyroxine (T4) levels and a slightly elevated TSH (24 μU/ml), both of which were confirmed with a blood sample. Nevertheless, she was not treated. The patient was firstly admitted at our hospital at 9 months of age because of elevated serum level of TSH (40 μU/ml - nv <4 μU/ml), with normal FT4 (8 pg/ml – n.v. 5–12.5 pg/ml). She had a supine length of 66 cm (<10th percentile), a body weight of 8 kg (<25th percentile) and a head circumference of 45.5 cm (97th percentile). The thyroid ultrasound revealed the absence of the gland in the neck , while the 99mTc-pertechnetate thyroid scintigraphy showed a small, ectopic, sublingual thyroid gland .
+Thus, levo-thyroxine therapy was promptly initiated (8 μg/kg/die) and the dose was gradually adjusted over several months with normalization of FT4 and TSH levels.
+Due to the persistence of hypotonia and poor response to stimuli, associated with the absence of sucking reflex in the first weeks of life, a brain computed tomography scan was done at 12 months of age, which showed ventricular enlargement and craniosynostosis.
+Two years later, at the age of three, the patient showed poor physical and developmental progress, despite being biochemically euthyroid on levo-thyroxine substitution therapy, and associated hyperphagia, weight gain, short stature and decreased growth velocity. In addition, physical examination revealed a more distinctive phenotype, characterized by peculiar facial features (narrow bifrontal diameter, dolichocephaly, almond-shaped eyes, downturned angles of the mouth) with abundant thick saliva, small hands and feet. At this age a severe scoliosis was diagnosed, treated initially with a corset. The patient later required surgery at the age of 13.
+To evaluate growth retardation, two growth hormone (GH) stimulation tests (clonidine 0.150 mg/m2 orally and insulin tolerance test 0.1 UI/kg i.v. bolus) were performed and both of them were consistent with a diagnosis of GH deficiency [GH peak 1.7 ng/ml and 5.6 ng/ml, respectively (nv >10 ng/ml)]. The combined test [GHRH (1 μg/kg) + Arginine (0,5 g/kg iv)] confirmed the presence of reduced GH response [GH peak 8.7 ng/ml (nv >20 ng/ml)]. Pituitary MRI revealed an empty sella with a small, hypoplastic pituitary gland at its base.
+Therefore, GH therapy was initiated at 0.24 mg/kg/week, subsequently dose adjusted based on IGF-1 levels and growth curve, and continued until the age of 12.9 years.
+At the age of 9, given her constellation of signs and symptoms, PWS diagnosis was considered, as a possible cause of her clinical picture, but because of the mother’s initial refusal genetic tests were performed only at the age of 16. Methylation analysis and DNA polymorphism analysis of chromosome 15 confirmed the presence of UPD15.
+Since the age of 10.2 both central and obstructive sleep apnea were noted on polysomnographic study, for which the child subsequently required non-invasive ventilation (NIV).
+She also presented skin-picking starting at age 11 and worsening with age.
+At the age of 14.1 a right ovarian cyst was removed. Since our patient had no spontaneous menarche, she underwent a LHRH test at age 22 that documented a complete hypogonadism of central origin with concomitant low estradiol levels. Consequently, sex steroid replacement was initiated.
+Corticotrophin deficiency was excluded because cortisol response to low-dose ACTH test was normal (22 μg/dL - nv >18.1 μg/dL).
+Starting from transition phase, she had episodes of psychosis that required antipsychotic therapy. Over the years a progressive worsening of obesity was observed, due to her uncontrolled eating habits and poor compliance with diet therapy. At the age of 24 a bioenteric intragastric balloon (BIB) was inserted for treatment of morbid obesity, with a transient weight loss of 13 kg in 9 months.
+At the last examination (28.9 years), the patient’s anthropometric data were the following: height 142.8 cm (−3.07 SDS); weight 119.2 kg, body mass index (BMI) 59 kg/m2. Blood pressure was normal. She presented mild mental retardation, outcomes of operated scoliosis and skin-picking, and continued utilization of NIV for sleep disordered breathing. Oral glucose tolerance test was normal, but hyperinsulinism was present. She is on therapy with L-thyroxine (125 μg/die), sex steroids replacement and psychotropic drugs (risperidone and carbamazepine) for recurrent psychotic crises.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2392_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2392_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ce86ccab6df21da63f8dc65385acb4b8d67e143d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2392_en.txt
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+A 13-year-old female patient presented to the Department of Endodontics with complaint of mild pain in the maxillary right anterior tooth that had persisted for 10 d.
+The pain in the upper right anterior tooth started 10 d before presentation. During that time, the patient had taken anti-inflammatory drugs whenever she felt the pain. Since the drugs had only provided temporary pain relief, she wanted to get it checked.
+The patient’s history of past illness was irrelevant.
+The patient’s personal and family histories were unremarkable.
+On physical examination, the maxillary right lateral incisor (tooth #7 by the universal numbering system) was found to be slightly rotated, without caries, restorations or fractures; it appeared identical to the maxillary left lateral incisor, without any coronal morphological variation. The tooth was slightly tender on percussion and had grade I mobility, but no pockets were detected. The tooth was considered non-vital as it did not respond to electric and thermal pulp vitality tests.
+Radiographic examination revealed an unusual configuration of root canals in tooth #7, with an invagination extending to the apex, suggesting the possibility of DI Oehler’s type IIIB and a periapical radiolucency. A panoramic radiography was undertaken to ascertain the root canal anatomy of the maxillary lateral incisor on the other side of the arch, which was found to be normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2396_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2396_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7ef2599cde653edc2dc523683bb7290414cd84a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2396_en.txt
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+A man in his late 60s with a history of Stage I melanoma of the upper thigh, for which he had undergone wide local excision and negative sentinel lymph node biopsy 2 years prior, presented with new metastatic disease. On imaging, he was found to have lesions of the lung, liver, vertebrae, and brain. Fine needle aspiration of a thoracic lymph node confirmed metastatic melanoma. Next generation sequencing was notable for BRAF V600E mutation.
+The patient started treatment with combination ipilimumab and nivolumab. While undergoing immunotherapy, the patient also received radiation to his T7-T10 vertebral metastases (30 Gray (Gy) in 10 fractions) and had stereotactic radiosurgery (SRS) to 16 brain metastases. Spinal irradiation was performed with a 3D conformal technique using opposed anterior-posterior/ posterior-anterior fields. The maximum dose to the spinal canal was 33.5 Gy.
+Magnetic resonance imaging (MRI) of the brain following SRS showed marked treatment response. Re-staging computed tomography (CT) of the chest, abdomen, and pelvis, performed 2 months after his initial staging scans, also showed major systemic response. Prior to starting his fourth cycle of ipilimumab and nivolumab, the patient noted the onset of intermittent numbness and tingling of the soles of his feet, with gradual ascension to his knees over the next 2 months.
+MRI brain 1 month later showed a new punctate cerebellar metastasis, which was treated using SRS. Positron emission tomography (PET)/CT demonstrated resolution of numerous hyper-metabolic lesions with a remaining area of increased focal uptake in the left ischial tuberosity . Given evidence of disease progression in the ischial tuberosity but not other systemic areas, the patient transitioned to pembrolizumab and received radiation to his ischial lesion. Approximately 2 weeks after starting pembrolizumab, the patient noted gait instability and ataxia, and further ascension of numbness to the level of his hips. At that time, he was still able to ambulate independently with the assistance of walking sticks. One month after starting pembrolizumab, the patient presented to the emergency department (ED) with 1 day of urinary retention and fecal incontinence. A spinal MRI was performed which showed T2 signal abnormality and patchy enhancement in the thoracic spinal cord (T5 to T10) concerning for myelitis or radiation necrosis without evidence of tumor or malignant cord compression. The T2 signal abnormality corresponded with the thoracic spinal radiation field . Given that the lesion was enhancing and initially confined to the radiation field, radiation necrosis was favored at that time.
+The patient’s immunotherapy was discontinued, steroids (dexamethasone 8 mg twice daily) were initiated, and two doses of bevacizumab (for possible radiation necrosis) were administered, without improvement. Lumbar puncture was deferred due to recent bevacizumab. Given the lack of improvement to optimal therapy for radiation necrosis, transverse myelitis was then favored. Results of serologic evaluation of metabolic (vitamin B12, thyroid stimulating hormone), infectious (human immunodeficiency virus, rapid plasma reagin), and autoimmune (anti-nuclear antibodies, anti-Ro/La, aquaporin-4 immunoglobulin G, erythrocyte sedimentation rate, C-reactive protein) etiologies of transverse myelitis were normal. The patient was trialed on high-dose intravenous methylprednisolone (1000 mg daily for 5 days) for transverse myelitis. His lower extremity numbness and gait instability progressed and he started plasmapheresis.
+Following 15 sessions of plamapheresis, a dose of cyclophosphamide 1000 mg/m2 was added but the patient continued to decline with worsening urinary retention, bilateral lower extremity spasticity, and complete loss of lower extremity sensation to T5. He did not have upper extremity involvement. Cerebrospinal fluid (CSF) analysis at that time was remarkable for elevated protein (total protein, 99 mg/dL; institutional normal range, 15–45 mg/dL) and negative for malignant cells. Myelin basic protein was elevated at 31.6 ng/mL (normal < 5.5), and oligoclonal bands were matched in the serum and CSF, consistent with an ongoing systemic immune reaction. CSF albumin index was mildly elevated, suggestive of slight impairment of the blood-CSF barrier. Serum studies for antibodies to human T-lymphotropic virus (HTLV) I and II, and a paraneoplastic panel (anti-NR1, anti-GAD65, anti-alpha 3AChR, anti-LGI1, anti-VGCC, anti-VGKC, anti-CASPR2, anti-amphiphysin, anti-CV2, anti-Hu, anti-Ma, anti-Ta, anti-recoverin, anti-Ri, anti-Yo, anti-Zic4) were negative. A serum IL-6 level was normal. A serum TNF-alpha level was not obtained. MRI of the brain demonstrated two new intracranial metastases. MRI of the spine showed progression of transverse myelitis from T3 to T11 , now clearly outside the radiation field. Body PET/CT revealed worsening osseous metastatic lesions; therefore the patient began dabrafenib and trametinib. Given his ascending transverse myelitis despite optimal therapy other options including tocilizumab and infliximab were considered. Based on the low IL-6 level, the patient was started on infliximab. Spinal MRI 3 weeks after the first dose of infliximab showed a dramatic reduction of the level of the T2 cord signal abnormality back to T6 to T10 with corresponding improvement in sensory level and muscle spasms. Continued treatment with infliximab led to additional incremental gains on imaging but without further clinical improvement. He subsequently developed systemic progression on dabrafenib and tremetinib (but with stable central nervous system disease) and ultimately succumbed to his disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2397_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2397_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a39f0e7db9c6ea88f5243876096ccb8810caab9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2397_en.txt
@@ -0,0 +1,9 @@
+A 20-year-old man was admitted to the emergency department with abdominal pain after hitting a tree while riding a sled 10 h ago.
+The patient’s symptoms started after the trauma, and the abdominal pain worsened over time.
+The patient had no previous medical history.
+The patient did not smoke and had no relevant family history.
+At the time of admission, the patient’s Glasgow Coma scale was 15/15, blood pressure was 120/70 mmHg, body temperature was 36.3 °C, heart rate was 94 bpm, respiratory rate was 20 breaths per minute, and oxygen saturation in room air was 98%. A physical examination revealed tenderness without rebound pain over the left upper quadrant.
+The results of the laboratory investigations were as follows: white blood cell count, 21.8 × 103/μL (normal range, 4.8-10.8); neutrophils, 86.8% (50-75); hemoglobin, 13.1 g/dL (12-18); platelet count, 172 × 103/μL (130-450); fibrin degradation products, 16.4 μg/mL (0-5); D-dimer, 6.19 mg/L (0-0.55); creatinine, 1.37 mg/dL (0.5-1.3); modification of diet in renal disease estimated glomerular filtration rate (eGFR), 66.938 mL/min/1.73 m2 (71.11-214.2); and chronic kidney disease epidemiology collaboration eGFR, 74.24 mL/min/1.73 m2 (79.1-157.0). Lactate, fibrinogen assay, activated partial thromboplastin time, and prothrombin time (PT) values were within normal limits.
+Radiological investigations revealed occlusion of the left renal artery with global infarction of the left kidney , occlusion of the branches of the splenic artery with infarction of the central portion of the spleen , a small amount of hemoperitoneum, and left adrenal hematoma .
+The percutaneous transluminal angioplasty attempted to revascularize the left renal artery occlusion failed due to difficulty in passing the wire through the total occlusion. In addition, considering the acute splenic and renal infarctions with multivascular occlusion in this young male patient without underlying disease, a laboratory evaluation of hypercoagulability was performed to exclude the possibility of other diseases. Lupus anticoagulant (LA), antinuclear antibody (ANA) titer, antineutrophil cytoplasmic antibody (ANCA), anti-cardiolipin (aCL) immunoglobulin M (IgM) and immunoglobulin G (IgG), and anti-β2-glycoprotein I (GPI) IgM and IgG tests were performed.
+Laboratory tests were reported on day 7 after the injury and were as follows: LA, weak positive (1.41) (0-1.30, negative; 1.31-1.50, weak positive; 1.51-2.0, moderate positive; > 2.0, strong positive; LA1 screening reagent, LA2 confirmation reagent; Siemens Healthcare, Marburg, Germany); ANA titer, negative (< 1:80, negative; ANA HEp-2 standard kit; Aesku Diagnostics, Wendelsheim, Germany); ANCA, negative (< 1:20, negative; ANCA Ethanol; Aesku Diagnostics, Wendelsheim, Germany); aCL IgM, negative (< 7 U/mL, negative); aCL IgG, negative (< 10 U/mL, negative; aCL IgM, IgG; Orgentec Diagnostika, Mainz, Germany); anti-β2-GPI IgM, negative (< 7 U/mL, negative); and anti-β2-GPI IgG, negative (< 7 U/mL, negative; Phadia EliA; Thermofisher, Freiburg, Germany).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2406_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2406_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..307d1637b41fccb9e3a66d44a6035fb0bf0644e5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2406_en.txt
@@ -0,0 +1,11 @@
+A 53-year-old Caucasian man presented with a five-day history of malaise, productive cough, fever and rigors. He had been treated by his primary care doctor for two days with oral clarithromycin without improvement. He had undergone dental root canal surgery two months previously; the dental filling fell out the day before admission and our patient may have accidentally swallowed it. He never injected drugs intravenously or received blood transfusion. He never smoked, rarely drank alcohol and took no other medication. On examination, he had a fever of 39°C, blood pressure of 132/68 mmHg, sinus tachycardia of 110 beats per minute. Auscultation of the chest revealed some crackles at the right lung base. His heart sounds were normal, and abdominal examination was normal.
+The haemoglobin level was 13.0 g/dL (mean corpuscular volume of 85fl); the platelet count was 84 × 109/L; the white cell count 10.0 × 109/L, with a neutrophilia of 9.0 × 109/L. The serum albumin was reduced at 29 g/L, bilirubin 2 micromoles/L, alkaline phosphatase 466 U/L (normal range 25 to 140) and alanine aminotransferase 239 U/L (normal range 10 to 40). The C-reactive protein (CRP) was raised at 178 mg/L. Serum urea, creatinine, electrolytes, glucose and coagulation were within normal reference ranges. Urine analysis showed nitrites, 1+ protein, 1+ bilirubin, and trace blood. The ECG showed sinus tachycardia. Chest radiography showed a prominent right hilum. Blood cultures taken on our patient after admission showed no growth.
+Community-acquired pneumonia was suspected for which our patient was treated with intravenous amoxicillin-clavulanic acid 1.2 g every 8 hours and oral clarithromycin 500 mg every 12 hours. A liver ultrasound performed because of the abnormal liver function tests revealed two well-defined areas of mixed echogenicity in the right lobe of the liver measuring 49mm and 40mm in diameter. Metastatic tumor was suspected.
+The fever of our patient continued, and on the third day, he developed a severe headache with persistent vomiting. Fundoscopy was normal. Computer tomography (CT) scanning of the head with contrast was normal. Lumbar puncture was performed which showed no white cells or red cells and no organisms identified on Gram stain or upon culture of the cerebrospinal fluid (CSF). A CT scan of the chest revealed minor basal atelectasis. A CT scan of the abdomen and pelvis revealed a single enhancing low attenuation 4.5 cm mass in the right lobe of the liver which showed some contrast enhancement [figure ]. The other solid organs and appendix were normal, and a metal artefact was seen in the colon [figure ].
+Because he was not improving, he underwent percutaneous aspiration of the liver lesion under ultrasound guidance after six days. This drained 30 ml of pus from our patient. Gram stain showed no organisms and culture was negative. He continued to have upper abdominal pain and high fever. A repeat abdominal CT scan showed persistence of the liver abscess, and a mildly dilated appendix (approx. 12 mm diameter). Plain abdominal radiography confirmed a dense radio-opaque object consistent with amalgam dental filling in the right lower quadrant. A percutaneous pigtail drain was inserted and a further 20 ml of pus was aspirated. He was treated with intravenous ertapenem 1 g once daily and intravenous metronidazole 500 mg three times a day.
+Both samples of pus that were aspirated from the liver abscess were culture negative. The causative organism was identified as Aggregatibacter paraphrophilus by polymerase chain reaction (PCR) amplification of the bacterial 16S ribosomal DNA followed by nucleotide sequencing, using published primers . Serological tests for influenza A and B, parainfluenza, adenovirus, respiratory syncytial virus, Chlamydia, and Mycoplasma were negative. All urine, stool, cerebrospinal fluid and methicillin resistant Staphylococcus aureus multisite cultures were negative. A trans-thoracic echocardiogram (TTE) prior to discharge did not show evidence of endocarditis. Repeat CT scan of the abdomen after 14 days showed improvement in the liver abscess and some bilateral basal consolidation. The fever of our patient was resolved. After completing 19 days of intravenous ertapenem, it was shifted to oral amoxicillin 500 mg every eight hours for two weeks. During discharge after 29 days, his liver function tests had returned to normal, but he was anaemic with a haemoglobin of 10.7 g/dL, an erythrocyte sedimentation rate (ESR) of 94 mm/hr and CRP of 17 mg/L.
+Three weeks after discharge and two weeks after having completed the course of oral amoxicillin, our patient re-presented to our hospital. Since discharge, he had been bumping into objects on his left side and for one day he had headache, rigors and a sore throat - he was re-admitted on that day 51. On examination, he was febrile with no signs of infective endocarditis. Ophthalmological examination revealed a left homonymous hemianopia with normal fundi. Repeat blood tests showed a haemoglobin of 11.4 g/dl (MCV 86.0fl) and a CRP of 62 mg/L; his renal and liver function tests were normal. A CT scan of the head with contrast performed on day 52 revealed multiple brain abscesses: a ring-enhancing lesion in the left occipital lobe and a non-enhancing low attenuation lesion in the right occipital lobe, with no mass effect. A CT scan of the abdomen showed a small resolving area of low attenuation in the liver; the appendix was normal. He was treated with intavenous meropenem 2 g every eight hours and transferred to a tertiary hospital. Magnetic resonance imaging (MRI) of the head confirmed multiple brain abscesses; there were multiple foci of contrast enhancement near the grey-white junction of both cerebral hemispheres, a more confluent area of signal change and enhancement was seen in the right occipital lobe, and a small enhancing lesion was seen in the right cerebellar hemisphere [figure ].
+On day 53, a mini-craniotomy and biopsy was performed on a left occipital ring-enhancing lesion. On microscopy, pus cells were seen but no organisms were observed on gram staining, and enriched aerobic, anaerobic and fungal cultures were negative. Results of the 16S rDNA PCR of the brain abscess biopsy again detected the sequence of Aggregatibacter paraphrophilus. Histopathology showed appearances typical of a brain abscess. A trans-oesophageal echo performed on day 55 showed no evidence of endocarditis but there was evidence of a patent foramen ovale (PFO) and an atrial septal aneurysm. A bubble echo was performed on day 60; during provocation by Valsalva maneuver, there was a large right-to-left shunt through the patent foramen ovale. Ultrasound scanning of the liver showed no remaining collection. Maxillo-facial assessment including dental panoramic tomography revealed no ongoing dental infection. His immunoglobulins were normal, anti-nuclear antibody and anti-neutrophil cytoplasmic antibody negative, and serological tests for human immunodeficiency virus, syphilis and toxoplasma were negative. He continued treatment with intravenous meropenem 2 g every eight hours and oral metronidazole 400 mg every eight hours added on day 54, and remained afebrile. He was discharged on day 65 since first presentation (white cell count 7.3 × 109/L and CRP 5 mg/L) with intravenous ceftriaxone 2 g every 12 hours to complete four weeks of out-patient antibiotics via a peripherally inserted central line.
+Follow-up CT scan of the head on day 71 showed surgical changes deep to the left occipital craniotomy; resolving right frontal and left occipital lobe abscesses; and a large hypodense area in the right occipital lobe in keeping with an established occipital infarct. Follow-up cranial MRI on day 81 revealed improvement in the size of the multiple small enhancing subcortical white matter lesions (likely microabscesses); with persistence of the right occipital infarct.
+On outpatient follow-up, intravenous antibiotics were extended to complete a six week course in total; our patient was then switched to oral amoxicillin-clavulanic acid 625 mg every eight hours for a duration of two weeks. Unfortunately, his left homonymous hemianopia persisted.
+Cardiology follow-up concluded that it was prudent to close the PFO as there was a possibility of further paradoxical emboli and this is planned. Our patient was put on anti-coagulant and anticonvulsant therapy and a cranial MRI on day 137 has shown further improvement of the cerebral abscesses.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2416_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2416_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b4d6017ab5a8489f90a919eaec06ad94e2fa3225
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2416_en.txt
@@ -0,0 +1,5 @@
+A 41-year-old Hispanic male (BMI: 44.6) presented to the emergency department after seven days of severe, novel, left-sided rectal pain. The patient denied fever, nausea, vomiting, bowel changes, or signs of blood in his stool. Though a proper rectal exam could not be performed due to pain, a 6 mm mass with surrounding erythema was noticed adjacent to the rectum in the 4 o'clock position. A diagnosis of perirectal abscess was made and incision and drainage were performed. One week after the procedure, the patient described a “ripping” sensation during a large bowel movement that led to worsening of his rectal pain. He was referred to a colorectal surgeon for presumed anal fissure, but confirmatory rectal exam was not possible due to physical discomfort. A subsequently scheduled rectal exam under general anesthesia was cancelled by the patient, and he was lost to follow-up.
+During an unrelated consult for weight-loss surgery three months later, the bariatric surgeon discovered that the patient had new onset pruritus ani for nearly one month. Evidence of anorectal pain, hemorrhoids, fissures, or fistulas were absent at this time. Patient was prescribed lidocaine 5% topical ointment for two weeks PRN. Four months later, at the patient's request, the bariatric surgeon rechecked for the possibility of an anal fissure. Between these office visits, patient continued to have rectal pain (though of diminishing severity), bright red blood on toilet paper, pruritus ani, blood in his semen, loose stools, and the onset of outright FI. Patient attempted self-treatment of his FI with stool-bulking agents, fiber, psyllium, lidocaine cream, and Sween Cream, but with no relief. As these conservative measures failed, it was determined that anorectal manometry was warranted, but this test showed no abnormalities. Both the physician and patient decided that DxHA injections were the next best option. One week later, 4 X 1 mL injections of DxHA were administered approximately 5 mm above the dentate line at the posterior, anterior, left lateral, and right lateral positions without complications.
+One month following DxHA injections, the patient underwent a previously scheduled screening colonoscopy because of a significant family history of colon cancer in his mother (diagnosed at 58 years; died at 62 years). A 5 mm sessile serrated polyp in the ascending colon and a 3 mm hyperplastic polyp in the sigmoid colon were removed during this procedure, but it was also noted by the gastroenterologist that a 15 mm benign-appearing submucosal lesion was present in the distal rectum (~5 cm from the anus). Unsure of what this lesion could be, a flexible sigmoidoscopy and endoscopic ultrasound were ordered to be performed two weeks later. On flexible sigmoidoscopy, the bulging submucosal lesion was again noted ~6-7 cm from the anal verge and endoscopic ultrasound showed this mass to be a homogenous, hypoechoic lesion (0.79 cm X 2.98 cm) that was contiguous with the muscularis propria. Fine-needle aspiration of the rectal lesion was performed and sent to pathology.
+Under microscopy, the hospital pathologist described the rectal FNA samples as having clusters of reactive macrophages, acute inflammation, giant cells, mucin, and multiple, spherically shaped dark microparticles . Though noted as clearly foreign by the pathologist, the presence and etiology of these particles were perplexing. After calling the gastroenterologist to describe these findings, additional history attained by the gastroenterologist from the patient revealed the recent history of DxHA injections. Thus, it was surmised that the rectal lesion and corresponding histopathology were both a result of the patient's FI treatment.
+Unfortunately, though there was initial improvement with the DxHA injections, at the two-month follow-up appointment the patient described worsened FI (several episodes daily, especially after bowel movements). As of this report, supportive measures, biofeedback training, and topical ointments were being used to treat the patient's incontinence.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2425_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2425_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e8e79004c15dd57203d9a0b5a77309e24e137fc1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2425_en.txt
@@ -0,0 +1,7 @@
+A 60-year-old Chinese male farmer presented with a 3-mo history of right scrotal enlargement.
+The patient presented with right scrotal enlargement and had no scrotal tenderness, chills, fever, or other discomfort. No abnormality of the left testis, epididymis, or spermatic cord was discerned. The patient did not self-medicate or seek alternative therapies. He reported no lumbar or abdominal pain and no increased frequency, urgency, or pain associated with urination, but had a slight weight loss.
+The patient had no history of trauma, tuberculosis, or other relevant infectious disease.
+The patient denied any family history.
+A 4 cm × 5 cm, slightly moveable, solid mass was palpated in the right scrotum, which drooped and was pale in color. No normal testicular or epididymal structures were palpated in the affected testis. No abnormality of the left testis, epididymis, or spermatic cord was discerned.
+The results such as routine hematological testing, blood sedimentation rate, vascular endothelial growth factor, human chorionic gonadotropin (HCG), serum carbohydrate antigen (CA)199, CA125, CA153, alpha-fetoprotein (AFP), thymidine kinase 1, and carcinoembryonic antigen (CEA) were normal.
+Within 1 wk from presentation, the patient underwent scrotal ultrasound showing a 4.5 cm × 2.7 cm × 3.7 cm oval-shaped hypoechoic mass, with uneven internal echogenicity in the right testicle . Color Doppler showed scattered color blood flow signals within the lesion. Meanwhile, the patient underwent computed tomography (CT), which revealed an enlarged right testis, with indistinct contour, uneven density, and uniform nodular change . No normal testicular or epididymal structures were palpated in the affected testis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2442_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2442_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..69b443fe3514d059468688c95b61908f11cf90b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2442_en.txt
@@ -0,0 +1,4 @@
+A 17-day-old male premature twin, delivered by caesarean section in the 31st gestational week without external malformations was referred due to systolic heart murmur. On the initial examination at rest, the heart rate was 119 b.p.m., blood pressure at upper limb 93/54 mmHg, femoral artery pulses were weakly palpable and the pulse-oximetric measured oxygen saturation was 99%. Cardiovascular examination revealed a 3/6 systolic murmur at the lower-left sternal border, the lungs were clear. Transthoracic echocardiography showed a CoA with a vessel diameter of about 1 mm and an associated systolic peak pressure gradient of 66 mmHg and a low-velocity Doppler-flow pattern obtained from the coeliac trunk. The arterial duct was closed, the aortic valve normal. The hypertrophied left ventricle contracted well, but with a significant mitral regurgitation and associated restrictive interatrial communication of 2–3 mm with a turbulent left-to-right shunt . Considering the body weight (1.2 kg), vascular lesion, haemodynamics, and risk-benefit assessment, we decided on palliative treatment with a percutaneous transcatheter procedure using the AA access from the right arm. Following written informed consent of the parents, the baby was catheterized for interventional treatment of the CoA in balanced analgo-sedation, the right armpit was prepared in an aseptic condition . For positioning, the head was slightly turned to the left, the upper right limb was angled away from the chest by about 100–120°. After axillary artery puncture, a 0.014-inch Hi-Torque Balance Middleweight (BMW) guide wire (Abbott Vascular, Abbott Park, IL, USA) could easily be advanced to the descending aorta (DAO) and a 2.7 Fr arterial leader Cath (Vygon GmbH, Aachen, Germany) was launched over the wire within the DAO. The position was confirmed by injection of a small amount of contrast medium; the BMW guide wire was exchanged to a 0.021-inch guidewire for subsequent placement of a 4 Fr Glide-sheath Slender (Terumo Corporation, Tokyo, Japan) in the right subclavian artery. After removal of the sheath mandrill, a 0.014-inch Hi-Torque Extra S'port guide wire (Abbott Vascular, Abbott Park, IL, USA) was additionally positioned in the DAO for the interventional procedure and the 0.021-inch guide wire was removed. The invasively measured blood pressure was 160/54 mmHg despite sedation. Angiography through the 4 Fr sheath using 1-ml bolus injection of contrast medium revealed a bovine aortic arch and an extreme coarctation with a diameter of <1 mm and about 4 mm post-stenotic DAO . For stenting, the CoA, a 4 × 8 mm Xience Pro coronary stent (Abbott Vascular, Temecula, CA, USA) was advanced over the S’port guide wire through the 4 Fr sheath. After confirming the correct position, the stent was expanded to a diameter of about 4.3 mm. The angiography showed the desired result with a harmonically modelled stent on the vessel wall without pressure gradients . Immediately after placement of the stent, the left subclavian artery showed a temporarily decreased blood flow, which looked like a contrast agent-induced vasospasm or may be an air bubble, but without any sequalae. The single intravenous administration of 100 U heparin after placement of the sheath was supplemented with a second dose of 50 U heparin, followed by heparin in a continuous infusion of 300 U/day for further 3 days, before 2 mg/kg of body weight aspirin was administered orally. The 4 Fr sheath was removed, and the right AA very carefully compressed. The total fluoroscopy time was 1.9 min, the product dose × area was 14 μGym.
+The improvement of the clinical condition correlated with the excellent result in angiography and in the follow-up echocardiography. The post-procedure peak gradient across the coarctation was 25 mmHg. The post-procedure Imaging and Doppler-flow profile of the coeliac artery are shown at .
+Follow-up visits were performed monthly after the child was discharged at 6 weeks of age . The systolic blood pressure ratio between the upper and lower body remained between 6 and 12 mmHg. However, the calculated peak-Doppler gradient increased meanwhile from 25 mmHg to currently 44 mmHg, which probably represents the progression of the reduced stent-related vascular compliance. The small atrial septal defect was not detectable in the follow-up.
+Aspirin administration is expected to continue until the final surgery. Surgical correction with removal of the stent and subsequent end-to-end anastomosis is intended to perform at an age of 8 months.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2458_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2458_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f41a0fc0f52a7444fe5423ac9369596829507064
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2458_en.txt
@@ -0,0 +1,8 @@
+A 55-year-old Caucasian man presented with an episode of hemospermia. Our patient had a complex urological history with bilateral inguinal hernias and undescended testes as a child. At the age of 11 years he underwent a right orchidopexy; but the left intra-abdominal testis could not be located during the operation. At the age of 26 years, our patient presented with a large mass in his abdomen, which was removed surgically and confirmed as a testicular cancer arising within an intra-abdominal testis. Postoperative treatment with cisplatin-based combination chemotherapy was delivered and regular check-ups showed no evidence of disease relapse.
+Our initial investigations for hemospermia included a cystoscopy, which revealed a 9cm mass present within his bladder. The result of a biopsy of this mass was suggestive of adenocarcinoma of the seminal vesicle, because the tumor appeared to arise from the seminal vesicle epithelium. Computed tomography imaging revealed no evidence of metastatic spread. His serum prostate-specific antigen level was normal at presentation, but his serum CA-125 was 783kU/L. Following diagnosis, a referral was made to Charing Cross Hospital for specialist surgical input, resulting in a radical cystoprostatectomy and orchidectomy (required for local disease clearance) with the formation of an ileal conduit.
+Histopathology confirmed the diagnosis of adenocarcinoma of the seminal vesicle (Figure ) with immunohistochemical studies positive for CK-7 and CA-125, while staining for prostate-specific antigenand CK-20 was negative. The tumor was noted to be widely infiltrative, involving the bladder, perivesical fat, prostate, prostatic urethra and ductus deferens, with additional pelvic lymph node metastases and a positive biopsy from an inoperable peritoneal deposit.
+In view of the biopsy-proven distant metastasis (the peritoneal deposit), adjuvant radiotherapy was considered inappropriate and the initial management was of expectant observation. After three months observation, updated imaging demonstrated disease progression with malignant lymphadenopathy in his pelvis and a recurrence of the intra-peritoneal nodule combined with a rising CA-125 level.
+Androgen withdrawal was commenced using goserelin, but after an initial response of five months, the tumor demonstrated evidence of progression with rising CA-125 levels and enlarging lymphadenopathy. Despite the serological and radiological progression, our patient remained asymptomatic and a decision regarding the role of chemotherapy treatment in disease palliation was deferred. Approximately six weeks later, our patient presented as an emergency with a short history of nausea, vomiting and diarrhea. The admission investigations showed his previously normal creatinine levels to now be elevated at 537μmol/L and urine testing revealed proteinuria >300mg/dL and hematuria with red cell casts. Imaging did not demonstrate an obvious cause for this rise in creatinine: ultrasound showed no hydronephrosis or evidence of obstruction, and computed tomography continued to show enlarging abdominal lymphadenopathy but was not significantly altered from the imaging that took place six weeks earlier.
+A renal biopsy (Figure ) showed pauci-immune crescentic glomerulonephritis with a segmental glomerular necrosis suggestive of ANCA-associated disease. A serum ANCA screen was ANCA IIF positive with a cytoplasmic ANCA pattern, while proteinase 3 and myeloperoxidase antibodies were negative.
+Renal replacement therapy (hemodialysis) and immunosuppressive therapy was commenced with prednisolone, cyclophosphamide and rituximab but his renal function did not significantly recover. His glomerular filtration rate remained less than 10mL/min. A repeated renal biopsy performed in July 2011 after three months of therapy showed glomerular and tubulointerstitial scarring secondary to ANCA-mediated glomerulonephritis but no active ANCA-mediated disease.
+An updated computed tomography scan performed at this point demonstrated significant tumor progression, with new sites of disease in his liver, bones and adrenal glands. In view of these findings and the challenges of delivering chemotherapy while on dialysis, attempts at disease palliation with chemotherapy were withheld. Our patient was referred to our community palliative care team for end-of-life care and died at home two months later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2487_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2487_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a9287a50ce538af2566b8180cefb943cd8d6a914
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2487_en.txt
@@ -0,0 +1,2 @@
+A 12-year-old girl child presented with complaints of swelling around the nape of the neck associated with pain. The swelling, as reported by the parents, progressively increased in size over the period of 1 year. Pain was constant and dull aching in nature. Plain radiograph showed an expansile lytic lesion arising from the posterior elements of C2 vertebra . Accordingly, magnetic resonance imaging (MRI) was advised that showed multiple loculated lesions in the posterior elements of C2 that extended anteriorly to the body as well. There were fluid–fluid levels seen in most of the loculi. There was no extension into the spinal canal . Computed tomography (CT) scan reported expansile giant soap-bubble lesion with distorted trabeculae and thinning of cortices . Radiological appearances were consistent with ABC of C2 vertebrae. Subsequently, embolization of the feeder vessels to the lesion was done . Within 3 h of the procedure, navigated percutaneous biopsy was done under GA to prevent the patient movements during procedure. Tissue was sent for histopathology. Then, diluted contrast was injected into the lesion to confirm if there was any spinal canal leak. After ruling out any leak, methylprednisolone (120 mg) mixed with calcitonin (200 IU) was infiltrated into the lesion in different directions using navigation guided Jamshidi needle. Procedure was uneventful, and the child was sent home within 24 h. Histopathology showed numerous osteoclastic giant cells arranged non-spatially in spindle cell stroma with dissimilar nuclei. Blood-filled spaces rimmed by osteoclasts were seen. The appearance was suggestive of ABC . The patient was followed up in 2 months, and a repeat CT was done that showed few scattered calcifications along the trabeculae. She was further subjected to another session of selective feeder embolization followed by percutaneous intralesional injection of methylprednisolone and calcitonin in a similar fashion.
+In view of COVID pandemic, patient’s parents were on telephonic contact who reported gradual reduction in pain and decrease in swelling size. She was followed up at the end of 18 months. Clinically, the pain had subsided with evident decrease in the size of the swelling. Repeat CT was done that showed dense ossification of the lesion, including the body of the vertebrae with significant shrinkage in fluid-filled cavities. There was reduction in the size of the lesion and spinal canal remained uninvolved .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2496_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2496_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a629fac24c94bf6076523e9c1c29a76f83013875
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2496_en.txt
@@ -0,0 +1,4 @@
+We report the case of a 67-year-old woman who presented to our institute in August 2006 with a 2-month history of pain and swelling of the right hand and wrist, and a more recent onset of pain in the right shoulder. Her medical history included arterial hypertension and depression. Blood tests performed prior to hospitalization were unremarkable except for a high erythrocyte sedimentation rate (ESR) of 78 mm/hour. Plain radiography of the right hand showed osteoarthritis of the first carpometacarpal joint. Non-steroidal anti-inflammatory drugs and acetaminophen were given without significant improvement.
+On physical examination, the fingers of the right hand were flexed, the right wrist was swollen and the right shoulder was extremely painful with a limited range of motion. Routine blood tests were normal but ESR was still high (46 mm/hour). A radiograph of the right shoulder showed demineralization of the humeral head and of the scapula, and an ultrasound study of the right shoulder, wrist and hand showed a supraspinatus tendinopathy without tendon tears and swelling of radiocarpal and intercarpal joints with marked power Doppler signal. SHS was suspected and a radionuclide scintigraphy was performed . The triphasic study of the right arm revealed an increased perfusion with increased and delayed activity of bone images, suggesting RSD of the wrist.
+However, the whole body study, which revealed diffuse spots of hyperfixation in the right humeral head and acromion, medial right clavicle, sternum, ribs, dorsal and lumbar spine and pelvis, was consistent with skeletal metastases. Magnetic resonance imaging (MRI) of the spine and pelvis confirmed the presence of multiple metastases located in the dorsal and lumbar spine, sacrum, pelvis and both femurs. The patient was treated with a single intravenous infusion of 90 mg pamidronate.
+Further diagnostic studies were performed to identify the primary neoplasm. Mammography, thyroid ultrasound and lung computed tomography scan were unremarkable. Gastric endoscopy revealed an adenocarcinoma of the angular region. Despite chemotherapy, a radionuclide scan performed in November 2006 showed progression of the metastatic bone lesions. Signs and symptoms of SHS were completely resolved, but the images of the right hand were unmodified.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2500_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2500_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..816f39f1fece1a88e98b8920f69c69298a0c99f1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2500_en.txt
@@ -0,0 +1,5 @@
+A 9-month-old male infant weighing 8450 g presented to the primary care pediatrician with acute onset high fever, non-bilious vomiting, and continuous crying in a glum mood. He showed no bloody stool. On clinical examination, his abdomen was almost flat and it seemed that there is no apparent tenderness but he is crying constantly.
+Blood investigations revealed no remarkable inflammation, and the white cell count was 7700/mm3 and CRP was 0.35 mg/dl (< 0.14) with normal coagulation parameters. Liver function tests showed mild transaminase elevations with ALT 57 U/L (10–42), AST 71 U/L (13–30), and normal level of total bilirubin 0.7 mg/dl (0.4–1.5). Blood urea was 3.5 mg/dl (< 20), and creatinine 0.26 mg/dl (< 1.07). Serum CK level was in the normal range with 237 U/L (59–248).
+The plain X ray-film showed no sign of bowel obstruction, but the ultrasound demonstrated micro-gas bubbles continuously floating in the intrahepatic portal vein, suggesting any deteriorating clinical problems (Additional file 1: Video S1). The infant was emergently transferred to our department. On admission, he appeared with no acute distress and showed no irritability. Contrast-enhanced CT, performed 1 h later from echography, revealed a whirlpool sign at the right upper abdomen but with neither intrahepatic portal venous gas nor signs of pneumatosis intestinalis . Contrast upper gastrointestinal series showed a corkscrew sign of the jejunum, and additional contrast enema showed a cecum at the mid-upper abdomen . The preoperative evaluation was concerned for intestinal malrotation with midgut volvulus.
+Emergent laparoscopic operation was performed. The patient was placed in reverse Trendelenberg position. At a first laparoscopic glance, the cecum was located just under the liver at mid-abdomen . The small bowel showed a 180° clockwise volvulus, but with neither congestion nor ischemic signs. Using atraumatic bowel forceps, the small bowel was examined from distal ileum end to proximal with continuous spreading of the anterior mesentery surface in a stepwise fashion, ensuring no residual volvulus or local twists. After the complete volvulus reduction, the Ladd’s band was divided and the duodenum was mobilized with dissection of adhesions using SonoSurg™ ultrasonic surgical device (Olympus, Tokyo, Japan). For the separation of the duodenum and ileocecal region, mesentery was widened with dissection of interlaced thin ligaments on the anterior surface of mesentery. The gastrocolic ligament connecting Ladd’s band was additionally dissected to mobilize the right colon furthermore to the left . Appendectomy was added outside the umbilical porthole.
+The postoperative course was uneventful, and the patient was discharged at the sixth postoperative day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2501_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2501_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..25578fea54e65e59c7d96acdbb67b0c018d8aca0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2501_en.txt
@@ -0,0 +1,3 @@
+A 76-year-old woman presented at our department with an abdominal pulsatile mass. She had hypertension (nifedipine 20 mg, candesartan 4 mg, indapamide 0.5 mg), dyslipidemia, congestive heart failure, and complete atrioventricular block. She had previously undergone an operation that included endovascular aneurysm repair and prophylactic accessory renal artery coil embolization for advanced uterine cancer. Enhanced computed tomography (CT) imaging revealed an abdominal aortic aneurysm (AAA) with a maximum diameter of 53 × 57 mm and a right ARA (4 mm in diameter) . Since open repair was considered risky due to her coexisting diseases, we decided to perform EVAR despite the presence of ARA.
+Under general anesthesia, bilateral transfemoral access was obtained via surgical cutdown, and 7Fr short sheaths were placed in both common femoral arteries. Prior to EVAR, the ARA was selectively catheterized with a 6Fr RDC guiding catheter and a 5Fr RDC catheter, and embolization was performed with two 0.018-in coils (Interlock, Boston Scientific, Marlborough, MA, USA). After coiling, the main body of the stentgraft (Aorfix™, Lombard Medical, Oxfordshire, UK) was deployed with its proximal end just below the renal arteries, and bilateral common iliac arteries were used as distal landing zones. We completed the procedures having seen no perfusion defect of the inferior pole of the right kidney from the right renal artery on completion angiography .
+The postoperative course was uneventful, and the patient was discharged 7 days later. Postoperative eGFR (58.4 ml/min) was not significantly different from preoperative (56.7 ml/min). After surgery, blood pressure was under control, and no additional blood pressure medicines were required. Postoperative enhanced CT showed that there was no endoleak. The distal portion of her right ARA from coils including the right kidney was well perfused .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2507_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2507_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0fe91ce493866e3feacff55a5477932113eac45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2507_en.txt
@@ -0,0 +1,2 @@
+A 68-year-old male presented to the outpatient clinic complaining of drowsiness and fatigue for 2 weeks. He had a history of left-sided cerebral infarction 5 months ago and no hypertension, diabetes, coronary artery disease or atrial fibrillation. Since then, dual antiplatelet and statin therapy was taken and there was no transient ischemic attack. Neurological examination showed right limb dyskinesia along with aphasia. The admission low-density lipoprotein cholesterol was 1.64 mmol/L, preoperative coagulation was normal with prothrombin time (PT) of 11.9 s, activated partial thromboplastin time (APTT) of 27.3 s, international normalized ratio (INR) of 1.04, thromboelastography arachidonic acid (AA) inhibition rate of 96 % and adenosine diphosphate (ADP) inhibition rate of 90 %. The electrocardiogram showed sinus tachycardia. Because of claustrophobia, only computed tomography (CT) images could be provided. After admission, one-stop computed tomography angiography (CTA)/computed tomography perfusion (CTP) was performed. CTA showed that the Willis circle was well developed . CTP showed that cerebral blood volume (CBV) and cerebral blood flow (CBF) in the left hemisphere were lower than those in the right hemisphere, while time to peak (TTP) was significantly higher .
+Digital subtraction angiography (DSA) revealed occlusion at the beginning of the left ICA and 75 % stenosis in the right ICA according to the North American Symptomatic Carotid Endarterectomy Trial criteria . The right ICA stent (XACT 6–8*40 mm, Abbott) implantation was performed after DSA . During the procedure, there was no significant decrease in blood pressure or heart rate, nor any neurological deterioration. Unfortunately, 8 h after CAS, the patient developed restlessness, accompanied by a marked increase in blood pressure (170/100 mmHg). After the exclusion of intracranial hemorrhage by CT, sedation and antihypertensive treatment were used, and the blood pressure was controlled below 120/80 mmHg. However, the patient developed left limb hemiplegia 24 h after the procedure. Then one-stop CTA/CTP was performed again. Intracranial vessels were comparable to that before CAS . CTP showed CBV and CBF in the left hemisphere were improved and TTP was reduced significantly. But CBV and CBF in the right hemisphere were not only lower than pre-operation, but also lower than that in the left hemisphere . Dynamic Transcranial Doppler (TCD) was also performed. Flow velocity of the right middle cerebral artery (MCA) decreased 24 h after CAS, while that of the right anterior cerebral artery (ACA) increased significantly . We supposed that hypoperfusion in the right hemisphere might be caused by left-to-right blood theft. Then hypervolemic treatment (intravenous infusion of saline 3000 ml per day) was accepted and the blood pressure was maintained above 140/90 mmHg. After 3 days, the patient’s restlessness and left limb hemiplegia were completely relieved. No recurrence of cerebral ischemia occurred during 3 months of telephone follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_251_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_251_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0760502bedb00ad7f3f9a8475215d8657b3023c7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_251_en.txt
@@ -0,0 +1,2 @@
+A 33-year-old man without a previous medical or surgical history presented with chief complaints of abdominal pain and vomiting. Physical examination revealed tenderness in the lower abdomen. Laboratory data were unremarkable: C-reactive protein level, 0.16 mg/dL; white blood cell count, 9600 /μL; neutrophil count, 91.3%; and lymphocyte count, 5.4%. Ultrasonography and radiography revealed no findings that could cause abdominal pain. Contrast-enhanced computed tomography (CT) demonstrated a 45-mm-sized mass with partial calcification in the ileum , without any signs of invagination, obstruction, or volvulus. No other findings suggesting the cause of abdominal pain were observed on CT. The patient was diagnosed with an ileal tumor. After the examination, the patient’s condition improved spontaneously. Several weeks later, for detailed examination of the tumor, magnetic resonance imaging (MRI) was performed, which revealed a tumor with hypointense signal on both T1-weighted (T1WI) and T2-weighted images (T2WI), and isointense signal on gadolinium-enhanced T1WI . Based on these findings, the differential diagnoses were a gastrointestinal stromal tumor, chronic distending hematoma, leiomyoma, and CFT.
+Laparoscopic surgery was performed for the pathological diagnosis and treatment. Two 5-mm ports were placed through a vertical 4-cm skin incision in the umbilicus using EZ access and Lap Protector (Hakko Medical, Nagano, Japan). Intraoperatively, a white-colored tumor was found in the ileum, 100 cm from the terminal ileum . Careful observation of the entire abdominal cavity did not detect any other tumors, lymph node metastasis, or dissemination. After careful observation, the tumor was lead extracorporeally through the umbilical incision and a partial resection of the ileum was performed. Reconstruction was performed with a functional end-to-end anastomosis. Macroscopic findings revealed that the tumor was pedunculated and located on the antimesenteric side. Microscopic findings revealed that the tumor extended from the muscularis propria to the subserosa. A few spindle cells and infiltration of lymphoplasmacytic cells were observed with dense hyalinized collagen and interspersed calcification in the background . Immunohistochemical findings revealed negative or nearly negative results for CD34, c-kit, DOG-1, desmin, S100, anaplastic lymphoma kinase, vimentin and smooth muscle actin. Factor-XIIIa was positive. The MIB-1 labeling index was less than 1%. Over 40% of the plasma cells in the stroma were IgG4 positive. The tumor was eventually diagnosed as a CFT. The patient was discharged on postoperative day 7 without any complications. No recurrence has been observed in the 6 months since the surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2525_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2525_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f60a88a5d7b62f6698942d88d8ff495fc2b6bb8e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2525_en.txt
@@ -0,0 +1,2 @@
+A 39-year-old healthy woman with normal menstrual periods presented to the emergency department because of postoperative cardiac arrest after a hysteroscopic myomectomy with general anesthesia. Preoperative blood tests revealed no anomalies. According to the local health facility, she had been irrigated with 8000 mL of 5% dextrose water with monopolar electrosurgery and subsequently underwent 35 min of cardiopulmonary resuscitation with medication including sodium bicarbonate 266 mmol (16 ampules) and other inotropic agents. On admission, her body weight was 74 kg (compared to presurgery body weight 62 kg); body mass index of 26.2; equal and dilated pupils; Glasgow coma scale of E1VTM1; low body temperature (32.9 °C), rapid heart rate (117 bpm), hypotension (74/47 mmHg), desaturation with SpO2 of 86% and less than 100% FiO2 support after intubation, and she was placed on ventilator support with a lung-protective strategy. Her laboratory tests revealed iso-osmotic hyponatremia, severe metabolic acidosis with hypercapnia and hypoxemia, hypoalbuminemia, and hemolysis with disseminated intravascular coagulopathy. The patient received a significant amount of sodium bicarbonate, so the acidosis was most likely much more severe at presentation and the acidosis may have been due to lactic acidosis. .
+The patient was immediately resuscitated with 300 mL of intravenous 3% sodium chloride within 4 h for acute hyponatremia. Because of altered consciousness, mannitol and furosemide were administered for suspected brain edema. Inotropic agents and vasopressors were administered for profound shock status. Initial chest X-ray and chest CT were compatible with acute pulmonary edema . Echocardiogram revealed severe hypokinesia of the left ventricular apex with ejection fraction of 35%.Although initial troponin level was 1.944 ng/mL, subsequently, the levels increased to 18.46 and 20.73 ng/mL. After resuscitation, serum sodium level increased from 125 mmol/L to 139 mmol/L 3 h after admission and was 141 mmol/L 7 h after admission; however, the patient remained comatose. Brain CT 1 day after admission revealed no evidence of focal swelling. Subsequently, she was treated with CVVH to remove accumulated fluid from acute pulmonary edema and anuric acute kidney injury, which occurred despite the use of diuretics. Because of acute respiratory distress syndrome with severe hypercapnia, hypoxemia, and poor motion of the heart wall, the patient received venous–arterial ECMO. Further follow-up laboratory examinations revealed unremarkable thyroid function and adrenal function . As follow-up echocardiography revealed improved left ventricular diastolic and systolic function with ejection fraction of 57%, the patient was successfully weaned off ECMO on the day 9; she regained consciousness on day 10 and was successfully extubated on the day 13 of admission . She was relocated to the ward on postoperative day 25 and was released from the hospital on postoperative day 28 without any detectable sequelae.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2526_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2526_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8eb04eb06ea5eba4a646babcf02a38cea1f926f6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2526_en.txt
@@ -0,0 +1,2 @@
+35 years old female presented to the casualty with bilateral lower limb paralysis for 1 month following child birth, the condition occurred suddenly, it was associated with back pain and complete loss of sphintric control. On examination patient looks generally well, with normal vital signs readings, GCS 15/15, intact cranial nerves, normal power, tone and reflexes in upper limbs with intact sensation to all modalities, but lower limb showed power grade zero, hypertonia, hyper-reflexia grade 4 and positive Babinski’s sign. Sensory modalities were examined and revealed sensory impairment up to the level of umbilicus (loss of vibration and position sense), and there was mild mid-dorsal tenderness.
+Patient haematological parameters were investigated and revealed normal readings. Dorsolumber MRI was done showed T1 weighted extradural hyperintense lesion from D5 to D8 compressing the spinal cord from posterior, T2 weighted images showed the lesion which is hyperintense in relation to spinal cord and almost isointense with normal fat signals and cord myelopathic changes and contrasted MRI images showed prevalent, a little inhomogeneous contrast uptake by the lesion. Surgical intervention was done through posterior approach dorsal decompressive laminectomies and total resection of the lesion with no intraoperative significant events was achieved, and specimen was sent for histopathology .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2539_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2539_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3faf0c508bdeb15f8a68a81599b8aa5bf79d8835
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2539_en.txt
@@ -0,0 +1,4 @@
+A 45-year-old Japanese man visited our clinic in September 1996 complaining of decreased vision in his left eye. His vision was decreased to 20/200, and ophthalmoscopy showed a retinal detachment involving the macula and a retinoschisis that extended from the optic disc pit through the macula in the left eye . Glial tissue was seen at the optic disc pit but a retinal tear was not seen. Fluorescein angiography showed hypofluorescence of the optic disc pit, and multiple hyperfluorescent spots in the area of the macular lesion , but with no dye leakage. In the late phase, the optic disc pit and glial tissue became hyperfluorescent with mild dye leakage. He was diagnosed with optic disc pit maculopathy and vitrectomy was recommended.
+After obtaining informed consent, vitrectomy was performed. A posterior vitreous detachment (PVD) was created by suction with a vitreous cutter until the 'fish-strike sign' was no longer seen. However, the vitreous cortex remained firmly attached at the optic disc pit. Neither condensed vitreous strands nor a residual Cloquet's canal was observed. It was decided intra-operatively that the glial tissue at the edge of the optic pit should be removed in order to remove the vitreous traction completely. Tapered forceps with a fine tip were used to avoid contact with the neural tissue at the edges of the optic pit. During this procedure, it was noted that the glial tissue was firmly attached to the temporal wall of the optic pit. An excavated space at the bottom of the optic pit was then clearly observed after removal of the tissue.
+The vitrectomy was completed with a 14% octafluoropropane (C3F8) gas tamponade, and the patient was instructed to maintain a face-down position for a week. Under these conditions, the retinal detachment and retinoschisis gradually decreased, and the retinal detachment and retinoschisis were absent six months postoperatively . Vision improved to 20/20 without any visual field defects (Goldmann perimetry).
+The patient's vision deteriorated to 20/40 owing to a nuclear sclerosis cataract two years after the vitrectomy, and the lens was extracted. Vision has remained 20/20 for 10 years without any recurrence of the retinal detachment or retinoschisis. Optical coherence tomography (OCT) at this time did not detect a retinal detachment or retinoschisis, but two channels were seen running from the vitreous cavity to the longitudinal space of the optic nerve, possibly the subarachnoid space and the intraretinal space. The exit of these channels to the vitreous cavity was closed .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2543_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2543_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5b8fa30097f85095df6af43b24df57122de7a5b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2543_en.txt
@@ -0,0 +1,3 @@
+A 49-year-old immunocompetent Caucasian woman presented with a 3 week history of fever, shivers, breathlessness and weakness. These symptoms started 2 days after she returned from a trip to South Africa and Zambia, which included a visit to Kruger National Park. During this period, she had been fully compliant with anti-malarial prophylaxis (Malarone). She complained of headaches and light-headedness, which were worse in the evenings and substantially impaired her ability to concentrate.
+On the first day of symptoms she noticed a painful swelling in the right side of her groin, which gradually increased in size. A large lesion on her left lower abdomen was also observed, which evolved from an initial 'white head' to reveal an eschar that gradually increased in size . On the next 2 weeks several vesicular skin lesions emerged on her legs, right arm and abdomen. She manifested profound anorexia and discomfort in the left hypochondrium. Musculoskeletal pain and insomnia were very prominent at this stage.
+When seen at our hospital, a left lower abdominal wall tache noire lesion was noted. In addition, there were 20 small vesicular lesions on her trunk, and she had right sided painful inguinal lymphadenopathy. Routine bloods were all normal and malarial films were negative. C-reactive protein was slightly raised at 29. Blood samples were collected for serological studies on initial presentation and 2 weeks later . A working diagnosis of African tick bite fever was made and the patient was started on doxycycline 100 mg twice daily. On the 3rd day of treatment new skin lesions on both her lower limbs were observed, fever and lassitude persisted and new visual floaters occurred. Therapy was switched to ciprofloxacin 500 mg twice daily. She responded within 24 hours and her symptoms resolved completely after 7 days of therapy. Retrospective serology performed with a commercial immunofluorescence assay confirmed recent rickettsial infection. Serological tests for individual Rickettsia species were not available.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2551_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2551_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..502776fb7df40c05fc653f3dc8bce07ec6dff45f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2551_en.txt
@@ -0,0 +1,3 @@
+A 12-year-old Asian female patient was referred from the pediatric hematology-oncology service, department of pediatrics, for the evaluation and management of swollen gingiva and chin . The patient had a history of patent ductus arteriosus (PDA) closure at age 6. She underwent four cycles of induction chemotherapy for acute myeloid leukemia (AML), which had been diagnosed a year previously. She was admitted for the management of neutropenic fever over 39 °C. She was on antibiotics (linezolid, meropenem, sulfamethoxazole, metronidazole, teicoplanin, cefpiramide, amikacin), antifungals (fluconazole, nystatin, amphotericin B, voriconazole, caspofungin), and an antiviral (acyclovir) for her febrile condition, under the impression of neutropenic fever and vancomycin-resistance enterococci (VRE) sepsis. The results of complete blood count with differential were as follows: white blood cell (WBC) counts 40/μL, platelet counts 8000/μL, absolute neutrophil count 0/μL.
+As the patient was already on every possible antibiotic, antifungal, and antiviral, close observation and oral hygiene maintenance was the only possible management. Surgical intervention was contraindicated due to her systemic condition, especially considering her hematologic status. Six days after the initial presentation, the patient developed cardiac arrest under the background of uncontrolled fever. Return of spontaneous circulation was achieved after resuscitation, and her general condition improved as days went by. The oral and facial lesion progressed to full-thickness gangrene and underlying alveolar bone separated from the surrounding mandible . Teeth on the segment spontaneously fell out . The necrotic alveolar bone segment also spontaneously fell out.
+After the patient had become afebrile and able to return to regular activities, not only the disfigurement but the incompetency of the lips and resultant drooling posed severe obstacles in her daily life since oral intake was disabled. Considering the pancytopenic condition of the patient, surgical repair was done as simply as possible, by local flap, to achieve continuity of the orbicularis oris muscle and competency of the lip, thus enabling oral intake afterwards .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2565_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2565_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..57591feaf0e51f087eca86b2d19dfb0310d02c7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2565_en.txt
@@ -0,0 +1,7 @@
+The proband was a 54-year-old French male patient with a personal history of dyslipidaemia and tuberculosis in childhood. From the age of 41 years, he slowly developed progressive weakness and atrophy of proximal upper-limb muscles and later (at 46 years of age) involvement of the lower limbs, associated with axial weakness. At that time, the walking test was unlimited, whereas at 50 years of age, he was only able to walk 50 m using a cane for support.
+Then, the proband developed acute behavioural changes including irritability, severe anxiety and major depression, which led to him being hospitalised in a psychiatric hospital at 53 years of age. He developed gradual cognitive decline characterised by impairment of executive functions. The deterioration of upper- and lower-limb weakness and cognitive functions accelerated. The patient was eventually unable to walk and was confined to a wheelchair. His cognitive dysfunctions consisted of impaired frontal lobe functions, dominated by major behavioural changes (such as changes in affects, decline in social interpersonal conduct and perseveration) and aphasia (phonemic and semantic paraphasia). His score on the Frontotemporal Behavioural Scale was abnormal (3 items out of 4 were pathological). However, his memory was not impaired: the Mini-Mental State Examination (MMSE) was normal (29 out of 30 points).
+An electromyography (EMG) showed fibrillation potentials and positive sharp waves at rest, and myopathic or neurogenic features according to the muscles examined: polyphasic small-amplitude short-duration motor unit potentials and polyphasic long-duration with slow-frequency motor unit potentials were found together in the EMG study. These results suggested inclusion body myopathy, which was confirmed by a muscle biopsy revealing histopathological changes consisting of rimmed vacuoles. Plasma creatine kinase levels were mildly increased (262 IU/l, normal values 20–220 IU/l). Nerve conduction studies were normal.
+Cerebral magnetic resonance imaging (MRI) was performed at 54 years of age and revealed frontal and internal temporal atrophy . Fluorodeoxyglucose (FDG) positron emission tomography (PET) scan showed severe bilateral hypometabolism, involving especially the frontal and temporal lobes . The occipital lobe, basal ganglia and cerebellar metabolism were normal. Behavioural-type frontotemporal dementia was therefore diagnosed based on the clinical frontal lobe dysfunction and the results of the cerebral MRI and PET scan.
+Moreover, the mother and the grandfather of the index patient had died with an unknown myopathy (confined to a wheelchair at the end of their lives). His mother also suffered from dementia. The index patient has an asymptomatic 25-year-old son.
+The diagnosis of IBMPFD due to a mutation in the VCP gene was suggested given the personal and familial history of the patient. This diagnosis was confirmed by the genetic study of the VCP gene which revealed the VCP R155H mutation (exon 5, domain CDC48, 464 G>A). The genetic study was not performed in the mother and the grandfather of the index patient.
+The absence of bone pain, hearing problems or spontaneous fractures, the normality of the serum concentration of alkaline phosphatase and the normality of a 99mTC total-body bone scan ruled out Paget's disease of the bone. The cardiac exam was normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2568_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2568_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5e83a69f5ff679600ca9a9718f3b2057d983c907
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2568_en.txt
@@ -0,0 +1,4 @@
+A 39-year-old female with SSc was admitted at our hospital with a complaint of shortness of breath on exertion [World Health Organization-functional class (WHO-FC) was III]. The patient was diagnosed with SSc with positive anti-centromere protein antibodies when she was 28 years old. She developed pseudo intestinal obstruction for which a central venous (CV) catheter was employed for feeding at the age of 33. She was taking 5 mg of prednisolone and 240 µg of beraprost for Raynaud’s symptoms and intestinal disturbance due to SSc. Since the past 4 months, she became aware of shortness of breath while riding a bicycle and walking. She was referred to our department due to worsening shortness of breath and cardiac enlargement on chest X-ray. The outpatient doctor decided to admit her for a thorough examination.
+On admission, her blood pressure was 94/60 mmHg, pulse rate was 75 beat per minute, and oxygen saturation was 97% in room air. Physical examination revealed juglar veins dilation, systolic murmur (Levine III/VI), and Raynaud’s phenomenon. Laboratory testing revealed brain natriuretic peptide (BNP) levels of 754.8 pg/mL (<20 pg/mL) and D-dimer levels of 2800 ng/mL (<1000 ng/mL). In terms of coagulation factors, protein C, protein S, and lupus anticoagulant were normal. Electrocardiogram revealed findings of right ventricular loading . Chest X-ray revealed enlargement of the heart and a CV catheter inserted from the right subclavian vein . Echocardiogram revealed normal left ventricular ejection fraction and severe tricuspid valve regurgitation . Peak velocity of tricuspid regurgitation was 3.6 m/s, the diameter of the inferior vena cava was 14/11 mm, and the right ventricular systolic pressure was 61.8 mmHg. Right heart catheterization revealed severe PH evidenced by mean pulmonary artery pressure (PAP) of 38 mmHg, pulmonary vascular resistance (PVR) of 18.7 wood unit (WU), normal range of mean pulmonary artery wedge pressure (9 mmHg), and low cardiac output (1.5 L/min). We performed enhanced thoracic computed tomography (CT) and lung perfusion scans for CTEPH screening while investigating the cause of PH. Computed tomography detected multiple thromboemboli in the peripheral pulmonary arteries, mosaic pattern of the lung field, and dilation of the right heart . No thrombus was observed around the CV catheter that was inserted from the right subclavian vein. The spirogram of the pulmonary functional tests revealed a normal range. Perfusion scintigraphy of the lung revealed heterogeneous blood flow distribution in both the lungs and multiple segmental defects . There was no deep vein thrombosis (DVT) on lower limb echography. We performed pulmonary angiography, which revealed multiple webs and narrowing of the pulmonary arteries . Considering these results, we diagnosed the patient with CTEPH complicated by SSc. She did not have a history of DVT or pulmonary embolism (PE). Moreover, she did not have any risk factors for DVT/PE, including the use of birth control, travel, cancer, etc.
+shows the patient’s clinical course of medication for severe PH; 10 mg of macitentan (endothelin receptor antagonist), 20 mg of tadalafil (phosphodiesterase-5 inhibitor), and an anticoagulant were administered. Since she was suffered from gastrointestinal symptoms owing to pseudo intestinal obstruction, we did not use riociguat (stimulator of soluble guanylate cyclase).
+Oxygen therapy was also initiated. Two months following the start of these medications, mean PAP was still high at 34 mmHg (PVR was 15 WU); hence, we decided to perform BPA for CTEPH. We decided that the treatment with BPA rather than PEA was more feasible considering the absence of an obvious thrombus in the central pulmonary artery. We judged that the comorbidities, such as pseudo intestinal obstruction associated with SSc, rendered PEA a high-risk procedure. We mainly performed BPA to the regions at both sides of the peripheral pulmonary arteries, which gradually decreased her PVR. Perfusion scintigraphy of the lung following the 1st BPA session (targeted vessels: multiple peripheral right pulmonary arteries) revealed a reduced blood flow deficit in the right lung . We performed four sessions of BPA guided with the deficit image on perfusion scintigraphy of the lung in ∼1 year with the goal of improving the haemodynamics. Complications, such as haemoptysis and pulmonary oedema were not observed throughout the BPA sessions. Compared with the time of diagnosis, at ∼1 year after initiating treatment, PVR decreased from 18.7 WU to 8.7 WU, and BNP decreased from 754.8 to 131.7 pg/mL. Her 6-min walking distance increased from 250 to 450 m, and her WHO-FC improved from class III to class II. Since her PVR is currently high, we plan to repeat BPA to treat the residual CTEPH at the next follow-up (in 3 months) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2630_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2630_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..046a61b00506b5a4e7c98bb7e379d28267b980cc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2630_en.txt
@@ -0,0 +1 @@
+A 72-year-old female was admitted to hospital suffering from fatigue, weight loss and rectal bleeding. Total colonoscopy demonstrated adenocarcinoma of the sigmoid colon at 25 cm from the anal verge. A chest x-ray was normal. No sites of distant metastasis were reported on abdominal computed tomography (CT) scan. The serum carcinoembryonic antigen level was normal. The patient underwent sigmoidectomy in May 2008. During the operation, the left ovary was fixed at the site of the sigmoid colon cancer and was removed en block. Thorough macroscopic examination of the liver and rest of the abdomen showed no sign of metastatic disease. Histopathological examination of the specimen revealed a moderately differentiated mucus-producing adenocarcinoma, 3 cm in diameter located 5 cm from the peripheral surgical margin . The tumor invaded into but not beyond the muscularis propria (T2). Ki 67 antigen and p53 tumor suppressor protein staining were positive and epidermal growth factor receptor (EGFR) negative. The left ovary was free of neoplasmatic tissue. Only four lymph nodes were counted, free of metastatic adenocarcinoma. The patient had an uneventful recovery. On rectum examination one year later a palpable extramucosal mass was noticed at the anterior rectum wall. An abdominal CT scan revealed a tumor 2 cm in size at the lower anterior mesorectum in close relation with the posterior vaginal wall and a second mass 2 cm in size at the anterior abdominal wall midline . Total colonoscopy showed no mucosal lesion. A chest x-ray was normal. Rectal endoscopic ultrasound (EUS) showed a tumor infiltrating the rectum muscularis propria from outside. Core needle biopsy demonstrated the presence of a mucus producing adenocarcinoma with the same histological futures with the primary tumor and therefore it was considered as metachronous metastasis. Serum carcinoembryonic antigen level was normal. Since no other site of recurrence was identified, an abdominoperineal resection was attempted . At laparotomy, the anterior abdominal wall mass was located at the site of previous incision and after complete resection, fast biopsy showed adenocarcinoma. Surgical examination of the abdominal cavity showed no sign of reccurence. At that time, sinus bradycardia and ST segment depression was noticed on electrocardiogram (ECG) monitoring. The termination of the operation was decided and a loop transverse colostomy was immediately perfomed. Postoperative cardiologic examination revealed an acute muocardium infract and the patient was treated respectively. Chemo-radiation of the mesorectum tumor and re-evaluation for surgical excision was decided and she was discharged on the eleventh post operative day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2637_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2637_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b3326f0ac78b56accdcabde79b277884c7b76ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2637_en.txt
@@ -0,0 +1,11 @@
+A woman in her 40s presented to the emergency department following 4 h of acute chest pain. The pain was described as severe pressure on the chest and radiated to the left arm.
+The patient was 2 weeks following the birth of a healthy daughter (gravity 6, parity 3, caesarean section 3, spontaneous abortion 3).
+The pregnancy was uncomplicated. She had an elective caesarean section due to previous caesarean section with her first pregnancy (breech presentation). This was performed at week 38 + 3. However, during admission following the caesarean section, the patient was noted to have elevated blood pressure and proteinuria and was treated with magnesium intravenously for pre-eclampsia. She was discharged with no further medication and was currently breastfeeding her child.
+She was not on any other chronic medications, no past medical history, with no known allergies. She did not smoke, and her lipid profile 4 years prior revealed LDL blood level of 78 mg/dL.
+Her initial vital signs were blood pressure 145/80 mmHg, heart rate 95 b.p.m., normal oxygen saturation, and no fever. She was not in haemodynamic compromise or respiratory distress. The heart and lung examination were without abnormal findings.
+The electrocardiogram showed sinus rhythm, normal axis, narrow QRS complex with T waves inversion in the anterior leads, and Type 2 Wellens sign in leads V4–V5 with QTC 462 ms (Bazett formula). There was no recording or symptoms of an arrhythmia on telemetry monitoring in the emergency room.
+A focused echocardiogram in the emergency department showed reduced left ventricular dysfunction (ejection fraction estimated to be 40%) with hypokinesia of the mid and apical segments mostly of the anterior wall in the four-chamber and two-chamber views, with no valvular lesions and no pericardial effusion (see , )
+Blood results reported an elevated troponin T 1633 ng/L (normal value < 13 ng/L), NT ProBNP 1046 pg/mL (normal value < 125 pg/mL), creatinine kinase 1451 U/L, creatinine of 0.6 mg/dL (glomerular filtration rate according to MDRD 133.5 mL/min/1.73m2) (normal value: 0.51–0.95 mg/dL), AST 116 U/L (normal values < 31 U/L), no electrolyte abnormalities, haemoglobin 14 g/dL (normal values: 12–16 g/dL), and platelets 431 K/mcL (normal values: 150–450 K/μL).
+Due to ongoing chest pain, the patient was taken urgently to the catheterization laboratory. Angiography showed critical stenosis of 99% of the middle left anterior descending artery with TIMI flow score of 3 ( and and , ). This lesion was tapered and indicative of spontaneous Type 2 coronary artery dissection (SCAD). No other coronary lesions were noted with smooth contour of the coronary arteries otherwise. Due to the clinical presentation of ongoing chest pain, abnormal electrocardiogram, and reduced left ventricular function, percutaneous coronary intervention was pursued. This was done with a 5 French 3.0 EBU engagement catheter, careful wiring of the coronary artery using a floppy wire (RUNTHROUGH NS Floppy, Terumo, Japan) and direct stenting with a single long EluNIR™ ridaforolimus drug eluting stent (Medinol, Tel Aviv, Israel, 2.75 mm diameter × 28 mm length) with a good angiographic result and optimal distal angiographic flow . The patient had immediate clinical improvement and was transferred for observation in the coronary care unit. She was given a loading dose of aspirin (300 mg) and clopidogrel (600 mg).
+Her echocardiogram the following day showed a reduced ejection fraction of 40% with anterior-apical dyskinesia and no valvular abnormalities. She was found to be hypertensive during her admission with 24 h albuminuria of 838 md/day and was started on Enalapril 5MG BD following a nephrology and gynaecology consultation. Bisoprolol 2.5MG QD was added due to her left ventricular dysfunction. LDL results were 144 mg/dL, and a statin (atorvastatin 80 mg) was initiated.
+A shared decision-making discussion was done with the patient about the recommendations and relative lack of data on antiplatelet drugs and effects of drugs from drug eluting stents (DESs) in breastmilk. The patient decided to avoid the potential risk on her child from the drugs and to stop breastfeeding. Her antiplatelet regimen was then changed to dual antiplatelet with ticagrelor (90 mg twice daily) and aspirin (100 mg once daily).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2647_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2647_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d896c9ebf0b26fc89a628ffc395b5cfaf7765a40
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2647_en.txt
@@ -0,0 +1,2 @@
+A 44-year-old man with right vocal cord palsy and recurrent aspiration was admitted to the intensive care unit (ICU) for respiratory failure due to carbapenem-resistant Acinetobacter baumannii pneumonia. He was put on mechanical ventilator support and the ventilator (Servo-U, Maquet) was connected to a scavenging system (EVAC 180) as an additional infection control measure in face of the COVID-19 epidemic. On the fifth ICU day, the heat moisture exchange (HME) in the breathing circuit was changed to a heated humidifier (Fisher and Paykel MR850) due to copious amount of sputum. On the sixth ICU day, his condition continued to improve and he was on PS mode with PS of 10 cmH2O above a PEEP of 6 cmH2O. Twenty-eight hours after he was put on PS mode, he became dyssynchronous with the ventilator, and labored breathing was observed. Despite the patient's respiratory effort, the backup pressure control (PC) was activated with a backup mandatory breath rate of 15 breaths/minute (bpm). Despite low inspiratory flow being delivered at a rate of 15 bpm, neither triggered nor mandatory breath could be recorded . Paradoxical changes in airway pressures were observed with a decrease in pressure from 28 to 20 cmH2O during the inspiratory phase and an increase in pressure from 20 to 28 cmH2O during the expiratory phase. The ventilator wrongly regarded the expiratory pressure of 28 cmH2O as peak pressure and the inspiratory pressure of 20 cmH2O as PEEP. Ten to 20 seconds afterward, PS breaths were seen to be superimposed on a similar pattern of paradoxical pressure changes. Specifically, PS breaths of 10 cmH2O (with airway pressure up to 17 cmH2O) were triggered by flow when the airway pressure dropped below 8 cmH2O . End-tidal CO2 (ETCO2) varied between 75 and 90 mm Hg. It was also noted the reservoir bag of the scavenging system was hyperinflated and water condensate was seen in the tubing connecting the ventilator exhaust outlet and the scavenging system. The reservoir bag was removed for inspection and was found filled with water condensate. Patient-ventilator dyssynchrony was abolished immediately after the water condensate was drained . Such an event did not recur when the emptied reservoir bag was reinstalled into the scavenging system .
+The patient was weaned and extubated on the 8th ICU day. On the 15th ICU day, he developed right pneumothorax for which did not require drainage. He underwent further rehabilitation and was discharged from ICU after 29 days.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2651_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2651_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7f04e9d8162d21661e2123b2afb7872e6caff21
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2651_en.txt
@@ -0,0 +1,6 @@
+A 14-year-old girl was admitted to the gynecology outpatient department of Women and Children’s Hospital of Chongqing Medical University in April 2022, with complaints of a small amount of bloody vaginal discharge during the past month. Before this event she reported an average menstrual cycle of 25 days, with her menarche at the age of thirteen, and her periods averaging five days, with normal volume and no dysmenorrhea. In addition, the patient’s past medical history showed no history of infectious or genetic diseases, trauma, surgery, blood transfusion, drug or food allergies. Pelvic color doppler ultrasound scan revealed a mass with cystic and solid components in the left ovary extending upward to the inferior hepatic rim, downward to below the pubic symphysis, and forward to the anterior axillary line. Magnetic resonance imaging (MRI) scans of the abdomen and pelvis showed a large solid cystic mass lesion in the left ovary that measured 6.7 × 18.9 × 29.3 cm, and the contrasted scan showed an enhanced septum and solid component . The liver and intrahepatic ducts, gallbladder, pancreas, spleen, both kidneys and ureters were unremarkable. The patient’s pre-operative serum levels showed that carbohydrate antigen (CA-125): 22.3 U/mL (normal: < 35 U/mL), human epididymal protein-4 (HE4): 28.5 pmol/L (normal: < 70 pmoI/L), human chorionic gonadotropin (HCG): < 1.20 mIU/ml (normal: < 5.0 mIU/ml), alpha-fetoprotein (AFP): 3.3 ng/ml (normal: 0–7 ng/ml), carcinoembryonic antigen (CEA): 2.2 ng/ml (normal: 0–5 ng/ml), carbohydrate antigen 19 − 9 (CA19-9): < 2.0 U/mL (normal: 0–43 U/mL) were within normal limits. The patient, with a height of 155 cm and weight of 45.5 kg (BMI: 18.9), presented no particular concerns regarding nutritional status, general vital signs, psychosocial state, or risk factors for stress-related injuries. The results of complete hemogram ( WBC: 7.5 × 109/L, RBC: 4.2 × 1012/L, PLT: 216 × 109/L, HGB: 127 g/L, et al. ) in addition to liver and kidney function tests ( TBIL:10.5 μm/L, DBIL: 3.4 μm/L, IBIL: 7.1 μm/L, ALB: 45 g/L, GLO: 20 g/L, A/G: 2.3, ALT: 13 U/L, AST: 20 U/L, UREA: 3.25 mmol/L, Cr: 56 umol/L, UA: 323 umol/L, et al. ) and coagulation profile ( APTT: 27.9 s, PT: 12 s, INR: 1.01, TT: 18 s, FIB: 2.7 g/L, FDP: <2 mg/L, D-D: 0.31 mg/L FEU ) were also normal.
+After examination, given the patient’s pediatric status and the aim to minimize surgical invasiveness, the patient underwent laparoscopic adnexectomy (single-port surgery) which revealed a large left ovarian tumor measuring 29 × 25 × 15 cm with an intact capsule adhering to the omentum; however, the surrounding peritoneum and the right ovary appeared to be uneventful. A small amount of ascites was found in the abdominal cavity and the peritoneal lavage was sent for cytological examination. A left salpingo-oophorectomy was performed followed by frozen tissue sectioning. Subsequently, the patient underwent appendectomy and omentectomy, and the specimens were sent for routine histopathological examination. As no abnormalities were observed in the right ovary during the laparoscopic exploration, and in an effort to minimize surgical impact on the right ovarian function, we did not remove any part of the right ovary for pathological examination.
+Frozen sections revealed an enlarged dissected ovary measuring 15 × 9 × 4 cm, with a cystic cut section and presence of solid areas. Cysts were filled with turbid mucus, and their walls were mostly smooth with a few surface irregularities and a 3 × 2.5 × 1.5 cm pink nodular excrescence in the interior . No significant abnormalities were found in the fallopian tubes.
+Microscopically, frozen sectioning followed by routine histological examination revealed a continuum of architectural and cytological atypia that included benign, borderline, and carcinomatous areas. Carcinomas with papillary and cribriform-shaped glands exhibited expansile growth, with anastomosing architecture and minimal or absent stroma; most of the epithelial cells were moderate to severely atypical in their lining, with reduced/absent mucinous differentiation and conspicuous mitoses. Based on these observations on the tissue pathological aspects, a diagnosis of mucinous cystadenocarcinoma with expansile invasion was finally made . The immunohistochemical staining results were as follows: ER-negative, PR-negative, CK7-diffuse positive, CK20-focal positive, CDX2-negative, SATB2-negative, GATA3-negative, Mammaglobin-negative:, GCDFP-15-negative, Pax8-negative, Vimentin-negative, Ki67: about 20% (+), WTI-negative, P53: wild-type expression.
+For this patient, the levels of tumor markers, such as carbohydrate antigen (CA-125), human chorionic gonadotropin (HCG), alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), carbohydrate antigen 19 − 9 (CA19-9) and human epididymal protein-4 (HE4) were all within normal limits. The diagnosis of mucinous cystadenocarcinoma with expansile invasion was mainly based on imaging and pathology, especially pathology.
+The patient was followed up after surgery every three months with gynecologic ultrasound and analysis of tumor markers (CEA, AFP, CA19-9, CA-125, HE4). Ultrasound results showed no pelvic mass and tumor markers were within normal range. Her current menstrual cycle is about 15 days, with an average period of 3–4 days, low volume, and no dysmenorrhea. The patient has so far shown no signs of recurrence and is still being followed up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2653_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2653_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..72a276377bc09cb2dd44669f97d7c5635fdbe492
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2653_en.txt
@@ -0,0 +1,5 @@
+A 42-year-old Indonesian female, presented at Hamad General Hospital in Doha, Qatar complaining of an on and off lower abdominal pain mainly in the right iliac fossa. She had a normal delivery 15 years ago, had regular menstrual cycles, and no previous medical illnesses.
+She was vitally stable, with no significant lymphadenopathy or pedal edema. Abdominal examination revealed midline palpable firm mass with mild tenderness. The mass arose from the pelvis, extending 2 cm below the umbilicus. There was no ascites. Complete blood picture, renal and liver function tests were normal except for hemoglobin of 11.7 g/dl, and CA 125 was elevated (251 KU/L).
+Abdominal ultrasound showed a large solid cystic mass in the right adnexa region, reaching the midline (≈6 × 13 cm) with mild vascularity in the solid component. Both ovaries were not separately visualized. There was mild left hydrosalpinx and mild ascites. Transvaginal ultrasound did not show the left ovary, but the right ovary was visualized separately (2.5 × 2.1 cm) and confirmed the presence of complex solid cystic mass in the middle of the pelvis. The mass (13.5 × 9.8 cm) extended to the left adnexa, with cystic area (9.2 × 5.9 cm) and a solid component (9.1 × 7 cm) that had increased vascularity. Further chest/abdomen/pelvis CT and MRI confirmed the size and solid/ cystic nature of the mass and showed no metastatic lesions, and also deviation of uterus to the left side.
+The patient’s clinical picture was discussed at our gynecologic multidisciplinary meeting and total abdominal hysterectomy (TAH), bilateral salpingo-oopherectomy (BSO) and lymphadenectomy were decided. Patient underwent TAH + BSO plus infracolic omentectomy. During surgery, a freely mobile left ovarian mass was found with irregular surface and intact capsule. Right adnexa and uterus were normal. Patient had a smooth post-operative recovery and was discharged. Microscopic examination revealed an 11.0 cm left ovarian papillary thyroid carcinoma arising in SO , with metastatic papillary thyroid carcinoma to the right ovary. No malignancy was found in right fallopian tube, uterus or cervix and there were negative lymph nodes. Following the histopathology results, patient had thyroid function tests (TSH, free T4, thyroglobulin) that were all normal. Thyroid ultrasound revealed 7 × 11 mm complex nodule, a 6 × 6 mm complex nodule and a 3 × 4 mm cyst in the left thyroid lobe. No lesions were observed in the right thyroid lobe. The patient’s clinical findings were discussed at our thyroid multidisciplinary meeting where total thyroidectomy and radioactive iodine therapy were decided; however the patient refused further surgical management, and was lost to follow up as she left the country.
+Upon histopathologic examination, a papillary thyroid carcinoma was identified arising in SO tumor (11.0 cm in greatest dimension) of the left ovary , and a small metastatic focus measuring 0.1 cm in the right ovary. There was no malignancy in right fallopian tube, uterus or cervix and negative lymph nodes. Thyroglobulin immunohistochemical stained section highlighted the thyroid tissue in a background of ovarian tissue with SO, and confirmed the origin from thyroid tissue . AJCC Pathologic tumor staging was p T1b and FIGO stage was IB.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2683_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2683_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a459b61cc00c0e55de911a5a4c7ccb68285b6d16
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2683_en.txt
@@ -0,0 +1,3 @@
+A 49-year-old Asian woman presented with severe abdominal distension and dyspnea. She suffered from the feeling of swelling abdomen, dull nature abdominal discomfort and pain, edema in both legs, and dyspnea from 3 weeks before her visit. She visited another hospital 2 days prior to her visit and was transferred to our emergency room owing to huge ovarian cystic mass occupying almost all of the abdominal cavity and large amount of left pleural effusion on computed tomography (CT) scan. On initial vital sign assessment, her blood pressure was stable and she had tachycardia but no fever. Her laboratory findings showed anemia (hemoglobin 8.3 g/dL), leukocytosis [white blood cells (WBC) 21.00 × 103/μL], C-reactive protein (CRP) elevation of 25.8 mg/dL with prolongation of prothrombin time (PT) (90.4 seconds), PT international normalized ratio (INR) , and activated partial thromboplastin time (aPTT) (no coagulation), which could possibly imply disseminated intravascular coagulation (DIC). Physical examination showed abdominal distension, severe tenderness, and rebound tenderness in the whole abdomen. Due to severe dyspnea and abdominal distension, chest arrow insertion at left lung and paracentesis were performed, draining approximately 850 mL and 2 L, respectively. While performing transfusion, we reexamined dynamic abdomen-pelvis CT scan and found 30-cm-sized multiseptated cystic mass and peritoneal thickening with large amount of ascites suggesting ovarian malignancy and peritoneal carcinomatosis . The patient’s preoperative cancer antigen 125 (CA125) level showed a significant increase with 674.3 U/mL, human epididymis protein 4 (HE4) was 286.4 pmol/L, and premenopausal/postmenopausal risk of ovarian malignancy algorithm (ROMA) index was 86.67%/92.83%. The other tumor markers such as carbohydrate antigen 19-9 (CA19-9), carcinoembryonic antigen (CEA), and alpha-fetoprotein (AFP) were within normal range. With all the results combined, rupture of a malignant ovarian tumor was suspected, and an emergent operation was planned.
+On the initial operation findings, ruptured 30-cm-sized right ovarian multiseptated cystic mass showing diffuse adhesion to retroperitoneum, abdominal wall, and uterus was identified. Although frozen section biopsy from the right ovarian mass was revealed as a poorly differentiated carcinoma, debulking surgery including hysterectomy could not be performed owing to persistent oozing pattern bleeding from multiple sites, which was due to DIC. We performed bilateral salpingo-oophorectomy and partial omentectomy. The pathologic diagnosis of the right ovary was high-grade stromal sarcoma with features of brisk mitosis (30–40/high-power field), focal necrosis, adenofibromatous component, endometriosis with mucinous metaplasia, and hypercellular stroma . The tumor consisted of monotonous uniform cells with endometrial stromal differentiation . Mitotic figures were frequent , and highly atypical neoplastic cells were noted . Metastasis to omentum was also identified. On immunohistochemistry, tumor cells were positive for CD10 , Cyclin D1, and FOXL 2 and positive focally for desmin and smooth muscle actin (SMA). They were negative for beta-catenin and inhibin A. After the surgery, endometrial biopsy was done for excluding metastasis from the endometrium, and the pathologic result was nonspecific. The patient underwent adjuvant chemotherapy with three courses of Adriamycin (75 mg/m2). On the follow-up CT scan that was performed 6 months after the chemotherapy, new 11-mm-sized probable seeding nodules in the right omentum and left paracolic gutter were seen. A 1.5-cm-sized partly solid nodule in the right upper lung field was also identified on the chest CT. As for the lung lesion, we had both primary and metastatic lesion in mind, and planned to perform the surgery separately.
+We performed the secondary debulking operation including total hysterectomy, metastasectomy, omentectomy, peritonectomy, appendectomy, and HIPEC (paclitaxel 175 mg/m2). In the final pathologic report, it was confirmed that the uterine cervix, myometrium, and endometrium had no specific finding except atrophy, which excludes the possibility of endometrial origin malignancy. Peritoneum, omentum, and appendix specimens were confirmed as metastatic high-grade endometrial stromal sarcoma. Two months after the surgery, the patient underwent another right upper lung lobectomy operation, and the biopsy was revealed as adenocarcinoma, which means double primary malignancy. Currently, she has been alive for 28 months under a new chemotherapy regimen: paclitaxel (175 mg/m2) and ifosfamide (1.6 g/m2).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2686_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2686_en.txt
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index 0000000000000000000000000000000000000000..edcb51deada39f0ebd9ba1eb5e2af5fbba4a6bbc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2686_en.txt
@@ -0,0 +1,8 @@
+A 55-year-old man with a background of alcoholic liver cirrhosis (Child-Pugh Class B) presented with a two-day history of fresh per-rectal bleeding and postural dizziness. Whilst he had a history of vomiting, he did not have hematemesis. As a known patient with oesophageal varices, he was on oral propranolol, 10 mg twice daily.
+On examination, the patient was jaundiced with conjunctival pallor. Clubbing was present and a fine tremor was observed in both hands. His abdomen was soft with mild tenderness, and a per-rectal examination revealed fresh blood.
+At the time of admission, the patient was alert and orientated, haemodynamically stable with a blood pressure of 135/98 mmHg, borderline tachycardic with a heart rate of 101 bpm, had oxygen saturations of 100% on air, and a temperature of 36.7 °C. Laboratory tests revealed haemoglobin 6.0 g/dl, platelets 134, albumin 25, bilirubin 50, ALP 91, ALT 59, AST 104, GGT 121, pro-thrombin time 10.8 and INR 1.03.
+The patient was transferred to the intensive care unit where he was intubated, and oesophago-gastro-duodenoscopy was subsequently performed. This revealed four columns of grade 2–3 oesophageal varices with red wale signs (i.e. longitudinal red streaks on the varices), portal hypertensive gastropathy and a small duodenal ulcer, but no active bleeding. As the patient had fresh per-rectal bleeding of unknown aetiology, he was referred for computed tomography (CT).
+Triphasic (non-contrast, arterial and porto-venous phases post 85mls of Omnipaque 350 mg/ml delivered at a rate of 4 ml/s with bolus tracking performed on a Siemens Somatom Diefinition Flash) CT showed multiple right para-colic portosystemic collaterals around the hepatic flexure and ascending colon , in addition to the known cirrhosis and features of portal hypertension. No active extravasation was noted, and the patient was given a somatostatin infusion, 500 mcg/h, before colonoscopy was performed. Colonoscopy confirmed fresh blood in the colon up to the caecum, with a submucosal varix deemed the most likely source of haemorrhage. Endoscopic clips were placed adjacent to the varix to act as markers to guide subsequent therapy.
+The patient was administered intravenous vasopressin (Terlipressin 2 mg 4-hourly), a beta blocker (Carvedilol titrated up to 18.75 mg twice daily) and multiple units of platelets, packed cells and fresh frozen plasma. His haemoglobin improved to 8.4 g/dl and he remained haemodynamically stable for the next few days. After multi-disciplinary team discussion, he underwent balloon-occluded retrograde transvenous obliteration as TIPS was potentially technically difficult due to left portal vein thrombosis and a small right portal venous system.
+The procedure was performed under general anaesthesia in the Interventional Radiology angiography suite. The right internal jugular vein was accessed, through which free and wedged hepatic venous pressures were measured with a calculated hepatic venous pressure gradient of 15 mmHg. The decision for BRTO was re-affirmed, considering his overall morbidities. Right renal venogram was performed with a 4Fr catheter confirming the large colo-renal shunt with multiple tortuous pericolic varices around the caecum and ascending colon. The large colo-renal shunt was catheterised via the right renal vein using a reverse curve catheter. A stiff wire was advanced deep into the tortuous shunt and the catheter was exchanged for an occlusion balloon catheter (6Fr, 8.5–11.5 mm) (Berentstein, Boston Scientific, Natick, MA, USA). Balloon occlusion venography , in which a balloon catheter is inflated to occlude the venous shunt and contrast subsequently injected upstream/retrogradely, was performed to delineate the anatomy of the pericolic porto-systemic collaterals and drainage pattern. With the balloon inflated to achieve relative stasis of blood and prevent efflux of sclerosant, a microcatheter was advanced through the occlusion balloon catheter deep into the varix before injecting 3% sodium tetradecyl sulphate (STS) sclerosant with the aim of filling the entire varix. The occlusive balloon remained in situ for approximately 4 h until there was satisfactory stasis of sclerosant. Small residual variceal collaterals were embolised with N-Butyl cyanoacrylate (NBCA) glue. Venograms confirmed satisfactory embolisation of the abnormal pericolic varices. The balloon catheter was then deflated and removed.
+The patient remained hemodynamically stable following the procedure and experienced an uneventful post-procedure recovery. His Hb levels remained stable at 8.7 g/dl and there were no further episodes of gastrointestinal bleeding. An outpatient follow-up bi-phasic (portovenous and delayed post contrast with 70mls of Omnipaque 350 mg/ml) CT 2 months later confirmed thrombosed varices .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2687_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2687_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ab4783ae6da3c68837cffccac1f2ee912550d118
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2687_en.txt
@@ -0,0 +1,6 @@
+A 56-year-old man with no history of tobacco use or alcohol consumption presented with a three-month history of an enlarging left-sided neck mass and worsening headaches. A positron emission tomography/computed tomography (PET/CT) showed an [18 F]fluorodeoxyglucose FDG-avid soft tissue density at the left tongue base measuring approximately 1.8 × 2 cm, a centrally hypodense hypermetabolic left level IIB nodal conglomerate measuring 3.6 × 4 cm, and multiple bilateral hypermetabolic cervical lymph nodes, without evidence of distant metastasis. Brain MRI was negative for brain metastasis.
+The patient underwent a core biopsy of the left neck level II node which read as a poorly differentiated neuroendocrine carcinoma consistent with small cell carcinoma.
+Core biopsy of the left neck level II node revealed sheets of malignant cells with small to intermediate-sized nuclei, indistinct nucleoli, and scant cytoplasm consistent with SCC. The tumor exhibited areas of necrosis as well as abundant mitotic figures and apoptotic bodies. The neoplastic cells were positive for cytokeratin AE1/AE3, synaptophysin, p16, and TTF-1 with a nuclear staining pattern; they were negative for cytokeratin 5/6, CAM 5.2, p63, chromogranin, CD56, and EBV (by in-situ hybridization) .
+The tumor was positive for p16, but the combined morphologic and immunophenotypic features argued against conventional HPV-associated OPSqCC. Polymerase chain reaction demonstrated that the tumor was positive for HPV16, negative for HPV18, 31, 33, 35, 39, 45, 51, 52, 56, 59, 66, and 68.
+The tumor was staged T1N2cM0 (stage IVA). A percutaneous endoscopic gastrostomy tube (PEG) was placed before the beginning of treatment to meet his nutritional and hydration needs during treatment. He received four cycles of chemotherapy at 21 day-intervals. The chemotherapy regimen consisted of cisplatin 75 mg/m2 on day one and etoposide 80 mg/m2 on days one to three. On cycle two, day eight, he started radiotherapy to the oropharynx and involved neck nodes. He received a dose of 70 Gray (2 Gy/fraction) over a seven week-period. During the concomitant phase of chemo-radiation, the patient experienced grade IV mucositis, grade II nausea, and dehydration for which he received additional outpatient fluid and electrolyte replacement. Due to grade III neutropenia, the dose of cisplatin and etoposide was reduced by 25% during the last cycle of chemotherapy.
+Three months after completion of therapy, a PET/CT showed complete resolution of the tumor and metastatic lymph nodes along with and no evidence of distant metastasis . He also had complete resolution of his mucositis and was able to resume a full oral diet resulting in removal of the PEG tube.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2706_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2706_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..469b46b0cfd5ce764618138c0fc8ef59ad89f5de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2706_en.txt
@@ -0,0 +1,4 @@
+A 58-year-old Caucasian man was referred to the eye clinic in view of multiple raised yellowish lesions in both fundi. He had originally visited his optician for occasional flashes and floaters. He had recently been diagnosed with diet controlled type 2 diabetes mellitus and was on a low dose of amlodipine (5mg/day) for well controlled hypertension. His other drug history included analgesics (paracetamol, dihydrocodeine) and omeprazole. He admitted to heavy alcohol consumption in the past and had chronic liver disease with ascites.
+His examination revealed that he had hepatomegaly with a palpable liver edge three fingerbreadths below the right costal margin, but no splenomegaly. An ultrasound of the liver showed generally increased echogenicity suggestive of liver cirrhosis. A computed tomography (CT) scan confirmed the presence of liver cirrhosis and showed evidence of esophageal varices, in keeping with decompensated chronic liver disease.
+There was no evidence of a localized lesion in the liver, ruling out the possibility of both hepatocellular carcinoma and metastatic disease as causes of decompensation. His liver function tests (LFTs), including alkaline phosphatase (ALP), alanine aminotransferase (ALT) and γ-glutamyl transferase (GGT), had been elevated for several years. Interestingly, he was also found to have a marginally elevated plasma viscosity of 1.81mPa/s (normal range 1.5 to 1.72mPa/s) with no evidence of paraprotein.
+His ocular examination was within normal limits for the anterior segment. His visual acuity was 6/6 in both eyes. Ophthalmoscopic examination of both eyes revealed a symmetrical pattern of dozens of variably sized, slightly yellowish, translucent raised lesions throughout the fundi . These lesions were confirmed as multiple neurosensory retinal detachments on optical coherence tomography (OCT) and fundus autofluorescence . The patient was followed-up in the eye clinic and was asymptomatic until his last follow-up. Visual acuity, fundus and OCT findings were unchanged. As the visual acuity was good and there was no evidence of choroidal neovascularization, conservative management was recommended.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2726_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2726_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f9b866e6784fe953e5b442fc802c8a796858a90
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2726_en.txt
@@ -0,0 +1,4 @@
+A 33-year-old non pregnant woman (G3P1) was admitted to the obstetric emergency ward of Amiens Teaching Hospital (Amiens, France) for a 3-day genital pain located in the left labia majora. Her past medical history was unremarkable (term delivery, normal blood sugar, no previous history of diabetes in her family) except for a recurrent left Bartholin’s gland abscess. On admission, she was afebrile and presented no urinary functional signs. Gynecologic examination revealed a large abscess which was incised and drained under spinal anesthesia. The purulent fluid was sent for culture to the bacteriology laboratory.
+Gram staining of the pus showed a lot of neutrophils with Gram negative coccobacilli and the next day cultures revealed a pure culture of small, high-convex, grey colonies only growing on chocolate culture medium (Polyvitex PVX, bioMérieux, France) under 5 % CO2. Catalase and oxidase reactions were negative. The isolate was identified with the use of matrix-assisted laser desorption ionisation-time of flight mass spectrometry (MALDI-TOF MS; Bruker Daltonik GmbH, Germany; MALDI Biotyper 2.2) as A. aphrophilus. Identification was confirmed by sequencing the 16S RNA gene as previously described . The isolate was identified as A. aphrophilus with a maximum identity of 100 % for A. aphrophilus strain NJ8700 (GenBank accession number CP009230.1). Susceptibility testing was performed using E-test (bioMérieux, France) on chocolate culture medium (Polyvitex PVX, bioMérieux, France) under 5 % CO2. The minimal inhibitory concentrations (MICs) for amoxicillin, amoxicillin-clavulanic acid, ceftriaxone, tetracycline and rifampicin were 0.38 mg/L, 0.38 mg/L, < 0.016 mg/L, 1.0 mg/L and 0.25 mg/L respectively.
+The patient received no antibiotics for the treatment of this left bartholinitis and the clinical course was favourable. She went home a few days later with only local care and analgesics. A cold resection was recommended by the surgeon who operated on her to prevent any recurrence but could not have been done.
+Unfortunately, the woman came back to the hospital 5 months later for a new abscess of the Bartholin’s left gland. A wild-type Escherichia coli was isolated and the treatment was the same as for the previous abscess, except that a marsupialization was performed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2729_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2729_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c8bd5957f110dc33d6fcecc96c645d146fd3d00
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2729_en.txt
@@ -0,0 +1,6 @@
+A fifty-five year old male with a history of hypertension, hyperlipidemia and renal calculi presented in December 2001 with flushing and mildly elevated 24 hr urinary 5-hydroxyindole acetic acid (U-5HIAA) (“carcinoid syndrome”). A small bowel neuroendocrine tumor (NET:<2 cm) with two right lobe neuroendocrine liver metastases (NELMs) (2.8, 6.5 cm) was identified by OctreoScan® and MRI (CT identified one abnormality). A distal ileal resection with mesenteric lymphadenectomy, appendectomy and right lobe hepatic resection with cholecystectomy, was undertaken.
+Histology (2001) indicated a Grade 2 NET, staging: T3, N2 (4/4), M1, G2, V1, R0. Ki-67 was not undertaken. His postoperative course was complicated by a right sub-diaphragmatic abscess, Staphylococcus aureus sepsis and was treated with antibiotics and percutaneous drainage. Annual follow-up, using CT, MRI, OctreoScan® and PET/CT, was instituted.
+Initial progression free survival was three years. Thereafter, 11C-5HTP-PET/CT detected local mesenteric recurrence and re-resection of mesenteric lymph nodes was undertaken (March 2005, September 2006). Plasma chromogranin A (CgA) and U-5HIAAs were normal. A repeat 11C-5HTP-PET/CT (July 2007) identified no abnormal tracer accumulation, CgA was slightly elevated (23U/ml, upper limit of normal = 19U/ml: DAKO ELISA Kit [K0025]
+) but U-5HIAA was normal. In April 2008, octreotide (20 mg) was empirically initiated (x1) but severe nausea and diarrhea precluded further therapy. CgA and U-5HIAA remained normal (June-July 2008). In October 2008, 11C-5HTP-PET-CT identified a solitary liver metastasis at the resection margin (right lobe); both CgA and U-5HIAA were normal, circulating 51 marker gene NET Index were elevated. The metastasis was successfully percutaneously cryoablated (December 2008).
+In April 2009, 11C-5HTP-PET/CT demonstrated five small (<1 cm) NELMs and a rib lesion . CgA was elevated (30U/ml) as was the NET Index . Retreatment with octreotide (20 mg/monthly) was initiated. After 8 months, lesions were no longer visible (PET/CT December 2009). No new lesions were evident on PET/CTs, MRIs and colonoscopy. In April 2011, CgA was normal. By June 2011, serotonin was slightly raised (402, ULN = 400U/L). PET/CT in June identified no abnormalities. The NET index was abnormal during this period.
+A cardiac ECHO (January 2012) identified borderline LVH, and normal appearing tricuspid valves with trace insufficiency. In February 2013, 68Ga-DOTATOC-PET/CT identified hepatic recurrence in Segment IV, periphery of IV-V, and two lesions in Segment III . Right XII rib positivity was again noted . CgA levels were normal but the NET Index remained elevated. The patient currently exhibits stable residual NELM disease. A key management concern is the identification of progressive disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2730_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2730_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..321f06d906a1dab776c260bf5314904f8457a133
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2730_en.txt
@@ -0,0 +1,6 @@
+A 63 year-old male patient diagnosed with PDAC was referred to the BC Cancer Agency’s Hereditary Cancer Program for hereditary cancer syndrome assessment due to a strong family history of PDAC . As the starting point for the genetic study of a family, this patient is considered the proband. The family history was noteworthy for the occurrence of PDAC in the proband and his brother, as well as an aunt and uncle on the maternal side. Diagnoses occurred between the ages of 63 and 69. Ancestry was reported as English on both sides.
+The proband presented with a three-month history of weight loss and epigastric discomfort. A computerized tomography (CT) scan showed a 2.9 cm lesion in the head of the pancreas. He was deemed to have locally advanced unresectable PDAC and began treatment with a combination of 5-fluorouracil, irinotecan, and oxaliplatin (FOLFIRINOX). His medical history included type 2 diabetes, hypertension, osteoarthritis, gout and hyperlipidemia. He reported being a non-smoker who consumes 6–8 alcoholic drinks per day.
+The proband’s brother presented with left upper quadrant pain and underwent an ultrasound as well as a CT scan which revealed the presence of a mass in the pancreatic head and uncinate process. He was deemed to have resectable PDAC and underwent a pancreaticoduodenectomy (Whipple) procedure. Pathology confirmed a 3.5 cm moderately differentiated PDAC. Margins were negative. He was treated with adjuvant gemcitabine for six months. He reported being a non-smoker, rarely consuming alcohol. He denied a significant prior medical history.
+During the initial genetic consultation, the proband denied any history of breast, ovarian, colon cancer or melanoma in the family. There was no reported history of pancreatitis, multiple moles, lip freckling or gastrointestinal polyps. In this pancreatic-cancer prone family, none of the diagnoses occurred under the age of 50. The family history of cancer did not meet the current provincial guidelines for hereditary cancer genetic testing . The patient was informed of the options of self-pay genetic testing through one of several genetic testing companies or banking DNA at the BC Cancer Agency should criteria change in the future. He elected to bank a DNA sample and consented to future research.
+The proband’s brother was referred to the Hereditary Cancer Program six months later at which time a research study had opened that offered index genetic testing to unselected, newly diagnosed cases of PDAC utilizing a commercial-grade genetic test provided by Color Genomics. The test is designed to assess clinically relevant pathogenic variants in 30 genes associated with hereditary cancer risk, including the hereditary breast and ovarian cancer and Lynch syndrome associated genes. Details of their assay are published . After reviewing the advantages and limitations of multi-gene panel testing as well as the implications of possible results, he consented to the research study and provided a saliva sample for genetic testing. Genetic test results revealed a pathogenic missense variant in CDKN2A, c.377 T > A (p.Val126Asp). The pathogenic variant is associated with FAMMM syndrome, characterized by an inherited susceptibility primarily to melanoma but also to PDAC. No variants were detected in the remaining genes on the panel.
+Due to an inherited predisposition to cancer being diagnosed in his brother, the proband was subsequently seen in follow-up, where he consented to genetic testing. His results were positive for the familial CDKN2A pathogenic variant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2741_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2741_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..beb24bdff19938a3f756ca91cc0059276d56cb58
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2741_en.txt
@@ -0,0 +1,6 @@
+A 21-year-old female of Sukuma ethnicity from the northern region of Tanzania presented at Bugando Medical Centre (BMC) outpatient clinic in Mwanza city with complaints of abdominal distension and pain, fever and abnormal vaginal discharge for the past 3 weeks. She was apparently lactating for the previous 8 months after cesarean section delivery of her first child. On physical examination, she appeared to be weak, febrile of about 38.5 °C with blood pressure of 110/70 mmHg. She was a blood group ‘A’ rhesus positive and her hemoglobin level was 6.3 g/dl.
+On abdominal examination, a sub-umbilical midline scar was seen, and palpable suprapubic mass of about 16 weeks size of the uterus. The mass was soft, tender and mobile. The digital pelvic and vaginal examination elicited a closed cervix with tenderness on mobility and a non-bulging posterior fornix. There was no adnexal mass detected and gloved finger stained with pus-like discharge. Pelvic gynecological ultrasound suggested pelvic abscess .
+Patient was counseled for emergency laparotomy. Intraoperatively, the uterus was found to be bulky with discharging sinus on left fundal position. Both ovaries were healthy-looking and there was no fluid in the pouch of Douglas. The transverse incision was made on the uterus at the level of the discharging sinus. The yellowish mucinous tenacious materials with hairy tissues were observed. The decision to perform a total hysterectomy was reached; in which the removed uterus had hairs and sticky sebaceous matter found freely in the cavity. After surgery, the patient was transfused one unit of blood and intravenous antibiotics ceftriaxone, Gentamycin and Metronidazole were given with an addition of prophylactic Heparin. The patient had an uneventful recovery.
+The sample was sent for histological examination. At the pathology department, the bisected uterus of 18 cm × 9 cm × 4 cm with no adnexa was identified. There was a cystic mass of 10 cm on the left fundal position in the myometrium containing hairs, sebaceous material, and pus.
+The tissue sample was selected and sections were stained by Hematoxylin and Eosin (H&E) and observed by a light microscopy. Histology revealed a cyst in a myometrium contained keratin debris, and it was lined by squamous epithelium with dermal skin appendages with areas of denudation with lymphocyte and neutrophil infiltrate. The myometrium and endometrium was normal. Diagnosis of infected mature teratoma (dermoid cyst) was made .
+The patient has not shown any sign of disease recurrence for 8 months following hospital discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2742_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2742_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f7abd7762058dc5214af407bdb9fdfcc5f6905f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2742_en.txt
@@ -0,0 +1,6 @@
+We report a case of a 65-year-old male with a medical history of hepatitis C (Genotype 1b, F0-1) infection treated with Exviera plus Viekirax (DAA) with a sustained virological response (SVR) and porphyria cutanea tarda also successfully treated.
+The patient was admitted to the hospital with a 72 h history of abdominal pain in the right upper quadrant, exacerbated by food intake and partially relieved by vomiting; other remarkable symptoms such as acholia, choluria and a body temperature of 38 °C were documented. On inspection, the patient presented skin and conjunctival jaundice, and abdominal examination revealed diffuse pain upon palpation predominantly in the right upper quadrant with positive Murphy’s sign.
+Blood analysis data on admission were: leukocytes 6.72×103 mm−3 (neutrophils 83.4%), platelets 184×103 mm−3, total bilirubin 6.17 mg dl−1, gamma-glutamyl transferase (GGT) 289 U l–1, glutamic oxaloacetic transaminase (GOT)/aspartate transaminase (AST) 148 U l–1 and glutamate pyruvate transaminase (GPT)/alanine transaminase (ALT) 439 U l–1. An ultrasound scan of the patient’s abdomen indicated an acute lithiasic cholecystitis and an intra- and extrahepatic dilatation of bile duct, without the identification of an obstructive cause.
+Given the patient’s symptoms and the results of complementary tests, the patient was empirically treated with piperacillin/tazobactam and was admitted to the hospital. During hospitalization, an endoscopic retrograde cholangiopancreatography (ERCP) showed a stenosis at about 20 cm from the distal common bile duct, and a biliary endoprosthesis was inserted. An abdominal computed tomography scanner revealed a lithiasic gallbladder without lesions suspicious of malignancy. The patient was discharged for detailed medical studies but required hospitalization 3 weeks later in the context of acute cholecystitis suspicion. Percutaneous cholecystectomy was performed and piperacillin/tazobactam treatment was initiated (4 g every 8 h for 14 days). Three biliary samples were obtained for microbiological studies. Seven days later, the patient was submitted to a pancreatoduodenectomy and the prosthesis previously implanted was also sent for microbiological procedures.
+Cultures were performed following conventional procedures in the media and environment recommended. Identification and susceptibility tests were performed using matrix-assisted laser desorption/ionization-time of flight (MALDI-TOF) MS (Bruker Daltonics) and MicrosCan Walkay panels (Beckman Coulter), respectively. MICs were interpreted according to EUCAST 2020 criteria , and carbapenemase production was detected by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept).
+The three bile samples yielded the culture of OXA-48 carbapenemase-producing and in two of them was also isolated. OXA-48 carbapanemase-producing and were obtained from the culture of the biliary prosthesis, as well as ( gives a summary of microbiological results of the different samples). After microbiology results, antibiotic treatment was changed to amikacin (300 mg every 8 h) and meropenem (1 g every 8 h), for 6 days. Results of the antibiogram showed carbapenem resistance that revealed the presence of a carbapenemase. Carbapenemase production was confirmed by immunochromatography (RESIST-4 OKNV carbapenemase; Coris BioConcept) being positive for OXA-48 carbapenemase. The strain was sent to the National Center for Clinical Microbiology (Carlos III Research Institute, Madrid) that confirmed OXA-48 production by sequencing. Antimicrobial treatment was changed to ceftazidime/avibactam (2 g every 8 h for 10 days) and tygecicline (50 mg every 12 h for 5 days) due to an increase in procalcitonin and C-reactive protein (CRP); both parameters decreased after administration of the new treatment. Eighteen days after the pancreatoduodenectomy, the patient was discharged and attended at outpatient consultation area.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2747_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2747_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..546f6d7084b3b187d8cb32ac77fe4e5aaa41c121
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2747_en.txt
@@ -0,0 +1,16 @@
+During pregnancy a 36-year-old portuguese caucasian female patient started recurrent crisis of urticaria/angioedema, and three months after the delivery she underwent an allergological study. She referred a wide range of symptoms 15-20 minutes after ingestion of the majority of vegetable foods: oral allergy syndrome (OAS), urticaria/angioedemea, skin flush or rhinoconjuntivitis requiring high doses of systemic H1 antihistamines, so a severe dietary restriction was established. The allergological evaluation including commercial skin prick tests (SPT, Bial/Aristegui-Spain), prick-prick with fresh foods, and serum specific IgE (Phadia-Sweden) demonstrated a polysensitization to almost all vegetables food (fresh fruits, nuts, legumes, cereals, spices in others). Interestingly, the intensity of SPT reactivity and the serum specific IgE levels showed changes along the time of each 6 months clinical evaluation. They increased or decreased according to the specific food intake. The strictly restriction of a group of foods resulted on a decrease of sensitization to them however a progressive increasing sensitization was observed to those other vegetables foods better tolerated on the moment of setting up the diet and as a consequences not withdrawn from it. This oscillating clinical profile during a period of 4 years was implicated on metabolic disorder (hypertension, hypoalbumin and hypercholesterol serum levels). At the age of 40 years old she was submitted to a study that results on a specific treatment.
+Skin prick tests confirmed the sensitization to a wide range of vegetable foods and no sensitization to most common aeroallergens. Total IgE was 70 UI/mL, and serum specific IgE levels confirmed the SPT reactivity. Specific IgE against peach and peach LTP (rPru p 3) were 1.5 kU/L and 3.5 kU/L respectively whereas negative values (<0.35 kU/L) were obtained for peach profilin (rPru p 4), birch profilin (rBet v 2) and CCD (Phadia, Upsala, Sweden).
+The double-blind placebo-controlled food challenge (DBPCFC) to peach, according previous description of Fernández-Rivas et al. , was positive at first dose with OAS and rhinitis, and promptly remitted under convenient parenteral treatment.
+Regarding these clinical and laboratory data the patient underwent an individualized treatment using a specific allergen which we were strong convinced that was responsible for the etiopathogenesis of the allergic vegetal food disease.
+The study was performed with the approval of the hospital ethics committee, and the written consent of the patient. All the clinical evaluation and laboratory measurements were performed at the beginning of the treatment period, and at 4, 8 and 12 months after the beginning. The tolerance of the treatment was observed during the immunotherapy period and the integrity of the immune system were evaluated by analysis of blood cell counts, blood biochemistry, liver enzyme studies, ionogram, glucemia and renal function.
+Peach peel was homogenated into Björksten buffer and after centrifugation the supernatant was dialysed against 20 mM phosphate, pH 6), filtered (0.22 mm) and applied onto a 5 mL Capto S cationic column using an Akta prime system. Bound proteins were eluted with 20 mM phosphate, pH 6; 1 M NaCl, at a flow rate of 5 mL/min. Further purification was achieved by gel filtration using a Superdex 75 16/60 column equilibrated with PBS buffer. nPru p 3 was obtained at the 10 kDa fraction.
+The SPT were performed in duplicate on the volar surface of the forearm according to standard procedure with native Pru p 3 at the following concentrations: 1, 10, 100 and 500 μg/ml, with prick lancettes (Stallergenes, Antony, France) using one sterile lancette for each test. Histamine phosphate (10 mg/ml) and sterile serum saline (Bial/Aristegui, Spain) were used as positive and negative controls, respectively. Wheal areas were marked 15 minutes after the puncture with a fine-tipped ball-point pen and transferred by transparent adhesive tape onto paper for subsequent evaluation.
+Total IgE was determined by the CAP System IgE FEIA (Phadia, Sweden). Serum specific IgE to nPru p 3 was measured by means of EAST technique (Enzyme Allergo Sorbent Test) and IgG against the same allergen by ELISA method .
+As previous referred challenge foods (masked taste) were prepared immediately before the challenge, and 3 doses (one eighth, one fourth, and five eighths of total weight of 150 g of fresh peach (peel and pulp) were administered at 1-hour intervals. The test was conducted in the hospital setting, with careful medical monitoring of the patient, and full emergency treatment was readily available.
+The active specific immunotherapy consisted of native Pru p 3 at only one concentration of 40 μg/ml in NaCl 0.09%, Phenol 0.5% and 50% glycerol. The patient was instructed to keep the allergen solution in the mouth for at least 3 minutes and then swallow. The build-up phase was performed in an ultra-rush schedule and was completed in one day; it was administered in a one drop step every 30 minutes from 1 drop (2 μg) to 5 drops (10 μg) giving a cumulative dose of 30 μg of nPru p 3 in the first day. A maintenance dose of 10 μg per day (5 drops) and administered 5 times a week was established, obtaining a cumulative dose of 200 μg of nPru p 3 per month.
+The build-up phase and the diary sublingual administrations during the first week of treatment were performed in a hospital setting with the availability of complete resuscitation equipment and trained personnel, and the patient was kept under constant observation after each administration and for at least 240 minutes after the last one.
+All the rest of the treatment was accomplished by the patient alone without any kind of special care on the treatment administration.
+Evaluation period of SLIT was from October 2007 to October 2008, and she was yet under treatment. During maintenance phase patient attended clinical observation once every 15 days.
+SLIT with nPru p 3 was safe and well tolerated because it did not elicit any adverse reaction. The metabolic parameters namely cholesterol, albumin and triglycerides returned to normal values. During the build-up phase the first 3 doses induced oral pruritus and paresthesias of tongue and lips however, increasing the doses with no additional pharmacological treatment was decided. We also emphasize the excellent adaptation of the patient to treatment, and the full compliance with the schedule of allergen administration and clinical and laboratorial tests.
+Regarding the allergologic study, a reduction of the mean diameter in the SPT to nPru p 3 was observed, whereas no relevant changes on serum specific IgE, IgG, IgG1 and IgG4 to nPru p 3 were detected . Besides the excellent clinical and SPT responses a non-expected maintenance of nPru p 3 IgE and IgG levels were observed after twelve months of treatment.
+Regarding the clinical efficacy, DBPCFC was positive at the first dose (18.75 g) before SLIT, inducing SAO and rhinitis, and it was negative at a cumulative dose of 150 g (maximum dose, 93.75 g) since the first challenge tests within the treatment period (4 months). We stress that the clinical symptoms improved steadily after the first month of SLIT, and by the 3rd month she had no major vegetables dietary restrictions, except for nuts, fruits and pepper. The antihistamines consumption markedly reduced. She was advised to avoid any nuts and pepper. Nevertheless when accidental intake occurred she only reported slight SAO symptoms, the majority with no need for medication.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2755_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2755_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a80194d2c4ec84476ce0b787a7f7cb0af83446b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2755_en.txt
@@ -0,0 +1,9 @@
+The 22-year-old female patient was admitted to the hospital on August 25, 2021 with the chief complaint of “double knee joints pain for 10+ years, aggravation for 2+ months, accompanied by groin pain for 2+ weeks”. 10+ years ago, she had recurrent pain in both knees without obvious inducement, occasionally with knee valgus and knee dislocation. 2+ years ago, she developed low back pain which was relieved after rest, but the spine moved freely. 1+ years ago, she experienced severe pain in her low back and loss of mobility. She needed help to get up and down stairs, usually could only walk slowly. 2+ months ago, the pain became progressively worse and she developed pain in the groin area and the right 12th rib after a tumble. MRI showed bone marrow edema in the right intertrochanteric, femoral neck, lower left femur, and tibial intercondylar crest. 2+ weeks ago, she had occasional wandering pain of joints all over the body, accompanied by difficulty in walking and increased pain after weight bearing. Biochemical tests revealed hypophosphatemia (0.47 mmol/L), high serum alkaline phosphatase (257 IU/L), low 25-OH Vit D (41.1 nmol/L), and dual-energy X-ray absorptiometry (DXA) demonstrated reduced bone density. Then she was admitted into the Department of Endocrinology of our hospital for further treatment. She had lost 3 cm in height over 10 years. Her medical history included polycystic ovary syndrome (PCOS) for nearly 3 years, with irregular menstruation. Deny bad eating habits, long-term absence from sunlight, chronic diarrhea and the history of taking adefovir dipivoxil or other drugs. No history of recurrent skin hemorrhages or tooth loss or fracture. No family history of skeletal, metabolic or hormonal disorders.
+She is 142 cm tall and weighs 46 kg, with no obvious positive signs in heart, lung and abdominal examination. Lower limbs are unequal in length and circumference (Relative length of lower limbs: R 77.5 cm, L 76 cm; absolute length of lower limbs: R 68 cm, L 67 cm. Thigh circumference: R 47.5 cm, L 45.5 cm; calf circumference: R 37.5 cm, L 33.5 cm) . Physical examination reveales scoliosis deformity without tenderness and percussion pain in spinous process, hip flexion, extension, internal and external rotation (+), adduction, abduction (−), Moberg sign (+), Lasegue sign (−), both knee joints pain, limited movement, left knee joint evagination deformity, “X” shaped leg. No swelling, tenderness, dislocation of joints, no atrophy of muscles, no paralysis of limbs, no enhancement or weakening of muscle tension.
+(1) Alkaline phosphatase: 270.4 U/L (n: 35-100 U/L); (2) Phosphorus: 0.52 mmol/L (n: 0.85–1.51 mmol/L); (3) Calcium: 2.29 mmol/L (n: 2.11–2.52 mmol/L); (4) Magnesium: 0.91 mmol/L (n: 0.75–1.02 mmol/L); (5) Creatinine: 42.9umol/L (n: 41-73umol/L); (6) Calcitonin: 15.3 pg/ml (n: 0.0–18.0 pg/ml); (7) Parathyroid hormone: 61.23 pg/ml (n: 8.70–79.60 pg/ml); (8) 25-OH Vit D: 16.00 ng/ml (deficiency: < 20 ng/ml); (9) Total procollagen I N terminal peptide: 90.84 ng/ml (n: premenopausal 8.53–64.32 ng/ml; Postmenopausal 21.32–112.80 ng/ml); (10) β-Crosslaps: 623.40 pg/ml (n: premenopausal 68.00–680.00 pg/ml; postmenopausal 131.00–900.00 pg/ml); (11) N-MID osteocalcin: 15.30 ng/ml (n: premenopausal 4.11–21.87 ng/ml; postmenopausal 8.87–29.05 ng/ml) .
+Old fractures of multiple ribs on both sides. Left ilium and left sacrum bone islands .
+An elliptic slightly high signal near the cortical bone of the posterior edge of the left middle tibia (1.6*0.7 cm), and a small nodular, vertical strip abnormal signal outside the bone (1.5 cm) .
+L1-L2 –1.5; L1-L3 –1.5; L1-4 –1.7; L2-L3 –1.7; L2-L4 –1. 8; L3-L4 –1.8; Neck −2.9; Wards triangle −2.7; Great trochanter −2.4; All −2.3.
+Osteomalacia, with pseudo fractures of the anterior segment of the right 2nd rib, the axillary segment of the left 7th and 8th ribs, right side of the sacrum, left acetabulum, and right femoral neck .
+Abnormal density of left middle and upper tibia with increased somatostatin receptors (SSTR) expression. Pseudo fracture of multiple ribs (the posterior segment of the left 5th rib, the axillary segment of the left 7th to 8th rib, the anterior segment of the right 2nd rib) and right femoral neck with increased SSTR expression. TIO was considered in the above lesions .
+Combined with the above clinical history, physical examination, laboratory evaluation, the patient was initially confirmed to have TIO. The responsible tumor was located in the left proximal tibia. The patient then underwent resection and biopsy of the left tibial tumor on September 6, 2021. During the operation, there was a bony protrusion and bone destruction in the left proximal lateral tibia, and white soft tissue beside the bone. The damaged bone tissue and soft tissue beside the bone were taken and sent for pathological examination. Then we used Kirschner wire to drill holes in the lesion area, and used electric knife to kill the lesion tissue at high temperature. Postoperative histopathological examination demonstrated a spindle cell tumor with prominent vascularity, smoky matrix, “grungy” calcification and a small amount of multinucleated, osteoclast-like giant cells . Immunohistochemical staining was also performed, and the results are as follows: Vim (+), SATB2 (partly+), CD34 (−), S100 (−), Desmin (−), SMA (−), P53 (−), Ki-67 (positive rate, 1%), STAT6 (−), AE1/AE3 (PCK) (−), compatible with a PMT . By postoperative day 5, the serum phosphorus normalized (0.94 mmol/L) and symptoms improved . And now the patient’s systemic bone pain has improved significantly.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2756_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2756_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b7767f87c247d18e41165402704743ddc029790a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2756_en.txt
@@ -0,0 +1,4 @@
+A 56-year-old Chinese male smoker was diagnosed with stage IV NSCLC in December 2019. His chest CT scan ( and ) revealed a mass in the right lower lobe and right-side pleural effusion. PET-CT indicated a mass in the right lower hilar region with an elevated standardized uptake value (SUV) , multiple lymph node enlargement, and bone metastases . A diagnosis of lung adenocarcinoma was made on endobronchial ultrasound-guided transbronchial needle aspiration (TBNA-EBUS) of lymph nodes . Lung adenocarcinoma cells were also found in pleural effusion samples . Next generation sequencing (NGS) of peripheral blood ctDNA indicated EML4-ALK, variant 2 (E20-A20). Alectinib was given orally, at a dose of 600 mg twice daily from January 7, 2020, which resulted in partial response and patient continued to respond after four months of treatment ( and ). He was noted to have an increased total bilirubin (TBIL) of 59.2 μmol/L on May 5, 2020 (on alectinib for 119 days) but did not refer to the doctor.
+On May 29, 2020, the patient presented with jaundice, pruritus and fatigue. His Karnofsky performance status (KPS) rating fell to 60 points. The laboratory result showed TBIL 315.0 μmol/L, DBIL (direct bilirubin) 260.7 μmol/L, and IBIL (indirect bilirubin) 54.3 μmol/L. Serum ALP (alkaline phosphatase) was 374 U/L, total bile acid 179.9 μmol/L, GGT (gamma-glutamyl transferase) 47U/L and aminotransferase levels were AST 34 U/L and ALT 42 U/L. Therefore, a diagnosis of alectinib-induced grade 4 hyperbilirubinemia (>10.0⨰ULN if baseline was normal, Common Terminology Criteria for Adverse Events, v.5.0) was considered. Alectinib was held due to hepatotoxicity. Of note, he had no known liver metastases at baseline nor at follow-up scans. Assessment for viral hepatitis was unrevealing.
+After hepatoprotective treatment comprising ursodeoxycholic acid, glycyrrhizin and glutathione was administered for one week, his bilirubin levels were still worsening, while AST and ALT levels remained similar. Drug-induced liver failure was diagnosed. Although artificial liver support or liver transplantation were both therapeutic choices for liver failure, considering he was a patient with advanced cancer, ALSS was an optimal choice. He received ALSS using a double plasma molecular absorption system (DPMAS) on June 5 and June 8, 2020, for the severe liver dysfunction. The total bilirubin continuously decreased after two courses of ALSS .
+Alectinib was, therefore, discontinued for more than two months when a chest CT scan on August 5, 2020 revealed enlargement of lung lesions ( and ) and overall disease progression. Ensartinib 225 mg once daily was given orally from August 29 as a second-line ALK TKI with initial tumor shrinkage after three months ( and ) and stable disease overall by RECIST (Response Evaluation Criteria in Solid Tumors) criteria version 1.1. Toxicity of second-line ensartinib was grade 1 ALT and AST elevation and grade 1 skin rash, with no abnormality of bilirubin. The timeline of this patient is summarized in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2761_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2761_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a928a11893f6c3e7bd12d37c974341fafb0857f0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2761_en.txt
@@ -0,0 +1,2 @@
+A 22-year-old Caucasian female was seen in the neurosurgical outpatient clinic. The family history was irrelevant. Her medical history revealed a congenital anal atresia and an ectopic anus. At the age of 3 years, the latter was corrected with an anterior sagittal anorectoplasty (ASARP) procedure. Furthermore, she had suffered from grade III vesico-ureteral reflux. X-ray imaging of the lumbar spine confirmed a partial sacral agenesis, sickle-shaped sacrum . After surgery, constipation resolved without fecal incontinence. She was followed-up by the pediatric surgeon. Otherwise, she was in healthy condition and is currently employed as a registered nurse.
+During the second part of 2010, she experienced transient defecation difficulties. For that reason, the pediatric surgical team performed an MRI without contrast of the pelvic region. This showed the formerly known changes as expected from the ASARP procedure and the partial sacral agenesis. Coincidentally an anterior presacral mass of unknown origin, suggestive of a meningocele, as well as a bicornuate uterus was diagnosed . Neurological examination did not reveal any deficits, explicitly there were neither pyramidal tract nor posterior column signs. The history of anorectal malformations, partial sacral agenesis and the presacral meningocele should prompt to the diagnosis of Currarino’s triad. This syndrome can be accompanied by a tethered cord, and a presacral mass of another origin, such as a teratoma. Therefore, we decided to perform a contrast-enhanced MRI of the lumbosacral spine, to rule out any of the above. It confirmed the presacral mass to be a meningocele. Furthermore, a moderate tethered cord was observed with the medullary conus at level L3–4, as well as a small syrinx. The radiologic findings and the absence of symptoms showed no need for surgical intervention. We decided to pursue a conservative approach and follow her in the outpatient clinic. If complaints or neurological symptoms should occur, depending on the incident pathology, transdural ligation of the meningocele or untethering of the spinal cord could be considered. Genetic counseling was initiated.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2776_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2776_en.txt
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index 0000000000000000000000000000000000000000..c9515a5cfb6e7079c20fbd195a41557a555d7fe8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2776_en.txt
@@ -0,0 +1,14 @@
+A 56-year-old woman, 70 kg, of Algerian origin was referred to us in August 2003 presenting with fatigue, proximal and bilateral muscular weakness (muscle testing score of 69 points compared to a score of 88 in healthy individuals), apprehension to grasp, and difficulties in getting dressed. Additional symptoms included effort dyspnea, swollen hands, and purple erythema of her eyelids. Appendicitis, sciatica, tachycardia, hypertension, and asthma were listed in her medical history. Her creatine phosphokinase (CPK, muscle enzymes) levels were six times the normal (N) level. Auto-antibodies measurements were initially not performed.
+A muscle biopsy was performed, and showed characteristic patterns of dermatomyositis with perifascicular atrophy, evidence of injury to capillaries and perifascicular myofibers, and inflammatory infiltrates in the perimysial region (predominantly CD4+). She was diagnosed as having dermatomyositis in November 2003 and prednisone treatment (1 mg/kg per day) was initiated. A repeated search for malignancy was negative. A diagnosis of a mild interstitial pneumonitis together with the presence of anti-Jo1 antibodies further confirmed the suspicion of aSS. Her gamma globulin levels were normal.
+Since treatment response was incomplete, immunosuppressant therapy with azathioprine (2 mg/kg per day), which was replaced after 9 months by MTX (15 mg per week), was introduced. However, both were poorly tolerated and she developed cytopenia. Therefore, infusions with IVIg (2 g/kg per month) were initiated for six months, in addition to steroids.
+In September 2006, due to lack of response to these different therapies, RTX (2 g every 6 months) was introduced and our patient reported an improvement in her articular and muscular pain. Yet, because of the development of hypogammaglobulinemia, RTX was discontinued in October 2011. Of importance, no immune deficit had been present prior to the introduction of RTX.
+She was readmitted in December 2012 with a muscle weakness score of 75.5 points (over 88 points in healthy individuals) . Her CPK levels were normal, but probing for anti-Jo-1 antibody was positive. In addition, a lung scan revealed the presence of interstitial basal lung infiltrate . Testing of pulmonary function showed a reduction of single-breath diffusion capacity for carbon monoxide (DLCO; 48%), with a total lung capacity (TLC) of 72%, and forced expiratory volume in 1 second (FEV1)/vital capacity (VC) at 73%. A slight muscle inflammation of her thighs was also evidenced by magnetic resonance imaging (MRI). In terms of treatment strategy, a bolus injection of IVIg (2 g/kg) was administered, but she developed adverse effects, including headache and distal paresthesia, after which she refused to receive another IVIg infusion. Her treatment adherence was poor and in addition to refusing to try a different IVIg formulation, she had also resumed the corticosteroid treatment in November 2012. In fact, she expressed wishes against hospitalizations and stopped all the treatments.
+An immunologic evaluation showed hypogammaglobulinemia (4.4 g/l), with reduced total immunoglobulin G (IgG) (4.2 g/l), and a reduction in each subclass of IgG: IgG1 2.48 g/l (N >3.82 g/l), IgG2 1.65 g/l (N >2.41), IgG3 0.14 g/l (N >0.2), and IgG4 0.038 g/l (N >0.18 g/l). Her IgA (0.5 g/l, N >0.7) and IgM levels (0.34 g/l, N >0.4) were also decreased. Her IgE levels were normal.
+She was seen again in May 2014, when her general health had deteriorated due to the discontinuation of steroids, RTX, and IgG treatment. In particular, she complained about severe fatigue and presented with swelling of the proximal interphalangeal joints of her right index and middle finger. An MRI scan of her right hand revealed an advanced and destructive arthropathy associated with significant synovitis of the proximal interphalangeal joints of the first, second, and third rays and, to a lesser extent, of the fourth and fifth rays . Her metacarpal phalangeal joints were not affected, but an erosive synovitis of the dorsal scapholunate articulation and beginning erosion of the lunate were observed. Her radioulnar joint was not affected.
+At this point, her muscle weakness score was 70/88, with a muscle strength of +3 as measured bilaterally at her middle trapezius, major gluteal, and psoas muscles. Her muscle disability was rated 18/75 (score ranging from 0 no disability to 75 maximum disability) . An MRI of her thighs did not reveal any significant evolution of myopathy since the previous examination in 2012. In particular, there was no important inflammatory signal of the muscle and no sign of amyotrophy.
+Likewise, a thorax scan confirmed the stabilization of the abnormalities reported in November 2012, with mostly the basal regions being affected. Pulmonary function testing was also indicative of overall stability compared to 2012: single-breath DLCO was 46%, TLC 70%, and FEV1/VC 73%. Whereas DLCO, TLC (−30%), and functional respiratory deficit (25%) were unchanged, a slight decrease of forced expiratory flow (FEF)25–75 was noted.
+Of importance, she complained of frequent infections of the upper airways, including pharyngitis, sinusitis, bronchitis, and otitis for the past 2 years. Consistent with these recurrent infections, an immunologic evaluation confirmed a persistent hypogammaglobulinemia (5.0 g/l), with reduced total IgG (4.1 g/l), and reduction of each subclass of IgG: IgG1 2.3 g/l, IgG2 1.48 g/l, IgG3 0.11 g/l, and IgG4 0.04 g/l. This picture was evocative of a persistent common variable immunodeficiency (CVID) secondary to RTX. Her C-reactive protein (CRP) level was 22.7 mg/l and her CPK level was 489 UI/l.
+Treatment with Gammanorm® (SCIg) was initiated in July 2014 (2 g/kg per month divided into two infusions per week). After 3 and 6 months, respectively, of treatment, she reported diffuse pain, which was present since discontinuation of Cortancyl® (prednisone), and general fatigue. Arthritis of her proximal and metacarpal phalangeal joints was still present, but her muscle weakness score had improved to 75/88 and muscle disability was rated 12/75 . Of importance, no novel infectious episode was reported. In fact, Gammanorm® (SCIg) was well tolerated and she confirmed a slight improvement in her general health state.
+In January 2015, MTX (15 mg/week) was reintroduced and a significant clinical improvement was achieved by April. Notably, her serum CRP (3.3 mg/l) and CPK (63 UI/l) returned to normalized levels despite persisting fatigue, along with arthritis of her metacarpal and proximal interphalangeal joints (arthritis confirmed at a consultation in May 2015). Nevertheless, the normalization of her immunodeficiency and the significant improvement in the state of her general health remained stable, as reassessed in November 2015.
+Finally, in May 2016, joint manifestations had disappeared and fatigue had regressed significantly. No infection had been observed during the past 18 months. Her muscle weakness score had also improved to 82/88 and muscle disability was rated 9/75. Her CRP and CPK levels were normal. As shown by immunologic evaluation, hypogammaglobulinemia had resolved and all subclasses of IgG were normalized.
+Moreover, the results of a thorax scan indicated a slight improvement in basal lung infiltrate, alongside pulmonary function testing: DLCO of 55%, TLC of 75%, and a FEV1/VC 74%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2778_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2778_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..23d7a627c665b1f599e323faa83d0ad155d89b86
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2778_en.txt
@@ -0,0 +1,10 @@
+A 68-year-old woman patient presented arrhythmias with hypotension requiring electrical cardioversion. Her electrocardiogram (ECG) was interpreted as atrial fibrillation (AF) by AP. She was brought urgently to our electrophysiology laboratory, where we are trained for electroanatomical mapping but it is not available. The ECG suggested the presence of posterior or right postero-septal AP ;
+In this case, with recurrent AF by AP and hypotension we did not decide to perform the electrophysiological study to determine the AP insertion sites due to the patient's clinical condition. Cardiologists who was in charge of the patient requested our intervention due to despite the group I-C antiarrhythmic drugs treatment (at recommended doses) the patient continued suffering AF by AP. Once in the electrophysiology laboratory secondary to catheters movement into the heart AF by AP began with hypotension and it was necessary to perform electrical cardioversión (2 Joules per kilogram of weight was calculated, discharge was synchronized with QRS of the electrocardiogram). A deep sedation was performed with midazolam (10 mg ampules in 2 ml), initial dose of 0.5 mg. A single shock was required to recover sinus rhythm.
+Considering the above we proceeded with the protocol of ablation stablished in our laboratory: two punctures on the right femoral vein with placement of introducers (8F and 7F) by Seldigner technique and one puncture on the left femoral vein (7F). The study was performed with BIOTRONIK technology (Multicath study catheter), a non-deflectable 7F quadripolar catheter with 2 mm tip electrode to record the His electrogram, a non-deflectable decapolar catheter with 5 pairs of CS electrodes. All electrograms into CS showed short AV from proximal to distal CS .
+Using a BIOTRONIK ablation catheter (Alcath gold fullcircle) through the 8F introducer. Delta wave in V1 showed negative suggesting the septal region accessory pathway.
+It seemed ventricular electrogram CS proximal (CP 9–10) was earliest during sinus rhythm in Fig. B. It is important to validate the electrogram component between atrium and ventricle. Nevertheless, AP mapping on the right posterior septal region showed no accessory pathway recordings. That is why we decided to perform anterograde mapping of the AP into the left cavities, using a St Jude deflectable sheath (Agilis 8.5 F) and by transseptal puncture we accessed to the left atrium. Mapping with the ablation catheter of the entire posteroseptal, posterior, posterolateral and lateral region of the mitral annulus, we never saw an AV shorter than those observed in the CS; the shorter AV into left chambers was observed on posteriorseptal región (delta-V of 5 ms), then we decided to apply radiofrecuency (RF) on there (temperature of 60 degrees, 55 watts and 60 s of application); finally it was not successful.
+We returned to the right cavities decided to map in sinus rhythm the entire CS from its proximal to the most distal portion, observing AP recordings with very short AV along the CS, the shortest delta-V was − 20 ms, always on proximal CS (CS 9–10), Fig. B. Nevertheless, the AP electrogram was not found nearby of it. Finally we decided to map into the CS finding the a continuous electrogram on ablation catheter, with intermediate accessory pathway potential spike into of the left posterior coronary vein (PCV) considering its probable radiological projection and here was applied RF with 50 watts and 50 Celsius degrees on the PCV anatomical region . During the first seconds of radiofrequency application the patient referred intense pain, so we decided a deep sedation with midazolam newly, this time 1 mg to achieve deep sedation. A trained specialist was in charge of the patient's airway management. This allowed us to gradually increase the temperature for ablation and fortunately there were no impedance increases in the ablation channel. It allowed us to continue and end the procedure.
+After we decided to increase 55 watts and 60 Celsius degrees; a junctional rhythm started and we moved the His recording catheter to the right atrium and started to pace with a higher cycle length than the junctional rhythm after 60 consecutive seconds of RF the AP was ablated on the ventricular site. We could recognize the accessory pathway was ablated because during pacing from the right atrium a normal PR segment can be observed on the surface electrocardiogram, without the presence of a delta wave . If accessory pathway were still present, pacing from the atrium at a basic cycle higher than junctional rhythm would reveal the presence of the accessory pathway (delta wave on electrocardiogram).
+The radiological projection suggests we were probably in the posterior coronary vein; however, a venography should have been performed to identify that site; there is a anatomical variation of the CS ostium. Some of the patients showed large ostium with trumpet-shape. It is still unclear the shortest delta-V was located at left posterior vein without CS venography or Geometry with 3D mapping system. In our laboratory we have not a 3D system, we should have performed CS venography and it was not performed. It was a limitation to diagnosis the anatomical site of ablation.
+According to our laboratory protocols, we waited ten minutes after ablation and administered adenosine, 12 mg intravenously for verification of AP ablation. After the administration of adenosine an electrocardiographic pattern reappears with the presence of delta wave ; however, compared to the initial ECG, a small R wave appears in DII and CS recording has been modified with shorter AV on CS 1–2 and 3–4 . Upon observing a new site where the CS 3–4 accessory pathway would be passing through, we decided to stimulate from that point of the atrium (CS 3–4) and observed maximum pre-excitation. We also stimulated from 9–10 CS and there was no change in the magnitude of the surface electrocardiogram delta wave. When pacing from the right ventricle, the first retrograde atrium was observed at CS 3–4. Considering that initially left intracavitary mapping had been performed, we decided to go directly through the CS.
+Mapping within CS with ablation catheter up to anatomical and fluoroscopic region where the CS catheter recording 3–4 was located (it was removed) . Successful ablation was achieved at this second point, on the mitral annulus. After waiting 10 min and administration of adenosine, ablation was successful at two distant epicardial points and the ECG was in sinus rhythm with normal PR .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2791_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2791_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eba11b55f1861f5386e655ed159e9d6217d534e3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2791_en.txt
@@ -0,0 +1 @@
+A 70 year old otherwise healthy male patient with a 50-pack year smoking history who quit approximately 3 years ago, presented with a slowly enlarging left cheek mass. He first noted the lesion approximately 1 year prior to presentation. The patient reported undergoing a fine needle aspiration at an outside facility at which time some fluid was drained from the cheek mass, but the mass later re-accumulated. Over time he developed mild local pain and ipsilateral left ear discomfort. Contrast enhanced CT-scan of the neck demonstrated a left parotid gland tumor measuring 3.3 cm (anterior-posterior) × 2.2 cm (transverse) × 3.4 cm (craniocaudal) without pathologic cervical adenopathy . The facial nerve function was intact, with a House-Brackmann score of 1 out of 6. The patient underwent a left superficial parotidectomy with a left sternocleidomastoid muscle flap reconstruction. He was discharged home on postoperative day 2 following an uneventful hospital course. Facial nerve function was full postoperatively. A complete blood count was within normal range at the time of diagnosis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2796_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2796_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6cc2f450a7b8dcace21441c1a9517871a8baf1a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2796_en.txt
@@ -0,0 +1,4 @@
+Parents of a 4 year old female child presented her with deformity of the nose and difficulty in breathing from right side of the nose for 1 year. She developed the deformity as a small swelling at the tip of the nose of about 0.5 cm which increased progressively to the size of about 1 cm in 1 year. There was no history of trauma, fever, sudden increase in size or pain associated with the swelling. There was no association of similar swelling in any family member. Child was immunised and had achieved milestones appropriate for her age. Parents of the child wanted removal of the swelling as it was a cause of social embarrassment for the child and she had difficulty in breathing from right nostril. The child had an identical twin who was operated for intususseption at 6 months of age.
+On examination, there was evidence of a diffuse 1.2x1x1.5 cm swelling at the tip of nose in maximum horizontal, vertical and anteroposterior dimensions. The skin over the swelling was found to be normal and free from the swelling. It was soft in consistency. Swelling extended to the nasal columella. Right ala was found to be slightly flared. It was non tender. The septum appeared normal. There was midline cleft of the upper lip . X ray chest showed levocardia. 2D echo was normal. Contrast enhanced Computed Tomography of para nasal sinuses and head showed a non enhancing fat density lesion of approximate size of 0.8x1.2x2.3 cm in the tip of nose and inferior nasal septum causing compromise of right nasal cavity . There was an incidental finding of lipoma in the genu of corpus callosum with bracket calcification. Patient was posted for exploration of the swelling after anesthetic fitness and written consent from the parents.
+Nose was opened with stair step incision in the collumella for open rhinoplasty. This incision was chosen over sublabial or septal incision in view of better operative view in the case of former incision. Fatty tissue was found over the left lower lateral cartilage. Right lower lateral cartilage was found to be deficient. Lipoma extended till the middle of collumella on the right of middle crus and right part of the caudal septum. It was excised in toto and specimen was sent for histopathological examination.
+Postoperative period was uneventful and patient was discharged on the third postoperative day. Histopathology was suggestive of lipoma . Early followup did not show any recurrence. There was a residual collumellar deformity which required secondary revision . Patient’s patient did not wanted any surgery at that time. Karyotype analysis was normal . She was advised further followup at regular intervals. Patient was satisfied with the surgical outcome.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2800_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2800_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..91efb74d65161eb264777dd34698b4ab5c734ac1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2800_en.txt
@@ -0,0 +1,3 @@
+A 10-day-old boy was born at 38 weeks’ gestation and had tachypnea at 65 breaths per minute. The liver margin was palpable 4 cm below the left costal margin. The heart rhythm was normal but a grade II-IV systolic murmur could be heard. Laboratory tests showed that his brain natriuretic peptide (BNP) level was greater than 5000 pg/ml. His CKMB was 110 U/L, C-reactive protein was 23.4 mg/L, alpha fetoprotein was greater than 1210 ng/ml, PTA 54%, INR 1.6, APTT 50 s, FIB 1.5 g/l, D-dimer 1064 μg/L, HGB, 123 g/L, MCH 36.4 pg, total bilirubin (BilT)196.7 umol/L, BilD 13.2 umol/L, ALT 44 U/L, and AST 23 U/L. Blood gas analysis revealed that the carbon dioxide pressure was raised to 53.4 mmHg and the oxygen partial pressure was 62.5 mmHg.
+Echocardiography demonstrated a small PDA of 1.5-1.8 mm with right to left shunting, a large ASD with left to right shunting, and severe right atrial and right ventricular enlargement. A severe systolic pressure gradient of 70 mmHg suggested marked elevation of pulmonary artery pressure at the near systemic level. Color Doppler scanning of the liver displayed abundant blood flow in the lesion. The left hepatic vein was dilated to 8 mm with two great branches feeding the mass. The right hepatic artery and a branch arising from the abdominal aorta were also in close association with the lesion.
+Contrast-enhanced computed tomography (CT) showed that the lesion enhanced irregularly in the left lobe of the liver. It was irregularly hypodense on plain scan with peripheral enhancement in the arterial phase and centripetal fill-in in the portal venous phase. In the delayed phases, the density of the leision was slightly higher than that of the liver parenchyma. The patient received diuretic therapy, fluid restriction, low-flow oxygen, and infection control for the management of the heart failure. After treatment his breathing difficulty improved. Then the patient was transferred to Beijing Children’s Hospital for surgery and the adhesion between the tumor and the intestine was found during the operation. The patient eventually died due to postoperative complications and multiple organ failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2816_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2816_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e821b535df12882c09b04217b4c4709e138ab7cf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2816_en.txt
@@ -0,0 +1,4 @@
+A 79 year old man was admitted at our emergency department due to exertion dyspnoea and swelling of the upper limbs, head and neck. Five years ago the patient had undergone elective replacement of the aortic valve with a prosthetic one (Carbomedics 23 mm) and a concomitant ascending aorta aneurysm replacement with a 28 mm synthetic graft. On admission the patient was dyspnoic with malaise. His blood pressure was normal (128/82 mmHg) and the oxygen saturation without oxygen supply was 92%. Pulses were irregular and increased in rate. ECG showed atrial fibrillation with fast ventricular response (135 to 145 beats/min). The physical examination documented cyanotic and swollen head and neck and distended jugular veins. Superior vena cava syndrome (SVCS) was clinically diagnosed. Laboratory data included a prolonged INR of 7 and Ht: 35.6%. Other elements of blood count and coagulation time were within physiologic values. Cardiac enzymes were negative. LDH was 620 IU/L. The rest of his biochemical profile was normal. Arterial blood gases showed mild respiratory acidosis (PH: 7.33) due to elevated PCO2: 48mmHg.
+Chest x-rays was further confirmatory of the clinical diagnosis showing a widened mediastinum. However the contrast CT angiography of the chest was remarkable, revealing a large pseudoaneurysm of the ascending aorta with a maximum diameter of 13cm compressing the superior vena cava and an extensive collateral circulation .
+Transfusions with 2 units of fresh frozen plasma were enough to lower the INR to 1.8 and the patient was then transferred to the operating room. Femoro-femoral cannulation was undertaken in order to establish cardiopulmonary bypass and decrease the patient's temperature to down to 16°C to safely commence circulatory arrest. After the completion of cooling with collection of the patient's blood within the reservoir of the extracorporeal device, repeat sternotomy was performed through safe surgical means. Retrograde cardioplegia was installed. The pseudoaneurysm was incised and the thrombotic material was carefully removed. Two sites of major leakage originating from the anterior and posterior segment of the distal anastomosis were revealed. Suturing with 3/0 prolene, reinforced by teflon patches, was performed. Eventually extracorporeal circulation was recommenced, gradual rewarming was carried out and successful weaning from cardiopulmonary bypass was achieved.
+The patient was extubated 6 hours later and he remained in the intensive care unit for 18 hours. His postoperative course was uneventful. Ten days following his admission the patient was discharged in good condition, presenting however atrial fibrillation with good rate control under Amiodarone treatment. Three months following his discharge he remains free of symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2851_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2851_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ef8630e7c2e10ba83fd6164c1f62978b50192dc7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2851_en.txt
@@ -0,0 +1,7 @@
+On February 6, 2019, a 62-year-old Chinese man presented with mild skin edema at the site of the peripherally inserted central venous catheter (PICC, median cubital vein) which had been inserted for 30 d, without skin redness and inflammatory exudation.
+He presented with a two-day history of dyspnea and was admitted to our emergency intensive care unit with a diagnosis of motor neurone disease on January 7, 2019. The patient received comprehensive symptomatic treatment including invasive ventilator-assisted ventilation, pulse oxygen saturation measurement, expectorant, and nutritional supplement.
+There was no history of past illness.
+There was no personal and family history.
+Physical examination revealed that he was stuporous with a Glasgow coma scale of E1VTM1. His body temperature was 35.0 °C, heart rate 66 beats per minute, blood pressure 90/54 mmHg, and respiratory rate 23 breaths per minute.
+Routine blood tests revealed 3.7 × 109 cells/L white blood cells (reference range, 4.0-10.0 × 109 cells/L) and 67.2% neutrophils (reference range, 40%-75%). Catheter and peripheral blood cultures were performed on February 10, 2019. On February 11, 2019, he presented with elevated body temperature (37.1 °C), white blood cells (10.2 × 109 cells/L), and neutrophils (86.7%). The serum procalcitonin and C-reactive protein levels was 0.99 ng/mL (reference range, 0-0.05 ng/mL) and 184.9 mg/L (reference range, 0-5 mg/L), respectively. The patient began to receive anti-infective treatment with vancomycin. On February 19, 2019, the blood culture showed positive results during Gram staining and acid-fast staining . The alarm time of catheter blood culture was 10.6 h earlier than that of peripheral blood culture. The treatment regimen of the patient was changed to combination therapy with vancomycin and amikacin.
+On February 23, 2019, repeat blood cultures showed positive acid-fast bacilli, and the treatment regimen was adjusted to amikacin plus clarithromycin. On the second day, his body temperature was 35.3 °C, his heart rate was 74 beats per minute, white blood cells 7.4 × 109 cells/L, and neutrophils 77.6%. After removal of the PICC on March 11, 2019, secretion culture and catheter blood culture were all positive. The blood culture isolate was identified as M. abscessus by matrix-assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) and 16S rDNA sequencing .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2858_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2858_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd6713c54ebe10ef1158e67cf5fbd34d720f341f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2858_en.txt
@@ -0,0 +1,5 @@
+A 10-year-old female patient was referred to our hospital due to right high-grade hydronephrosis and a right renal stone, which was detected due to hematuria. Ultrasonography (US) and CT scan revealed hydronephrosis and an 11-mm renal stone . Technetium-99m mercaptoacetyltriglycine (MAG3) renography showed decreased relative function of the right kidney (right:left = 38.2:61.8). While a growth hormone was administered due to growth-hormone deficiency dwarfism, no metabolic abnormalities were detected as a cause of renal calculi in this patient.
+Since urine stasis due to hydronephrosis was considered to be a potential cause of stone formation, we decided to perform surgical management for both the hydronephrosis and renal stone simultaneously. Laparoscopic UC and pyelolithotomy were indicated because of the completely intrarenal pelvis. Since the hydronephrosis was so severe with thinning of the cortex, especially at the lower calyx, bleeding due to incision at the lower pole could be controlled best under laparoscopy.
+A transperitoneal approach was implemented in a lateral flank position under general anesthesia. Four trocars, including a 12-mm trocar at the umbilicus and three 5-mm trocars, were inserted in a similar fashion to laparoscopic pyeloplasty . After exposing the renal hilum and the upper ureter completely by reflecting the ascending colon, the renal stone was extracted without lithotripsy by making a small longitudinal incision at the ureteropelvic junction . A flexible ureteroscope inserted from the working port confirmed no residual stone in the right kidney. Then, the ureter was transected, and the renal pelvis was closed using 5-0 absorbable sutures at the level of the renal hilum.
+To make the anastomosis, the thinning portion of the renal parenchyma at the lower calyx was identified using US, and a 2-cm incision was made with cold scissors . Bleeding from the incised thin renal parenchyma was minimal without clamping the renal vessels. Three anchor sutures were made using 5-0 absorbable sutures followed by insertion of a 5 Fr double-J ureteral stent in an anterograde manner. Uretero-caliceal anastomosis was completed in a running fashion using 5-0 absorbable sutures .
+Blood loss was minimal, and no transfusion was required. The operation time was 379 min. The postoperative course was uneventful. An indwelling urethral catheter was removed 4 days after surgery, and the patient was discharged 6 days after surgery. Stone analysis revealed that the stone was composed of calcium oxalate and calcium phosphate. The double-J ureteral stent was removed 8 weeks postoperatively under general anesthesia. US performed at 6 months after surgery showed improvement of the right hydronephrosis . CT scan revealed patency of the anastomosis , and ipsilateral renal function as assessed by MAG3 renography at 15 months postoperatively had improved from 38.2% preoperatively to 42.0%. No reoccurrence of hydronephrosis or renal stones were observed for 29 months after the procedure.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2860_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2860_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e7d3728f1548037ba80a7bd8f0584560cbedb9ea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2860_en.txt
@@ -0,0 +1 @@
+A 31-year-old male presented with chest pain and hoarseness of recent onset. The patient had suffered a traffic accident 3 months before admission, resulting with femur, radius, ribs and sternum fractures; and had undergone internal fixation of the femur and radius. The physical examination was normal. Computed tomography (CT) showed a ruptured aortic arch with pseudoaneurysm. The crevasse measured 20 mm and was located in the posteroinferior aspect of the aortic arch, involving the posterior wall of the innominate artery and the origin of left common carotid artery. The pseudoaneurysm of 40 mm × 48 mm × 30 mm was located in the upper mediastinum. The distance from the junction of aortic sinus and ascending aorta to the rupture was 7.9 cm . The recent appearance of symptoms suggested that the pseudoaneurysm had increased rapidly and compressed the left recurrent laryngeal nerve. In this case, to reduce the risk of cardiopulmonary bypass or cardiac arrest under deep hypothermia , a hybrid operation was performed: debranching + thoracic endovascular aortic repair (TEVAR). The involved branches of the aortic arch were rebuilt with artificial vessels, and a covered stent was placed in the aortic arch for endovascular repair via femoral artery. A hybrid operation is safer, more feasible, and more comprehensive than other treatments for some high-risk patients. Thoracic and abdominal CT angiography performed on the 7th postoperative day showed that the contrast agent did not leak and that the reconstruction of blood vessels was smooth . Recovery was uneventful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2864_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2864_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7344e1438794b0840b190fff42fb9c27bdd1add7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2864_en.txt
@@ -0,0 +1,4 @@
+A 56-year-old male patient with end-stage ischaemic cardiomyopathy, chronic kidney disease, chronic obstructive pulmonary disease, type 2 diabetes mellitus, and dyslipidaemia developed cerebral infarction due to thrombosis of the right medial cerebral artery approximately one and a half year after minimally invasive left ventricular assist device (LVAD) implantation (HeartWare HVAD®, Medtronic plc, Dublin, Ireland). The patient successfully underwent mechanical thrombectomy and was listed for HTx with high urgency waiting list status. Another 43 days later, the patient was finally allocated to a suitable donor organ of a 22-year-old donor and underwent HTx in orthotopic bicaval technic. Although reported donor ejection fraction was good (>60%) and transport time (157 min) and warm ischaemia (49 min) were not prolonged, the patient developed immediately PGD with biventricular failure and severe impairment of left ventricular function (ejection fraction < 20%). After a total reperfusion time of more than 150 min, we decided to implant a microaxial pump (Impella 5.0®, Abiomed, Inc., Danvers, MA, USA) via a vascular prosthesis connected to the right subclavian artery for temporary isolated left ventricular mechanically assistance. However, due to concomitant right heart failure, additional right ventricular assistance was inevitable. Thus, we upgraded the running Impella® system to ECMELLA configuration by additional VA-ECMO implantation via a second arm of the already implanted vascular prosthesis of the right subclavian artery and the right femoral vein as described before by Eulert-Grehn et al. Afterwards, the patient was stabilized and transferred to the intensive care unit.
+In the following, the patient developed progressive hyperaemia of the right arm with consecutive therapy-refractory lactataemia. At the first postoperative day, we therefore switched the arterial cannula of the VA-ECMO to the right femoral artery. Unfortunately, the patient suffered from multiple bleeding complications during ECMELLA support with need for a total of four thoracic revisions and temporary thorax apertum due to repetitive haematothoraces. Finally, ventricular function recovered after levosimendan therapy and the Impella® device was explanted eight days after HTx. Due to on-going right ventricular dysfunction, we maintained VA-ECMO support for additional 4 days. We explanted VA-ECMO on the 15th postoperative day achieving thoracic occlusion. A detailed timeline of all operative procedures is displayed in .
+Approximately one month after the HTx, the patient was transferred to the intermediate care unit and at the 46th postoperative day, the patient was finally discharged to a rehabilitation clinic. At discharge, echocardiography confirmed full biventricular recovery with left ventricular ejection fraction at 53% and apparently good right ventricular function without any valve pathologies.
+At follow-up, two months following HTx the patient presented fully recovered without any heart failure symptoms or chronic kidney injury. He reported regular physical exercise without any dyspnoea and echocardiography revealed normal cardiac function.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2879_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2879_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9bbbe4e7f8d0f981fc3bd1cbba1cbf00e88f8889
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2879_en.txt
@@ -0,0 +1 @@
+A 54-year-old female presented with a progressively enlarging mass in her right distal leg anterior aspect for 2 years, associated with occasional pain over the past 6 months. Physical examination revealed a palpable, non-tender, subcutaneous mass measuring approximately 2 cm in diameter, located in the medial aspect of the distal leg. Ultrasonography demonstrated a well-defined hypoechoic lesion with vascularity. Considering the suspicious nature of the mass, surgical excision was performed under regional anesthesia . Histopathological analysis revealed a well-circumscribed encapsulated neoplasm composed of myoepithelial cells proliferating with perivascular attenuation around slit such as vascular spaces, consistent with a diagnosis of angioleiomyoma . The patient recovered completely and was followed up at 6 monthly intervals for 2 years without any recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2886_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2886_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2f8339bad90d74be6820cd68326f5cfd2b9bfefa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2886_en.txt
@@ -0,0 +1,5 @@
+A 29 year old male visited the fertility center of Sree Avittom Thirunal Hospital of Government Medical College, Thiruvananthapuram for fertility treatment. Consent was taken from the patient before the study. The present finding of unexpected association between DSD and infertility in Kerala population was observed on 1st March 2018 at Sree Avittom Thirunal Hospital of Government Medical College, Thiruvananthapuram, Kerala, India during karyotyping and molecular characterization of azoospermic male patients.
+Physical examination and medical history showed that the patient having height of 170 cm and weight of 75 Kg had no history of smoking, alcohol consumption and tobacco chewing. He has been using modern electronic gadget (Mobile phone) for the last five years and did not have any history of orchitis, STDs, psychological and endocrine disorders. Clinical findings revealed that the subject did not have palpation of testis, cryptorchidism, testicular torsion and changes in his extremities. Family history of patient did not show any infertility related problems. The study subject showed normal male secondary sex characters, penile length and androgenic hair pattern and no erection problem, gynecomastia and hypospadias were observed. The testis volume was <2 ml and both testicles were soft and atrophic. Major noticeable changes observed during clinical evaluation were small sized testis and ejaculatory dysfunction. Semen analysis was done on sample collected after 3 days of abstinence and the results confirmed non obstructive azoospermia on repeated analysis. Volume was 2 ml, pH=7.4, liquefaction time 15 min, WBC 0–1 pc/ml and fructose was present. Percutaneous Epididymal Sperm Aspiration (PESA) was done on both sides and sperm could not be retrieved. The couples opted for artificial insemination by donor (AID). Ultrasonography (USG) of scrotum showed right testis to be 1.2 cm × 1.8 cm × 1.4 cm in size with normal echotexture. Epididymis was normal with dimensions of 1 cm × 0.7 cm. Left testis measured 1.3 cm × 1.7 cm × 0.9 cm in size with no indication of varicocele. Transrectal ultrasound (TRUS) showed prostate with 38 mm X 35 mm × 20 mm size. No lesions were observed in any of the transrectal components. Urinary bladder was normal with no dilation in the seminal vesicles and ejaculatory ducts. Hormonal analysis showed an increase in Follicle Stimulating Hormone (FSH) to 35 mIU/ml (1–12 mIU/ml) and Luteinizing Hormone (LH) to 19.9 mIU/ml (1.5–10 mIU/ml) whereas testosterone to 3.2 ng/ml (2.45–10 ng/ml) and prolactin to 6.7 ng/ml (3.1–16.5 ng/ml) which were within the limit of reference range.
+Chromosomal analyses of peripheral lymphocytes were used for identifying the numerical and structural aberrations of chromosomes. GTG banding was done for karyotyping. A total of 30 metaphase chromosomes were analyzed and the results showed that the patient had 46 XX karyotype known as de la Chapelle syndrome with no evidence of other structural/numerical chromosomal abnormalities including mosaicism.
+Molecular analysis of the Y-chromosome specific STS region by real time PCR and Uniplex PCR amplification of Y chromosome specific six sequence tagged sites (STS) primers were used for identifying AZF gene microdeletion . The primers were designed based on EMQN guidelines . Primers against SRY gene and a unique fragment in X chromosomes and ZFX gene were used as internal controls. Real time PCR analysis showed absence of entire AZFa, AZFb and AZFc region but the presence of SRY gene was confirmed as shown in . All STS primers were amplified in the male positive control. The female genomic DNA failed to amplify in any of the STS primers and the SRY gene, however, showed amplification of the ZFX gene. These findings confirmed that the patient is 46 XX male with the presence of SRY gene.
+Fluorescent in situ hybridization (FISH) analysis was performed on metaphase chromosomes from cultured peripheral lymphocytes to confirm the 46 XX male condition using LSI SRY/CEPX probe (Vysis Inc., USA) localized on Yp11.3 and p11.1-q11.1 of X chromosome. The probe hybridization showed two signals for CEPX (Green) at the centromeric region of both the X chromosome and one signal for SRY (Red) on terminal region of one X chromosome in all the metaphases analyzed . This finding confirmed the 46 XX karyotype, a case of DSD.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_28_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_28_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..94da2c8af2e11fbda912a433b0b04a293d84019d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_28_en.txt
@@ -0,0 +1,6 @@
+The patient was a 43-year-old man who had a soft tissue mass in the right paravertebral region discovered incidentally 1 mo earlier.
+The patient had no other significant medical history.
+There was no personal and family history.
+Physical examination on admission revealed no pain or tenderness.
+The results of routine blood and urine tests, blood biochemistry, and immune and infection indices were normal.
+Plain computed tomography (CT) showed a lobulated soft tissue mass on the right side of the T4/5 vertebra that measured about 47 mm × 28 mm in the transverse view and contained diffuse stippled calcification . The mass caused cortical scalloping of the right fourth rib , rim ossification, and narrowing of the myeloid cavity. Enhanced CT showed mild enhancement of the mass. T1-weighted magnetic resonance imaging (MRI) in the transverse view showed a lobulated tumor on the right side of the thoracic vertebra . The lesion was bordered by a hypointense rim and showed long Tl and T2 signals in the sagittal view on T1- weighted and T2-weighted images . On short tau inversion recovery imaging, the mass showed high signal intensity and contained mottling and patchy long TI and short T2 abnormal signals . Enhancement was seen predominantly at the periphery of the lesion on post-enhanced MRI .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2901_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2901_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..10dfd4cb669f092985732eed6b0a277e81c6b476
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2901_en.txt
@@ -0,0 +1 @@
+A 55-year-old Caucasian obese woman (body mass index = 35) was admitted to Surgical Department of our institution for acute abdominal pain. Her past medical history was negative for previous gastrointestinal disease or surgery. She was on medical therapy for hypertension, type II diabetes, and minor depression. Glasgow coma scale was 15. She referred an increasing acute abdominal pain risen 5 hours ago after a fish-based dinner. She has showed an acute diffuse peritonitis. White blood cell count was 32.000 U/μL, with neutrophilia (90%); other blood tests were in normal range. Body temperature was 39.2°C. Electrocardiogram showed sinus rhythm with 92 heart rate. Chest X-ray was normal. Abdominal X-ray showed free subdiaphragmatic air. CT scan confirmed the suspicion of small bowel perforation because of the finding of free fluid in the abdomen and an inhomogeneous mass in the small bowel. A nasogastric tube was placed, and it drained 50 mL of biliogastric material. Because of her status, she was immediately ran to the theater for exploratory laparotomy under general anesthesia and oral intubation. Although each clinical finding suggested a colonic or caecum perforation, during the systematic exploration of the bowel loops, surgeons found free intestinal fluid in the abdomen, fecal peritonitis, and (at 60–70 from ileocaecal valve) a 3 cm linear tear of the ileum which was caused by the curve edge of a shell mussel . The foreign body was completely extracted from the lumen through the hole , and the breach was sutured with simple double-strand stitches of polyglactin 3/0 parallel to the bowel tearing. Abdominal cavity washing was carried out with 2 liters of saline. Two drains were placed on suction for 24 hours. Antibiotic therapy (ciprofloxacin, meropenem, and metronidazole) and nil by mouth regimen were started. Patient was admitted in Intensive Care Unit for 12 hours, the weaning from the ventilator, and she was discharged at home in healthy status from the ward on the sixth postoperative day. At the 30-day follow-up, the patient was in good clinical condition, surgical wounds were completely sealed, blood tests were normal, and bowel function was recovered.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2909_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2909_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5022b64c7ff0a898265a6f4904dd1ba5ff4ca2e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2909_en.txt
@@ -0,0 +1,4 @@
+A 78-year-old Chinese woman had an isolated mass that was found in her right breast during a health checkup, and a pulmonary CT scan revealed multiple lesions in both of her lungs. She had a history of cough and expectoration for two months without fever, chest pain, dyspnea, or other complaints. During a physical examination, a nearly 2.0×2.0cm, firm nodule without tenderness was found in the lateral superior quadrant of the right breast. In a routine blood test and tumor marker screen, no remarkable abnormalities were reported. However, the anti-SS-A and anti-SS-B antibodies were positive. Our patient had high concentrations of polyclonal serum immunoglobulins (Igs): IgA 485.00mg/dL (reference range: 70 to 400mg/dL), IgG 2030.00mg/dL (reference range: 700 to 1600mg/dL), Ig light-chain kappa 432.00mg/dL (reference range: 170 to 370mg/dL), and Ig light-chain lambda 249.00mg/dL (reference range: 90 to 210mg/dL).
+Prior to a surgical resection of the mammary nodule, a whole-body PET/CT scan was suggested for the purpose of staging the possible malignant breast lesion. The scan was performed on a PET/CT system (Siemens Biograph TruePoint™ 64; Siemens Healthcare, Erlangen, Germany) at 60 minutes after intravenous injection of 6.5mCi (240MBq) of 18F-FDG and covered the range of the bottom of the skull to the mid thigh. On the PET maximum intensity projection image , an obviously hypermetabolic nodule in the right breast and slightly increased FDG uptake of the lymph nodes (LNs) at the hilus of the lungs and posterior cervical region bilaterally were revealed. On transverse images of PET/CT, the right breast lesion was a 2.3×1.9cm, round, well-circumscribed homogenous isodense nodule with a maximum standardized uptake value (SUVmax) of 7.30 . Multiple irregular nodules with slight to mild FDG uptake were observed in the lungs, and the largest lesion was a 2.7×2.5cm, round, well-defined solid nodule in the right lower lobe and had an SUVmax of 2.96 . In addition, the bilateral posterior cervical LNs were normal in size and had an SUVmax of 4.48. Given the multiple FDG-avid foci in a woman of our patient’s age, a primary breast malignant tumor lesion with pulmonary metastasis was considered first and surgery on the mammary lesion was performed three days later.
+Tissues of the mammary lesion were reviewed for histopathological features, and formalin-fixed and paraffin-embedded tissues were immunostained with antibodies to IgG4 (1:300, clone HP6025; Zymed, now part of Invitrogen Corporation, Carlsbad, CA, USA), IgG (1:200, clone A57H; Dako, Glostrup, Denmark), S-100 protein (1:1000, polyclonal; Dako), and CD68 protein (1:100, clone KP1; Dako). Congo red stain was used to test amyloid deposits. Pathologically, the mammary lesion showed abundant plasma cells and sinus histiocytes, including large pale pathognomonic histiocytes that exhibited emperipolesis . In addition, lymphoid follicle formation, patchy fibrosis, and obliterative phlebitis, accompanied by atrophy and loss of mammary lobules, were observed. Further immunohistochemical staining showed large histiocytes positive for S-100 protein and CD-68 protein but negative for CD1a. The average number of IgG4+ cells was 118 per high-powered field, and the ratio of IgG4+ to IgG+ cells was 65%.
+The lesion in the upper lobe of the right lung and the LN at the right carotid sheath were biopsied. Histology revealed deposition of strongly Congo red-positive materials with few histiocytes and fibrotic cell infiltration in the lung tissue. Reactive lymphoproliferation and deposition of Congo red-positive materials within the adjacent connective tissue were observed in the cervical LN.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2913_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2913_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9a84f200867537ab48fc73bf77fb47123e42f92b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2913_en.txt
@@ -0,0 +1,4 @@
+We report a case of a 29-year-old male patient with chief complaints were pain and instability on his left knee. He got injured when playing futsal with knee twisted externally. He suffered severe pain, swollen and difficult to walk. The magnetic resonance imaging (MRI) examination after the injury revealed ACL and PCL rupture of the left knee. He underwent arthroscopic surgical reconstruction for both ACL and PCL by previous surgeon. Two years after surgery, he felt instability, swollen knee without pain and no history of other trauma during the time after operation. On the physical examination we found posterior sagging and positive posterior drawer test as well as quadriceps active test. Anterior Lachman test for anterior cruciate ligament was negative.
+On the MRI, we found failure of PCL graft with intact ACL. On the MRI and three dimensional CT scan, with more clear projection for bone structure, it was found that the tibial tunnel placement done in previous surgery was not placed on its anatomical position. The tunnel was placed too anterior to the PCL footprint .
+Subsquently we performed the PCL revision reconstruction surgery. We performed the arthroscopic-assisted reconstruction surgery using transseptal portal approach. We avoided to use only the jig to guide us when tunnelling the tibia instead, we used additional technique to see the posterior aspect of proximal tibia clearly. In this case, we choosed to make a transseptal portal that penetrated from posteromedial side of the knee inside-out to the posterolateral side of the knee . An incision was made on the posteromedial side of the knee with guidance of arthroscopic view and also transiluminatic arthroscopic light. Blunt obturator with sheath was inserted gently passed through intercondylar notch to posterolateral side of the knee and we made inside-out incision on it.
+During arthroscopy procedure, we found that the PCL was gone with small PCL remnant on femoral site. The ACL was still intact and adequately attached. We performed the reconstruction of PCL using peroneus longus tendon as the graft from the left ankle. When tunneling the tibia, we used jig guide for tibial tunnel placement, we also made a transseptal portal from medial to lateral in order to get better view of posterior aspect of the tibia ( and ). We used it as the graft because hamstring tendon was already used in previous surgery. showed post-operative X-ray of the left knee that tibial tunnel was revised to appropriate site of its footprint. The shadow of two endobuttons on the lmedial femoral condyle was seen because the endobutton of previous surgery was not removed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2939_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2939_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ab2aee5eb937bdea5f487e7ccf51846e59c76de8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2939_en.txt
@@ -0,0 +1,3 @@
+Our patient was a healthy 72-year-old Japanese man, with an unremarkable previous medical history. He was referred to our institution due to jaundice and impaired hepatic function found during a health examination. We observed stenosis in the middle bile duct on a preoperative endoscopic retrograde cholangiopancreatography (ERCP) image , whereas class V adenocarcinoma was detected by biliary abrasive cytology. The preoperative image indicated low bifurcation in the posterior segmental branch. A pancreaticoduodenectomy was conducted due to the diagnosis of middle bile duct cancer. Because our patient had no post-surgical complaints, even given mildly increased inflammation, he was discharged on postoperative day 22. However, we found increased inflammation on blood withdrawal when he visited our institution on postoperative day 30. On computed tomography (CT) we observed abscess formation with suspected bile leakage around the hepaticojejunal site and posterior segmental bile duct dilatation . We initially completed percutaneous transhepatic biliary drainage (PTBD). During contrast radiography with PTBD, only the posterior segmental branch was visualized, but there was no bile leakage into the elevated jejunum . Later, we completed contrast radiography from the hepaticojejunal anastomosis site with the use of an endoscope, and only the anterior segmental branch and left branch were visualized . Thus, we concluded the damage was on the low bifurcation in the posterior segmental branch. Bile (approximately 250 ml/day) was discharged by PTBD on consecutive days.
+We conducted a drip infusion cholecystocholangiography (DIC)-CT test to determine the positional relationship between bile duct and elevated jejunum. We found contrast agent discharged into the elevated jejunum from the anterior segmental branch and left branch . We dorsally visualized the bile duct in the isolated posterior segmental branch . From the DIC-CT test, we at that time detected an unclear positional relation between elevated jejunum and posterior segmental branch. We determined that there was no intrusion of other organs between the elevated jejunum and the bile duct. Consequently, percutaneous transhepatic internal drainage of the posterior isolated bile duct, to the elevated jejunum, could be conducted.
+To secure the bile duct, we made a puncture in the bile duct under CT guidance , and visualized the hepaticojejunal anastomosis site by inserting an endoscope. We vibrated the bile duct wall by inserting a guide wire through a puncture needle, and verified the vibrations with the endoscope. We found a partially compressed elevated jejunal wall upon guide wire insertion; therefore, we could verify a puncture needle penetration into the elevated jejunum by endoscope on insertion . We also successfully inserted an 8.5-Fr pigtail catheter into the elevated jejunum . We removed all drains after percutaneously inserting an uncovered metallic stent (5 cm 10 mm; Fig. ). Our patient’s subsequent clinical course was unremarkable, and he visits our institution on an out-patient basis, without stent occlusion even after 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2953_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2953_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ccb872d5bee4df763850dd2198fc32d7aff643f5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2953_en.txt
@@ -0,0 +1,2 @@
+A 42-year-old Asian woman, gravida 0, para 0, underwent laparoscopic cystectomy for a suspected ovarian chocolate cyst at Kaiser Hospital in southern California, USA, in March 2014. Pathology revealed clear cell carcinoma. An optimal debulking operation was subsequently performed, and the patient was found to have FIGO stage II disease. She was administered adjuvant chemotherapy with paclitaxel and carboplatin for 7 cycles. However, an increasing serum CA-125 level and recurrent pelvic tumors were noted in January 2016. She underwent a secondary debulking operation, followed by administration of adjuvant chemotherapy using carboplatin and gemcitabine. However, secondary recurrence deep in the pelvic cavity close to the sigmoid colon, rectum, and bladder was found in September 2017. Her recurrence progressed despite the administration of salvage chemotherapy, including liposomal doxorubicin and topotecan. In February 2019, she presented to a medical center in Taiwan and underwent a third debulking surgery including resection of the sigmoid colon, rectum, and bladder, followed by small bowel bypass, T-colostomy and bilateral percutaneous nephrostomy. Tumor recurrence occurred, with two major masses observed in the pelvis and abdomen soon after surgery. Palliative treatment was suggested because she was refractory to cancer treatment. Immune cell therapy with unknown immunological cells was attempted at a clinic but was ineffective.
+She presented to our hospital with a high CA125 level, a pelvic mass with resultant vaginal bleeding, and severe cachexia in April 2019. Based on her history, genetic analysis of more than 300 genes was performed (Foundation Medicine, FoundationOne CDx) and revealed a stable microsatellite status, low mutation burden, and two mutations in ARID1A . Immunohistochemical staining of PD-L1 was negative . After discussion, the patient and her family agreed to treatment with a checkpoint inhibitor combined with bevacizumab, with the understanding that the checkpoint inhibitor alone would not effectively treat EOC based on previous clinical trials. The patient was administered pembrolizumab (200 mg) combined with bevacizumab (15 mg/kg; 400 mg) every 3 weeks. Her serum CA-125 level dramatically decreased from 1236.6 to 639.2 U/mL after 1 cycle of treatment; her CA-125 level reached the normal range (35 U/mL) after 7 cycles . Computerized tomography (CT) scanning also showed significant regression of recurrent masses and a partial response at 3 months after beginning treatment. The patient’s disease achieved complete remission after 9 cycles . She recovered from cachexia to a normal body mass index , as evidenced by an increase in subcutaneous fat and muscle in axial view CT images, as shown in Fig. . There were no adverse effects, such as hypertension, pneumonitis, colitis, or hepatitis, except for small joint arthritis in both hands in later cycles. As of the time of preparation of this manuscript, the patient has remained disease-free.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2958_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2958_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e1bce42dbefdc46b5eaa00d3bfff8f724c2816cb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2958_en.txt
@@ -0,0 +1,6 @@
+A 32-year-old male was referred to our hospital because of a suspicious lesion neighboring the hilum of the spleen, which was detected via conventional grayscale ultrasound in a local community hospital. The patient did not complain of obvious discomfort.
+The patient had a history of chronic hepatitis B.
+The patient did not complain of abdominal pain or any remarkable discomfort during the physical examination.
+In addition to a slightly increased albumin-globulin ratio (2.96) and glutamine transpeptidase level (63 IU/L), no abnormal laboratory test results, including those of related tumor markers, were found.
+The patient underwent contrast-enhanced ultrasound (CEUS) in our department. Before the CEUS, a baseline ultrasound illustrated a complicated cystic nodule measuring 2 cm, with a well-defined border in the tail of the pancreas without salient blood supply on color Doppler ultrasound . For the CEUS, a bolus injection of the US contrast agent SonoVue (Bracco, Milan, Italy) was administered through the antecubital vein, followed by a flush of 5 mL of 0.9% normal saline. The lesion demonstrated peripheral nodular and internal septal isoenhancement in the arterial phase, followed by slight hyperenhancement of the enhanced area in the venous phase. The predominant cystic area of the lesion did not show any enhancement in either phase. According to the aforementioned enhancing pattern in the CEUS, the lesion was suspected to be a pancreatic cystadenoma via CEUS .
+Contrast-enhanced computed tomography (CECT) was performed to further examine the lesion. On the unenhanced CT, a nodule with a diameter of 2.2 cm and slightly low density was identified in the tail of the pancreas. Septa were observed, whereas no significant enhancement was presented within the lesion . The nodule was diagnosed as being a pancreatic cystic lesion via the CECT. Moreover, no salient abnormalities were found in the liver, kidney, spleen or biliary system via imaging evaluations.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_295_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_295_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0cd6b7c200ea1b305d60cdc1ccff37f6e10660da
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_295_en.txt
@@ -0,0 +1,2 @@
+A 44-year-old man presented to the emergency department with acute onset of abdominal pain. He reported that his pain started 2 days ago and had become progressively worse. The pain was diffuse across his mid-to-lower abdomen. The patient had normal bowel movements and denied any fever, chills, nausea, or vomiting. His medical history was significant for end-stage renal disease (ESRD) from his congenital renal hypoplasia. He received kidney transplant 7 years ago. Unfortunately, he developed acute antibody rejection and had been requiring intermittent hemodialysis for the past 2 years. He desired to undergo renal transplant again and had been on immunosuppression with oral prednisone (5 mg/day) and mycophenolate mofetil (250 mg/day). On physical examination, the patient had a blood pressure of 105/60, heart rate of 103, respiratory rate of 20, body temperature 37.1°C. His abdominal examination demonstrated generalized tenderness. There was remarkable lower abdomen rebound tenderness, just below the level of the umbilicus. Bowel sound was absent. Computed tomography (CT) of the abdomen and pelvis with intravenous (IV) contrast was performed [Figures and ].
+Abdominal CT (axial view, and coronal, demonstrated ruptured jejunal diverticulum with associated free intraperitoneal air (white arrows) and surrounding mesenteric edema left mid abdomen. Numerous small bowel diverticuli were noted with marked jejunal diverticulosis. The patient underwent a segmental jejunal resection and anastomosis. His postoperative course was uneventful. The patient was dismissed from the hospital and continued his immunosuppression, including prednisone and mycophenolate mofetil. A month later after his hospitalization, the patient appeared with the same presentation and was found to have recurrent jejunal diverticulum perforation. He again underwent a segmental jejunal resection and anastomosis. Nephrology was consulted. The information on the risks and benefits of mycophenolate mofetil as well as information on alternative options such as azathioprine was provided. Mycophenolate mofetil was discontinued. Three months after hospitalization, the patient continued to do well without any further episode of abdominal pain.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2965_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2965_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dbb47cdf3bd0024d2831b69f77f4b6439d000a57
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2965_en.txt
@@ -0,0 +1,7 @@
+In January 2021, a 20-year-old male presented with swelling over the right hand for 5 years, insidious in onset, progressive in nature, located over the medial border on the palmar side ( and ). The swelling was associated with dull aching minimal pain, aggravated with excessive activities and relived on rest. However, the swelling was not associated with night pain, fever, and restriction in daily routine activities.
+On clinical examination, the swelling was of size 4 cm × 3 cm × 2 cm ( and ), bony hard, irregular surface, adherent to the underlying bone with no coronal or sagittal plane movement possible. It was palpable on the ulnar aspect of the hand. There was no local rise of temperature, and the patient has no regional lymphadenopathy, scars, sinuses, dilated veins, and skin changes on and around the swelling. There are no similar swellings elsewhere in the body.
+Radiographs (X-ray) showed a pedunculated bony lesion arising from the distal metaphyseal region of the fifth metacarpal .
+In magnetic resonance imaging, there was evidence of 2 × 2.5 × 3 cm (AP × TR × SI) sized bony overgrowth seen arising from distal metaphyseal region of 5th metacarpal bone showing continuity with a medullary cavity in growing away from epiphysis . This lesion is seen displacing the 5th flexor digitorum profundus tendon laterally and causing compression over flexor digiti minimi and abductor digiti minimi muscles. In addition, there was evidence of the formation of bursa with inflammatory collection within the bursa. A provisional diagnosis of osteochondroma was made based on clinical and radiological findings.
+Osteochondroma excised under general anesthesia and tourniquet control, the bony swelling was approached through the posteromedial incision . Tumor of size approximately 3 × 2 cm was excised from the root of the pedicle . The excised specimen was then sent for histopathological examination.
+The histopathological report (HPR) showed a cartilaginous cap with underlying bony tissue with bony trabeculae. The cartilaginous tissue is lined by perichondrium and is composed of clusters of chondrocytes. At foci, the chondrocytes are organized into cords and show endochondral ossification, which is continuous with bony tissue. HPR did not show any mitotic activity or necrosis in the sections studied .
+Post-operative period was uneventful, check x-ray of the hand was taken on day 1 with satisfactory findings , regular dressing was done and sutures were removed on post-operative day 12. The patient had minimal pain at the operative site with a complete and painless range of motion at the wrist and metacarpophalangeal joint. At 1 year of follow up patient was evaluated radiologically and clinically with satisfactory outcome.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2971_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2971_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b8a521b2e63a474f42b1f71c91bbdee2013f4b56
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2971_en.txt
@@ -0,0 +1,3 @@
+A 79-year-old female with a history of breast cancer and hypertension presented with the 1–2 days of acute-onset lumbar pain, paraparesis, and a T10 sensory level to pin with sphincter dysfunction. The CT of the thoracic and lumbar spine revealed extensive increased density throughout the thoracolumbar spinal canal, consistent with acute hemorrhage. The magnetic resonance imaging confirming the subdural/subarachnoid location of the mostly right-sided hemorrhage (mostly T12-L2) anterior to the spinal cord extending from the L2 up to the T6-7 level. [ and ]. MR angiography of the lumbar spine and CT angiography of the brain and neck were negative for any vascular lesions. A full diagnostic craniospinal angiogram was performed, including selective catheterization of T7-L3 radicular arteries [ and ], which also failed to demonstrate any vascular lesion (e.g., no SDAVF).
+T11-L1 laminectomies were performed. On opening the dura, a large, cylindrical, and well-organized subdural hematoma was encountered with blood products of varying chronicity these markedly distorted the spinal cord (e.g., right to left compression) [-]. After hematoma evacuation, further exploration identified a large arterialized vein on the right side of the thecal sac, exiting around the L1 nerve sheath; this was consistent with a dural AVF. After temporary occlusion of the vessel elicited no change on intraoperative neuromonitoring, the fistulous connection was coagulated and sectioned.
+The patient tolerated the procedure well and within the first several days experienced improved bilateral lower extremity motor and sensory function along with sphincter improvement. Six months later, she was neurologically intact.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_297_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_297_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a7c9089c2cf9b9701a7f9e5a6014216873222e97
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_297_en.txt
@@ -0,0 +1,5 @@
+A 21-year-old Sri Lankan male developed urticaria and difficulty in breathing one hour after ingestion of prawns, for which he was known to be allergic. He got admitted to the local hospital 2 h after the onset of symptoms. On admission to the local hospital he was dyspnoeic with a respiratory rate of 28/min and widespread rhonchi. His pulse rate was 94 beats per minute and the blood pressure was 100/70 mmHg. He was treated with intravenous hydrocortisone 200 mg, intravenous chlorpheniramine 10 mg and 0.5 ml of adrenaline (1:1000 solution) intramuscularly to the upper lateral side of the thigh (vastus lateralis). Ten minutes after the administration of adrenalin, he developed palpitations and tightening type central chest pain with autonomic symptoms. The pain lasted for about 30 min and resolved spontaneously. The first electrocardiogram (ECG), which was taken at the local hospital showed a sinus tachycardia and ST segment depressions in leads III, aVF and V1 to V5. He was not given any treatment for the chest pain in the local hospital and was transferred to our hospital about 2 h from the onset of the pain.
+On admission to our hospital, he was not dyspnoeic and his pulse rate was 100 beats per minute and the blood pressure was 100/60 mmHg. His respiratory rate was 18/min and had a few rhonchi on auscultation. Rest of the examination was normal. The second ECG which was done in our hospital, 2 h after the 1st one, showed resolution of ST segment depressions but new T inversions in leads I and aVL . These T in versions persisted in subsequent ECGs . Troponin I done 6 h after the event was positive with a titer 2.15 ng/ml (<0.5). The test was repeated on the second day and it was still positive with a tire of 0.69 ng/ml. He was given sublingual glyceryl trinitrate 0.4 mg single dose after admission to our hospital. However antiplatelets and statins were not given and anticoagulation was not started as the most likely cause was assumed to be coronary vasospasm rather than plaque rupture.
+He was previously healthy and did not have any risk factors for premature coronary vascular disease such as smoking. He has had a history urticaria to prawns but there was no previous history of anaphylaxis. He did not have asthma. There was no family history of diabetes, ischemic heart disease or premature deaths due to cardiovascular diseases. He worked as a computer operator trainee and was unmarried.
+Further investigations which were done at our unit included transthoracic 2D echocardiogram which revealed an ejection fraction of 60% with no wall motion abnormalities. We did not proceed with a coronary angiogram as the patient was a young healthy adult and the cardiology team concluded that coronary artery vasospasm to be the likely cause for the myocardial ischaemia rather than atherosclerotic coronary artery disease. Subsequent stress ECG with treadmill was normal and CT coronary angiogram revealed normal coronary arteries . Complete blood count and renal functions were normal. Chest x ray was also normal. Fasting blood sugar was 98 mg/dl and the lipid profile was normal.
+Patient was asymptomatic during the hospital stay and was discharged after 2 days. At subsequent reviews he remained asymptomatic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2980_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2980_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..85f18ee18add58788ba8e695c859addd53e6042f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2980_en.txt
@@ -0,0 +1,8 @@
+A 56-year-old man developed decreased visual acuity and blurred vision without obvious cause or inducement that lasted for 15 d.
+The patient presented to the Department of Neurosurgery, Clinical Medical College, Yangzhou University, with decreased visual acuity and blurred vision that lasted for 15 d. The neurological examination findings were normal, and he had previously been in good health without any infectious diseases or immune disorders. Enhanced pituitary magnetic resonance imaging (MRI) revealed multiple nodules in the suprasellar region with slightly shorter T1 signals, compression of the optic chiasma, and compression of the superior pituitary margin in a region of approximately 19 mm × 12 mm × 21 mm. The preoperative diagnosis was craniopharyngioma . The patient's routine laboratory results were normal. The tumor was removed by an endoscopic transnasal transsellar tubercle sphenoid platform approach. Intraoperatively, the tumor was located in the suprasellar suboptic space with cystic changes and was connected to the posterior part of the pituitary gland. Postoperative MRI showed a patchy mixed signal in the sellar region . Postoperative histopathology revealed hyperplasia, showing nests and a papillary arrangement of epithelial nests with a fenestrated arrangement of marginal cells in some areas; additionally, ghost cells were seen with calcification . The final diagnosis was craniopharyngioma of the sellar region (enamel-forming cell type). Postoperative review MRI showed a patchy mixed signal in the sellar region, and the sellar base was incomplete. A nodal shadow was visible in the sellar region, with significant enhancement; the shadow was approximately 10 mm × 9 mm in extent and poorly demarcated from the visual cross. The patient recovered well after surgery without special discomfort. Six months after the operation, the patient suffered from sudden hearing loss in the right ear, tinnitus in both ears, and numbness of the right side of the face and head, without any signs of infection. Physical examination revealed hearing loss in the right ear. Enhanced MRI of the inner ear showed multiple patchy and nodular, distinctly enhancing abnormal shadows around the right pontocerebellar horn, right cerebellum, and quadrigeminal cistern; the largest lesion was in the right pontocerebellar horn, approximately 17 mm × 14 mm in size, with gross margins and significant thickening of the right rocky meninges. Multiple IP were considered . The patient was treated with steroid pulse therapy, and he received an initial high-dose regimen of 80 mg of methylprednisolone for 4 d, followed by a one-day drug cessation and then a maintenance dose of 40 mg of methylprednisolone for another 4 d. Despite this treatment approach, the patient's primary symptoms remained unresolved, and subsequent cranial MRI indicated no significant change in the size of the pseudotumors. Ultimately, we opted for surgical resection to remove the tumor, and during follow-up and review, there was no recurrence of the IP. A lesion in the right cerebellum and pontocerebellar horn was resected under neuronavigation. Postoperative pathological examination showed fibrocollagenous tissue hyperplasia and extensive infiltration of inflammatory cells, including lymphocytes . Immunohistochemistry suggested the following: KP1 (scattered +), CD3 (scattered +), CD20 (scattered +), S100 (neural +), CD1a (-), GFAP (brain +), Ki67 (scattered 20%), SMA (vascular +), CD34 (vascular +), and MPO (scattered +). Special staining results were PAS (-), antacid (-), and silver stain (-). The postoperative diagnosis was IP. The patient was discharged 7 d after surgery and was reviewed 3 mo after surgery, without recurrence or significant abnormalities on neurological examination. The patient continues to be under close follow-up .
+The patient had no previous history of infectious diseases, traumas, or bad habits (such as smoking or drinking).
+The patient denied any family history of tumors.
+On physical examination, the vital signs were as follows: Body temperature, 36.4 °C; blood pressure, 110/88 mmHg; heart rate, 88 beats per min; and respiratory rate, 19 breaths per min. Annual physical examinations (including various laboratory tests and imaging examinations) indicated that the patient was healthy.
+The white blood cell count was 7.78 × 109/L, and neutrophil count was 7.37 × 109/L. Endocrine test results were normal.
+Pre-operative pituitary MRI suggested that there were multiple nodules with abnormal signals in the sellar region. The diagnosis was craniopharyngioma.
+Pre-operative contrast-enhanced MRI of the inner ear showed multiple patchy and nodular distinctly enhancing abnormal shadows around the right pontocerebellar horn, right cerebellum, and quadrigeminal cistern, with the largest lesion in the right pontocerebellar horn, approximately 17 mm × 14 mm, with gross margins and significant thickening of the right rocky meninges. MIP were considered.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_298_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_298_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c1cacf4647ac29f56f77242351d4c600aac48d0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_298_en.txt
@@ -0,0 +1,4 @@
+A 55-year-old Chinese female was admitted for a 10-month history of painless decline in her vision of the right eye. The patient was initially diagnosed with chronic uveitis and received glucocorticoid-based therapy; however, she responded poorly and was thus referred to our hospital. She reported a transient history of eye redness but no history of photophobia, floaters, flashes, or scotoma in her right eye. During the systemic review of the patient, no symptoms of oral ulcers, vitiligo, alopecia, headaches, or joint pain were revealed. The patient did not experience any eye trauma or surgery.
+Her ophthalmic examination revealed a visual acuity measuring 20/125 OD and 20/25 OS, and her noncontact intraocular pressure values were 13 and 15 mmHg, respectively. The results of both the extraocular appearance and muscle movement examinations were normal. The patient's pupillary light reflex was satisfactory, and her relative afferent pupillary defect was absent. Meticulous slip-lamp examination of the patient's right eye revealed diffuse mutton-fat keratic precipitates, 2 + anterior chamber (AC) cells, and 2 + AC flares. Severe vitreous opacities in the right eye obscured the dilated fundus examination (CLARUS™ 500, Carl Zeiss Meditec AG, Germany) . OCT (Cirrus HD-OCT, Carl Zeiss Meditec, Inc., United States) of the right eye showed high-density reflective spots (indicated by the arrow in Fig. a) in the retinal pigment epithelium (RPE) layer, while Bruch’s membrane remained intact. Spotted hypofluorescence was observed at the posterior pole and mid-peripheral retina, with clustered hyperfluorescent points at the mid-peripheral retina being observed on the ICGA OD . The results of fundoscopy, OCT, or ICGA of her left eye were unremarkable .
+Diagnostic aspiration of the right vitreous was subsequently performed. The cytometric bead array results showed that the ratio of interleukin (IL)-10/IL-6 in the vitreous humour was 1.05, slightly exceeding the upper normal limit (usually set as 1). Specifically, the IL-10 level in the vitreous humour was 39.4 pg/mL, while the IL-6 level was 37.5 pg/mL. The vitreous humour was positive for Epstein–Barr virus (EBV) DNA as determined by the polymerase chain reaction (9.90E + 03 copy/mL), and the vitreous was negative for EBV-IgG. Genetic testing by next-generation sequencing of the vitreous humour revealed several oncogenic mutations, including TP53, JAK2, and FAS. Vitreoretinal lymphoma of the right eye was suspected. Subsequently, whole-body positron emission tomography (PET-CT) showed a hypermetabolic nodule in the retroperitoneal left adrenal area, suggesting a malignant tumour. A core-needle biopsy of the retroperitoneal mass revealed malignant morphological features, including an irregular karyotype, karyokinesis, and karyorrhexis . Further immunohistochemistry and fluorescence in situ hybridization (by a Nikon camera and software, × 400 magnification. Scale bar, 50 μm) proved that the lump was ENKTL; the lump was CD7 + , CD2 + , CD3ε + , CD5-, T-cell intracellular antigen 1 (TIA-1) + , Granzyme B (GrB) + , Ki-67 + and EBV-encoded mRNA (EBER) + . Considering the homology of the two lesions, this patient was confirmed to have metastatic vitreoretinal lymphoma secondary to retroperitoneal ENKTL. Moreover, the positive EBV testing result and oncogenic mutations related to T-cell-derived lymphomas supported the diagnosis. Lymphomatous infiltrates are commonly confined to the space between the RPE and Bruch's membrane in metastatic intraocular ENKTL . Her nasopharyngeal area, a common site for ENKTL, was specifically examined to exclude possible lesions.
+Subsequently, the patient received radiotherapy and sintilimab-based chemotherapy treatment at a tumour specialist hospital. Moreover, 0.4 mg of methotrexate was intravitreally injected into her right eye once a week for two months and once a month for the following three months. At the time of submission, the vision of her right eye was improved from 20/125 to 20/32, and the vitreous opacity was significantly improved, as demonstrated in the fundoscopy photos . OCT at follow-up revealed irregular humps inward into the RPE, while Bruch’s membrane remained intact (indicated by the arrowheads in Fig. c, d). PET-CT reexamination showed that the retroperitoneal nodule decreased in size following treatment, and no new lesions were found.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_300_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_300_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a0961147acf506a270426226f1b9d14d4196e31a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_300_en.txt
@@ -0,0 +1,17 @@
+A 67-year-old woman was admitted with a 2-month medical history of odynophagia and a sense of progressing swallowing obstruction. She denied the other medical history, except for hypertension, which she had controlled well by pills. Her physical examination was normal, except for a tracheal shift. Doppler ultrasound on the neck revealed bilateral thyroid nodules and a substantive bump at the entrance of the thorax. Chest radiograph showed a tracheal shift . Enhanced computed tomography (CT) scan of the neck noted a large substantive mass below the right lower pole of the thyroid with calcification, and two lobes of the thyroid both had nodules without any hint of lymph nodes . Core needle biopsy and immunohistochemistry revealed papillary thyroid cancer (PTC).
+The positron emission tomography-computed tomography indicated that the lump from the thoracic inlet area to upper mediastinum had high metabolism, and malignant neoplasm should be considered. Moreover, the tumor, along with surrounding invasion, caused the trachea to migrate to the left. However, the metabolic image of the mediastinal and hilar lymph nodes increased mildly, which was non-specific. Both sides of the thyroid might also favor nodular goiter. Laryngoscopy showed right vocal cord paralysis. The bronchoscopy and cytopathology of the brush fluid were normal . The tumor mark and thyroid function tests were almost normal.
+After all the examinations, we still had no idea whether the mass metastasized to the substernum or originated there. We opted to diagnose after excision. During operation, we found multiple nodules in both sides of the thyroid, as well as the mass, which was right behind the sternum, outside of the trachea and inside of the right carotid artery. The mass was an observed invasion of the trachea, carotid artery, and the recurrent laryngeal nerve. And, it was so conglutinated with the right carotid artery that it could not be removed completely. Thus, we firstly took total thyroidectomy with cervical lymph dissection of the right VI area. Subsequently, we used sternotomy to excise more of the lump after separating it from the local (right carotid artery, trachea, and recurrent laryngeal nerve) gradually; silver clips were left to mark the residual cavity in preparation for radiotherapy. Postoperative pathology confirmed that the lump was primary ectopic substernal papillary thyroid cancer, and the eutopic thyroid was nodular goiter. After surgery, the patient had an excellent recovery.
+However, she refused to use postoperative radioactive iodine (RAI) or take adjuvant external-beam radiotherapy (EBRT), which had been planned before surgery. Instead, she took Euthyrox (100 mg every morning) for relapse prevention.
+Six months later, she complained of dyspnea. CT showed that the trachea narrowed in the level of the thoracic inlet, next to the silver clips . Bronchoscopy confirmed that it was blocked by something new, and pathological diagnosis revealed that it came from thyroid cancer but was poorly differentiated. Tracheal stent was inserted via bronchoscopy to reconstruct the airway for free respiration . After another 6 months of using Euthyrox, a second tracheal stent was inserted because of recurring dyspnea .
+After diagnosis and treatment of this woman, the following points were obtained.
+A patient with PTC usually has an exciting 5-year overall survival rate (OS) of 97.5 % . But, some risk factors for recurrence and death still exist. The most correlative factors affecting mortality are maximum tumor diameter (≥4), pre-operative neck gross metastasis, extrathyroidal invasion, and metastases [, ]. Postoperative RAI should generally be administered for these variants as they will generally be intermediate to advanced tumors . In addition, old age ≥45, surrounding invasion, distant metastases, and gross locoregional residual are indicators to perform adjuvant EBRT . EBRT will improve their survival and reduce the recurrent rate (51 % control group vs. 8 % EBRT group) . The toxicity-related side effects of EBRT, such as skin reaction, esophagitis, and laryngeal irritation, are limited and resolved during follow-up .
+In our case, the patient is a 57-year-old woman, and the tumor invaded the surroundings, such as trachea, right carotid artery, and right recurrent laryngeal nerve. It became even worse while the tumor cannot be completely excised because of the severe invasion in the right carotid artery. Depending on all of the above, RAI and EBRT are necessary for the patient just after the surgery.
+However, tracheal relapse was poorly differentiated, and the RAI therapy had lost the opportunity to benefit.
+The excision of big arteries was taken into account when the tumor invaded the vessels so severely that it cannot be removed completely alone. Therefore, a better option should be selected between postoperative radiation therapy without excision of the carotid artery and replacement surgery of vessels.
+The prognosis of those who have local invasion is worse than those who do not. Vessel invasion is a predictable index . Nevertheless, many complications peri-operatively and postoperatively are present for this index, such as neurologic sequelae, graft infection or occlusion, and cerebral ischemia. Embolization and hemorrhage also cannot be ignored . Hence, whether to reconstruct the invaded vessels or not is a dilemma.
+We searched the PubMed database, but there are few literatures about the controversy, in addition to cases involving vessel reconstruction along with thyroid cancer. It is said that it is helpful to decrease patients’ long-term metastasis and locoregional recurrence with vascular invasion artery resection and reconstruction [, ].
+However, other studies show that patients with T4 tumors can also have a good 5-year OS after adjuvant RAI and EBRT therapies . Furthermore, locoregional failures all occur at the neck node area . OS is not significantly different from those re-operated within cervical lymph node metastasis .
+In our case, the common carotid artery was invaded, but no obvious tumor-induced blockage was observed . Considering that the patient should take RAI and EBRT therapies, which depended on severe local invasion and old age (≥45), we opted for a milder surgery therapy after obtaining the family’s approval and consent.
+Unfortunately, the patient refused the therapy after surgery. Nonetheless, the cervix condition was not too bad, and no distant metastasis was observed.
+Tracheal invasion, one third of the extrathyroidal extension, is an independent predictor of death, followed by hemoptysis and dyspnea, in approximately 6 % of thyroid cancer . The status of trachea invasion can be divided into several stages. Stage A disease invades through the capsule of the thyroid gland and invades the external perichondrium of the trachea. Stage B disease invades between the rings of cartilage or causes minor cartilage destruction. Stage C disease invades through the cartilage or between the cartilaginous rings into the lamina propria of the tracheal mucosa or in the submucosal area. Stage D disease is a full-thickness invasion with the expansion of tracheal mucosa that is visible through a bronchoscope as a nodule or ulcerated mass . Generally, the patients without residual have the greatest prognosis . The patients with stage A invasion have an almost identical prognosis after shaving resection compared to segmental tracheal resection.
+This woman with stage A trachea invasion in our case had shaving resection because of the granted adjuvant RAI and EBRT therapy. She refused the adjuvant therapy, and the gross relapsed through the trachea without having invaded the common carotid artery and other distant metastasis. Interestingly, the tumor invaded through the trachea faster than the artery, which had been invaded and had not been excised with all invasion tissues. Shaving resection may have destroyed the tracheal anatomy and made it easier to invade through than before. However, the survival period and disease-free survival period of having shaving resection, even the survival period of having palliative surgery, are much better than those without any airway operation in the patients of locally invaded thyroid cancer. Hence, trachea invasion might be a worse independent predictor of prognosis than any other local invasion. Therefore, aggressive procedures should be performed to protect the patient from relapsing. If tracheal relapse occurs, the stent might solve the respiration problem safely. Stent can be used a few times to release the patient’s dyspnea and fear.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3014_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3014_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3205471fefa448de392e13548fb9d41637749285
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3014_en.txt
@@ -0,0 +1,21 @@
+A 6-year-old boy presented with cervical enlargement and recurrent bouts of high fever. Physical examination revealed a mobile lymph node enlargement in the left neck region. It was non-adherent to deeper tissues and elicited discomfort upon palpation. A comparable lymph node was also noted on the right side. Axillary lymph nodes were soft and moveable. Lymph nodes in the inguinal appeared smaller. The spleen was palpable. He had a history of recurrent tonsillitis and allergic symptoms.
+
+A CT scan revealed several axillary lymph node enlargements on both sides, with the largest on the left side measuring 12 × 21 mm and the largest on the right measuring 37 × 20 mm. The largest lymph node in the neck is located on the left medial side, directly in front of the sternocleidomastoid muscle, and measures 21 × 23 mm. The pulmonary parenchymal densities exhibited a hypodensified appearance, accompanied by vascular traces linked to bronchial traces and dilatational modifications of the bronchial branches in the impacted regions. Several lesions were found in the posterior apical segment, the anterior segment, the sinus of the upper lobe, and the superior segment of the lower lobe in the left lung. While in the right lung, there were no indications of interstitial lesions or alveolar abnormalities. Many nodular enlargements that appear suspicious are dispersed throughout the pulmonary aortic septum, the mediastinum space in front of the aortic arch, and the area surrounding the pulmonary umbilicus.
+
+Additionally, numerous homogenous nodular enlargements were observed in the liver's navel as well as along the course of the abdominal aortic branches behind the peritoneum and lateral to the left kidney. The liver measured 12 cm in apical-caudal diameter on the anterior axillary line. The spleen also measured 12 cm. Lymphoma was suspected, and it needed further investigations.
+
+An initial blood test revealed a slightly elevated white blood cell count (WBC), and high C-reactive protein (CRP) levels. A low hemoglobin level with a slight decrease in mean corpuscular volume (MCV) and mean corpuscular hemoglobin (MCH) were also noted.
+
+In the peripheral blood smear study, the erythrocytes appeared slightly small, but their shape was within normal limits, and there was a slight pigment deficiency. Furthermore, a biopsy from an axillary lymph node showed reactive lymphoid follicles with germinal centers and an increase in the Para cortex with histiocytes and immunoblasts that were focally affected in the architecture. There were no malignant alterations, necrosis, or epithelioid granulomas seen. An immunohistochemistry (IHC) study showed CD30 and CD20 positive scattered immunoblasts. The Antimitochondrial Antibody (AMA) marker was negative. This indicated signs consistent with atypical lymphadenitis, but autoimmune etiology could not be excluded. A 5-day prednisolone course at a dosage of 1–2 mg/kg was prescribed, resulting in a reduction of the lymph node size. However, two weeks later, they were enlarged once more, necessitating further investigation. A Second blood test was ordered, and it revealed a high WBC count with neutrophil predominance, and low HGB with iron deficiency. It also tested positive for EBV IgM and IgG.
+
+Based on these blood results, acyclovir intravenously was prescribed, in addition to iron supplements. Unfortunately, no improvement was observed two weeks later.
+
+After the first treatments were discontinued, an uncommon form of tuberculosis (TB) was suspected. The patient underwent TB medication therapy for six weeks; however, there were no signs of recovery, leading to the cessation of the drugs.
+
+Therefore, for further investigation samples from different lymph nodes were collected. Examination revealed enlargement with mixed lymphoid cells, histiocytes, and partial effacement of the architecture. Areas of necrosis, suggesting a reactive inflammatory response, were also observed. These findings led to the consideration of Kikuchi lymphadenitis as a potential diagnosis.
+
+Immunostaining results revealed Positive markers for CD3 and CD4, with some clusters positive for CD20. Markers for CD15, CD10, CD34, TdT, and CD117 were negative, as were markers for EBV, and strong Ki67 proliferation marker.
+
+These results indicated an absence of malignancy. Although certain cells were labeled with the CD30 marker, they were identified as immunoblasts rather than normal or Hodgkin cells. There was also benign salivary gland tissue.
+
+Given these findings, KFD was ultimately diagnosed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3027_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3027_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fe7a5f911b36f0db31ffda123569906963c468e2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3027_en.txt
@@ -0,0 +1,16 @@
+The patient was a 92-year-old man who had long been treated for chronic kidney disease with renal anemia, atrial fibrillation with a slow ventricular response, and chronic heart failure of unknown cause. He was admitted to a local hospital because of progressive shortness of breath and systemic edema. He was treated with intravenous diuretics, but the response to treatment was unsatisfactory. Moreover, his renal function progressively deteriorated as a consequence of the administration of high-dose diuretics. At that point, he was transferred to our hospital for further treatment.
+
+On admission, his blood pressure was 98/48 mmHg, his heart rate was 44 beats/min, and his oxygen saturation was 96% (room air). Cardiac auscultation revealed bradycardia with an irregular rhythm, a prominent second heart sound with fixed splitting, and a Levine III/VI systolic regurgitant murmur in the fourth intercostal space. On inspection, he had severe leg edema extending from the foot to thigh level, prominent jugular venous distention, and abdominal distention, which was consistent with right heart failure. Chest radiography showed enlargement of the cardiac silhouette and bilateral pulmonary effusion. Electrocardiography demonstrated complete right bundle branch block and atrial fibrillation with a slow ventricular response. Transthoracic echocardiography revealed significant dilatation of the right atrium and ventricle, which resulted in dilatation of the tricuspid annulus and severe tricuspid regurgitation. Furthermore, distention of the inferior vena cava to 30 mm in diameter was observed without a visible respiratory change. Doppler echocardiography revealed an increased pressure gradient of 45 mmHg across the tricuspid valve, consistent with pulmonary hypertension. Unexpectedly, from the subxiphoid view, a 13×10 mm ostium secundum ASD with left-to-right shunt was detected, and the pulmonary-to-systemic-blood-flow ratio was 2.36. Transesophageal echocardiography confirmed a 13×13 mm stium secundum ASD next to the sinus of Valsalva with a dominant left-to-right, bidirectional shunt. A cardiac catheter examination showed a pulmonary artery pressure of 34/8 mmHg (mean pressure 16 mmHg), pulmonary vascular resistance of 84 dyn·s·cm5, and a significant step-up of oxygen saturation from the superior vena cava (75%) to the right ventricle (91%).
+
+Radiography and electrocardiography of the 92-year-old male patient with heart failure of unknown cause. A chest radiograph obtained on admission shows significant cardiomegaly and bilateral pleural effusion. An electrocardiogram obtained on admission shows atrial fibrillation with a slow ventricular response.
+
+Transthoracic echocardiography on admission of the 92-year-old male patient with heart failure of unknown cause. Both the right ventricle and atrium are significantly dilated with concomitant tricuspid annular dilatation. Severe tricuspid regurgitation is visible. The pressure gradient across the tricuspid value was 45 mmHg, indicating pulmonary arterial hypertension. Subxyphoid view: The ostium secundum atrial septal defect was clearly visible. SVC: superior vena cava, IVC: inferior vena cava, RA: right atrium, RV: right ventricle, LA: left atrium, LV: left ventricle, ASD: atrial septal defect
+
+Transesophageal echocardiography of the 92-year-old male patient with an ostium secundum atrial septal defect (ASD). A preoperative mid-esophageal sagittal view shows an ostium secundum ASD. The M-mode echocardiogram clearly shows a dominant left-to-right shunt through the ASD with a small right-to-left shunt during early systole. A preoperative mid-esophageal aortic valve short-axis view shows an ostium secundum ASD next to the sinus of Valsalva. Intraoperatively, the size of the ASD was measured using a sizing balloon and a Figulla Flex II® (21 mm) occluder was successfully deployed. ASD: atrial septal defect
+
+
+Subsequently, the patient's heart failure proved to be refractory to the best-practice treatment with cardiotonic drugs [intravenous dobutamine (3.5 μg/kg/min)], high-dose diuretics [furosemide (20 mg/day) and tolvaptan (15 mg/day)], and of warfarin (2 mg/day). Further complicating the situation, the patient's renal function progressively deteriorated during this treatment, which negatively affected the hemodynamic control. In this case, the intractable heart failure was attributable to the combined hemodynamic disturbances, including an ostium secundum ASD with a large shunt burden, secondary tricuspid regurgitation, and atrial fibrillation with a slow ventricular response. The ASD was considered to play a central role in the condition of the patient. After a thorough discussion within the heart team, transcatheter closure was scheduled despite the fact that the patient was a nonagenarian with multiple comorbidities. On the 32nd hospital day, this procedure was performed under general anesthesia. Using an 18-mm balloon, a pre-procedural occlusion test was performed under right-sided catheter monitoring. This revealed the absence of a hemodynamic exacerbation. Because the measured defect size was 15.5 mm in diameter, to completely enclose the sinus of Valsalva, a Figulla Flex IIⓇ occluder device (21 mm, Occlutech, Jena, Germany) was finally selected and successfully deployed without any complications (Fig. 3C). After device implantation, only clopidogrel (75 mg/day) was prescribed on top of warfarin to avoid the hemorrhagic complications.
+
+Immediately after ASD closure, the patient's hemodynamics became controllable without the need for inotropic medication or intravenous diuretics, and his renal function gradually improved. The patient was discharged on the 9th day after ASD closure.
+
+Surprisingly, the patient's heart returned to sinus rhythm, and not only the cardiomegaly but also the bilateral pleural effusion showed significant improvement at one month after ASD closure. Moreover, despite the long-term volume overload, the right heart showed significant reverse remodeling, and the cardiac output markedly improved from 2.8 L/min to 4.4 L/min. At 10 months after ASD closure, his heart failure symptoms showed a marked improvement to NYHA functional class I. At present, he is caring for his sick wife in their own home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3028_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3028_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2c7d9f28a0723f3da8dde3f7f5bcac160cc8cc3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3028_en.txt
@@ -0,0 +1,7 @@
+A 48-year-old man was admitted to the emergency department 2 hours after falling from a height of 15 m, On admission, physical examination revealed a body temperature of 36.2°C, heart rate of 150 beats per minute, weak radial pulse, respiratory rate of 35 breaths per minute, blood pressure of 70/35 mm Hg, oxygen saturation of 89%, restlessness, shortness of breath, multiple skin abrasions across the body, and significant neck pain. The left chest wall was swollen, with subcutaneous emphysema and absent breath sounds on the left lung. The abdominal muscles were tense with abdominal tenderness and rebound pain. The left hip was tender with deformity and shortening of the left lower limb. Laboratory tests showed: arterial blood gases: pH 7.21, PO2 53 mm Hg, PCO2 28 mm Hg, lactate 3.6 mol/L; complete blood count: white blood cells 22.77 × 109/L, hemoglobin 114 g/L, hematocrit 33.6%, platelet count 233 × 109/L; coagulation profile: prothrombin time 17.8 seconds, international normalized ratio 1.57, activated partial thromboplastin time 42.2 seconds; liver and kidney functions were normal. The timeline of interventions summarizing key events from the initial presentation to the patient’s recovery is shown.
+
+The patient exhibited symptoms of shock, and given the clinical signs, traumatic acute left-sided tension pneumothorax was highly suspected. Immediate closed chest drainage was performed on the left side, which only drained a small amount of dark red fluid and air, suggesting other severe injuries. The patient received fluid resuscitation, norepinephrine infusion (3–6 mg/hour) to maintain blood pressure, and noninvasive ventilator support. His heart rate stabilized between 140 and 160 beats per minute, blood pressure between 90-100/50-67 mm Hg, and oxygen saturation between 95% and 98%. Bedside point-of-care ultrasound (POCUS) revealed substantial echogenic abnormalities within the left thoracic cavity and rightward displacement of the heart, suggesting left-sided tension viscerothorax. To confirm the diagnosis, an urgent chest and abdominal computed tomography (CT) scan was performed.
+
+Upon returning to the resuscitation room after the CT scan, the patient suddenly lost consciousness, was unresponsive when called, and his carotid pulse disappeared, indicating cardiac arrest. Immediate cardiopulmonary resuscitation and advanced life support were initiated, and the patient regained spontaneous circulation after 5 minutes. He was then urgently taken to the operating room. Emergency surgery repaired the lung laceration, diaphragmatic rupture, reduced left rib fractures, and repositioned the stomach, omentum, spleen, and part of the left liver lobe into the abdominal cavity, and a left-sided chest drain was placed. Postoperative chest CT scans were performed. The patient was discharged on the 18th day of hospitalization, showing satisfactory recovery.
+
+The patient was closely monitored for 2 years postdischarge. The first follow-up occurred 6 months after discharge, during which a chest CT scan was performed. At this time, the patient reported no symptoms and was able to engage in physical activities at pre-injury levels. The second follow-up took place 2 years postdischarge. This consistent monitoring confirms that the patient has had a favorable long-term outcome, with no complications related to the initial injury. The patient remained asymptomatic, and a chest X-ray conducted at this follow-up also showed normal findings.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_303_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_303_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8bd9fc3c9fef71f75abe0e450c2f0343b08c8b11
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_303_en.txt
@@ -0,0 +1,13 @@
+A 90-year-old female with atrial fibrillation treated with therapeutic apixaban and aortic stenosis status-post TAVR with a 29 mm self-expanding Medtronic core-valve placed 7 years prior presented to the clinic for the evaluation of acute onset chest pain and elevated blood pressure on home monitoring of 190/90 mmHg. The patient described the chest pain as substernal, severe, radiating posteriorly, and lasting for 45 min before resolving spontaneously.
+The patient had a routine echocardiogram performed 2 months prior showing a properly functioning bioprosthetic aortic valve with normal haemodynamic performance . The Doppler measured peak transaortic gradient was 4 mmHg and the mean transaortic gradient was 2 mmHg.
+Vital signs in the clinic (blood pressure of 110/41 mmHg, heart rate of 76 beats/min, oxygen saturation of 95% on room air) and physical examination were noted as unremarkable.
+The patient was referred to the emergency department for assessment of the coronary anatomy and to rule out aortic dissection . During imaging, the patient developed acute respiratory failure with severe pruritis and urticaria and was admitted for inpatient management.
+Evaluation in the emergency department was notable for the absence of hives, stridor, or other associated signs or symptoms of anaphylaxis.
+Lab evaluation in the emergency department demonstrated a troponin-I value of 0.22 ng/mL (reference <0.04 ng/mL), B-type natriuretic peptide (BNP) of 514 pg/mL (reference <100 pg/mL; patient baseline of 22–71 pg/mL), and a positive COVID-19 polymerase chain reaction rapid test.
+Chest x-ray was notable for diffuse interstitial pulmonary oedema. Electrocardiogram demonstrated sinus tachycardia with the left bundle branch block unchanged from prior. Computed tomographic (CT) angiography of the chest demonstrated trace bilateral pleural effusions, enlarged pulmonary arteries, and ruled out acute aortic dissection and pulmonary embolism.
+The patient was hospitalized for acute decompensated heart failure and treated with non-invasive positive pressure ventilation, nitroglycerine infusion, and intravenous furosemide 40 mg twice daily. The patient’s respiratory status improved by Day 1 of the hospital admission. The peak BNP was 1649 pg/mL.
+Point-of-care ultrasound (POCUS) performed with a handheld device on hospital Day 2 was suggestive of a significant diastolic flow across the TAVR valve and directed further investigation for the diagnosis of prosthetic valve failure .
+Transthoracic echocardiogram (TTE) on hospital Day 3 revealed severe aortic regurgitation with an eccentric and anteriorly directed jet and holodiastolic flow reversal in the descending thoracic aorta . A peak measured transaortic gradient was 9 mmHg and the mean transaortic gradient was 5 mmHg. At the time of the patient’s hospitalization, the hospital system where the patient was admitted was experiencing staffing shortages and resource limitations related to an ongoing community COVID-19 surge. This served to delay access to the patient’s echocardiogram. The hospital policy at the time was to delay routine transoesophageal echocardiography (TEE) until patients were designated as COVID-19 recovered.
+During hospitalization, the patient was treated for COVID-19 with intravenous remdesivir 100 mg for 4 days and intravenous dexamethasone 6 mg for 7 days. Initially, the patient was managed for 2 days with continuous heparin infusion for presumptive treatment of acute coronary syndrome but was restarted on therapeutic apixaban 5 mg twice daily. The patient was discharged after 7 days and was transitioned from intravenous furosemide to oral torsemide 20 mg twice daily.
+Three days after hospital discharge, TEE confirmed proper positioning of the bioprosthetic stent-valve with leaflet thickening, abnormal cusp mobility, restriction of the non-coronary cusp prosthetic leaflet, and an eccentric regurgitant jet consistent with severe aortic regurgitation . The acute TAVR valve regurgitation was subsequently treated with a valve-in-valve TAVR 17 days post-discharge.
+The patient was seen in the clinic 30 days after valve-in-valve TAVR. The patient denied chest pain and dyspnoea. A TTE demonstrated bioprosthetic stent-valve in the aortic position with normal leaflet mobility and without paravalvular aortic regurgitation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3071_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3071_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..674101d4154f86bd0cc4b7938e499e013965eaf2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3071_en.txt
@@ -0,0 +1 @@
+61-year-old woman who consulted the emergency department for abdominal pain of 5 days evolution, with exacerbation of the same in the last 24 hours, located in the lower abdominal area. She reported nausea without vomiting and intolerance to oral route. On physical examination, a soft abdomen was found, painful to the touch in the meso and hypogastrium, with no defense or peritoneal reaction. As a relevant antecedent, the patient suffered systemic lupus erythematosus with interstitial nephritis, treated with hydroxychloroquine, meprednisone and belimumab. In the last 3 years, she was in chronic treatment with non-steroidal analgesics for generalized body pain. Within the complementary studies, the laboratory was within the normal parameters: 9500 white blood cells with slightly leftward deviated leukocyte formula, lactic acidosis 1.8 mmol/L. An abdominal-pelvic tomography with intravenous contrast was requested, which evidenced marked dilatation of the colon framework, with predominance of the transverse colon and cecum, with a site of transition and parietal thickening at the level of the splenic angle of the colon. Surgical treatment was decided due to intestinal occlusion. An exploratory laparotomy was performed, which evidenced the distended right and transverse colon, at the expense of a fibrous stenosing ring in the distal transverse colon, close to the splenic angle. A transverse colectomy was performed and both colonic ends were brought together. It was decided not to anastomose due to the nutritional status of the patient and the consumption of immunosuppressors and corticoids. In the postoperative period, diet was progressed with adequate tolerance in the first 48 hours along with the initiation of transit by colostomy. The hospital discharge was granted at 72 hours. The results of the pathological anatomy showed a submucous fibrous obliteration and proper muscle, and mucosa with mild reactive changes.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3072_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3072_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..626f1fddb54af900e69bcefba32bf82e8a817088
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3072_en.txt
@@ -0,0 +1,17 @@
+A 57-year-old male with a history of diabetes presented to the ophthalmology clinic with chief complaints of sudden painless diminution of vision, metamorphopsia, and color vision deficits in the left eye (OS) for one month. At that time, his vision was 20/20 in the right eye (OD) and 20/40 in OS, and intraocular pressure (IOP) was 13 mmHg OU. Ophthalmic examination revealed a left relative afferent pupillary defect (RAPD), blurred optic nerve margin, creamy chorioretinal infiltration around the optic disc, and mild macular edema, with no evidence of diabetic retinopathy. Examination of the right eye was non-revealing. The patient denied any history of drug abuse, smoking, or recent travels, and other than type 2 diabetes mellitus with glycated hemoglobin of 7.2%, his past medical history was not contributory.
+
+All laboratory tests including complete blood count (CBC), C-reactive protein (CRP), anti-nuclear antibody (ANA), rheumatoid factor (RF), angiotensin-converting enzyme (ACE), viral hepatitis titers, lysozyme, Histoplasma antibody, Syphilis, HLA-B27, HIV, Bartonella serology, anti-neutrophil cytoplasmic antibody (ANCA), QuantiFERON, and thyroid-stimulating hormone (TSH) were normal except for an erythrocyte sedimentation rate (ESR) of 28 mm/hr. CXR was normal; however, calcified mediastinal lymph nodes were detected on a chest CT with contrast, and their endobronchial ultrasound biopsy results were normal for histology and culture. MRI of the brain and orbit with Gadolinium enhancement displayed soft tissue abnormality with enhancement in the left orbital apex with involvement of the extraocular muscles, anterior aspect of Meckel’s cave, and lateral cavernous sinus. It also showed dural-based lesions along the greater wing of the right sphenoid and inferior frontal convexity with underlying cortical erosion and enhancement of the calvarium and subtle leptomeningeal enhancement along the ventral surface of the pons.
+
+Additionally, lumbar puncture showed normal opening pressure (11 cm H2O), and CSF analysis demonstrated a white blood cell (WBC) count of 45 cells/µL (88% lymphocyte), protein of 174 mg/dL, and glucose of 59 mg/dL. Complement fixation (CF) test for Coccidioides immitis was positive (titer of 1:2); however, the culture was negative. Flow cytometry excluded lymphoma. According to these findings and the patient’s previously vague history of flu-like symptoms, headaches, intermittent nausea/vomiting, and neck pain (2–3 months before), a tentative diagnosis of Coccidioidomycosis meningitis was made. Fluconazole (800 mg) once daily was commenced. However, due to its adverse effects of intractable nausea and vomiting, it was later switched to posaconazole 100 mg three times daily.
+
+Three months later, the patient stated a mild improvement in his vision, which was in line with the change in his BCVA (20/25 OS). He also tested negative for Coccidioides immitis antibodies in CSF and blood. A repeat orbital and head MRI scan also displayed stable enhancement of the left orbit cavernous sinus, both optic nerves and meninges.
+
+Although the follow-up testing was negative, the patient was maintained on a lower dose of posaconazole (100 mg twice daily) according to the expert advice of three Infectious Disease specialists who believed Coccidioides immitis meningitis was the most probable diagnosis for the patient based on the existing evidence.
+
+Five months later, the patient presented with acute onset of anterior uveitis (3+ anterior chamber cells) in OD. In addition to increasing the posaconazole to the previous dosage (300 mg), he underwent an extraocular orbital muscle biopsy for further investigation. The biopsy revealed non-caseating granulomatous inflammation with negative polymerase chain reaction (PCR) results for Coccidioides immitis. To manage possible concurrent inflammatory etiology, his rheumatologist then attempted a trial of 60 mg of oral prednisone daily. New treatment improved his fundoscopic findings, including regression of the previously noted creamy choroidal infiltrate and resolution of optic nerve edema and subretinal fluid. However, his vision and visual field remain unchanged.
+
+Seven months later, a neuro-ophthalmologist noted significant active left optic disc edema, which had worsened due to poor compliance with his corticosteroid therapy. According to a diagnosis of presumed sarcoidosis flare-up, the patient was restarted on 20 mg prednisone daily and was referred to the Uveitis Clinic for further management.
+
+At that time, his vision was 20/40 OD and 20/60 OS, and IOP was 9 and 10 mmHg OD and OS, respectively. Ophthalmic examination revealed disc swelling with a blurred optic nerve margin, peripapillary chorioretinal atrophy, and 1+ cell in anterior vitreous OS and unremarkable findings OD. Although the spectral-domain optical coherence tomography (SD-OCT) image was normal OD, preserved foveal contour with intraretinal edema and ellipsoid zone disruption in the macular region were detected in OS. Moreover, SD-OCT of the left eye optic nerve showed elevated disc and subretinal fluid at the temporal side. Wide-angle fundus fluorescein angiography (FA) at the late phase showed moderate optic disc hyperfluorescence and window defect on the lesion with chorioretinal atrophy OS. A follow-up MRI displayed stable soft tissue abnormalities. As the constellations of findings were consistent with the diagnosis of NS, prednisone 20 mg was restarted for the patient, leading to the resolution of his ocular symptoms in OS. At the time, chest CT showed nonspecific solid and ground glass pulmonary nodules. Positron emission tomography (PET) CT demonstrated multiple fluorodeoxyglucose (FDG) avid lymph nodes above and below the diaphragm, consistent with a diagnosis of sarcoidosis. Multiple follow-up CSF testing showed no evidence of coccidioidomycosis, which made it unlikely for the patient to have active coccidioidomycosis meningitis, further supporting NS as our primary diagnosis. At that point, according to the highly probable diagnosis of NS, the Infectious Disease specialist discontinued posaconazole.
+
+Two months later, his vision was 20/30 and 20/60 in OD and OS, respectively. Fundus photo showed milder optic disc edema and SD-OCT manifested improvement, such as decreased size and echogenicity of intraretinal fluid OS. Likewise, FA showed improvement in the optic disc inflammation as reduced hyperfluorescence. Subsequently, prednisone was tapered to 10 mg daily, and methotrexate at 20 mg weekly was initiated with folic acid supplementation. Follow-up MRI showed improvement in soft tissue thickening and enhancement within the intraconal soft tissues near the orbital apex as well as the peripheral enhancement of the proximal intraorbital segment of the optic nerve sheath complex. However, three months later, methotrexate was replaced with monthly infliximab infusion (7.5 mg/kg for 4 months) to manage the worsening of his neurologic symptoms, such as severe headaches as well as ocular inflammation OU (+1 anterior chamber flare and cells). In the meanwhile, the patient underwent bilateral cataract surgery as well. During the most recent visit, the patient indicated an improvement in blurriness, light sensitivity, and eye pain OU, which was in line with the resolution of ocular inflammation (no anterior chamber flare and cells) and BCVA of 20/20 and 20/30 in OD and OS, respectively.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_308_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_308_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b2c6421c63eb71fd2439934228b1385b33360ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_308_en.txt
@@ -0,0 +1,7 @@
+A 27-year-old Chinese woman presented to the outpatient department of our hospital with abnormal pregnancy.
+The patient had experienced menopause for 60 d. Her normal menstrual cycle was 27-35 d, and a urine pregnancy test was positive at 40 d of menopause. After 52 d of menopause, 174.8 mIU/mL of blood beta human chorionic gonadotropin (β-hCG) and 3.79 nmol/L of progesterone were examined in the hospital, and TVS indicated a honeycomb mixed echo in the uterine cavity of approximately 7.6 cm × 6.2 cm and a rich blood flow, some of which seemed to be embedded in the CS scar. The patient had no abdominal pain or vaginal bleeding and was experiencing a mild early pregnancy reaction. She was admitted to our hospital because of the abnormal pregnancy indicated by TVS.
+The patient had been delivered by CS due to macrosomia 4 years previously.
+The patient has no relevant family history.
+The patient had a temperature of 36.7 °C, heart rate of 82 bpm, respiratory rate of 20 breaths per minute, and blood pressure of 117/62 mmHg, and the oxygen saturation in room air was 99%. After admission, a gynecological examination revealed some bloody secretion in the vagina, mild cervical erosions without lifting pain, enlargement of the anterior uterus similar to that at 60 d of pregnancy without tenderness, and no abnormalities in the bilateral appendages.
+Hemoglobin level was 126 g/L, blood β-hCG was 189.6 mIU/mL, progesterone was 1.0 nmol/L, and the white cell and platelet count were normal. The prothrombin and partial thromboplastin times were normal, and the d-dimer value was 1.98 mg/L. Serum C-reactive protein was normal. The blood biochemistry and urine analyses were normal.
+According to the TVS review, the scar area revealed a disorderly high echo mass, and multiple vesicular echoes were found in utero, with the largest being approximately 2.2 cm × 1.1 cm . An embryo abortion was considered, and a hydatidiform mole could not be excluded. The electrocardiogram and chest computed tomography scan were also normal.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3107_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3107_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5fd1734311c4d5eaa26c3d3c26a5050b2273d55
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3107_en.txt
@@ -0,0 +1,11 @@
+A 62-year-old individual with obesity (BMI 37.1 kg/m2) was admitted to the authors’ spinal surgery unit due to the presence of severe pain in the lumbosacral region, which radiated to the lower extremities (Visual Analog Scale [VAS] score of 6 out of 10). Additionally, the patient experienced severe neurogenic claudication (14 points on the N-CLASS scale) and exhibited weakness in the lower limbs (MRC scale: 4). No reports of bowel or bladder control loss were noted. The Oswestry Disability Index (ODI) score was 48%, indicating a state of severe disability.
+
+The magnetic resonance imaging (MRI) examination performed on the patient revealed findings consistent with complete spondylolisthesis (spondyloptosis) at the L5/S1 level. The MRI showed distortion of the vertebral bodies, with the L5 vertebral body displaced anteriorly to the S1 vertebral body. Additionally, critical stenosis of the spinal canal and intervertebral foramina was observed. Prior to the surgery, a preoperative computed tomography (CT) scan was conducted, providing further information. In addition to the previously mentioned findings, the CT scan revealed a significant degree of bone fusion (union) in the L5/S1 region. Furthermore, the transverse dimension of the dural sac at the L4/L5 level was measured to be 15×9 [mm].
+
+The surgical intervention consisted of decompression of the dural sac through laminectomy at the L3-S1 levels and stabilization of L3, L4, and L5-S1. Transpedicular screws were routinely inserted at the L3 and L4 levels. However, due to the significant bone fusion between L5 and S1, which hindered the reduction of spondyloptosis at this level, transpedicular screws were inserted using Grob’s technique, passing through the fused L5 and S1 vertebrae. Following stabilization, spinal canal decompression was performed, and the screws were connected to a connecting rod for further support and stability.
+
+The postoperative course was uneventful, without any complications. A CT scan conducted 24 hours after the surgery confirmed the accurate positioning and secure anchorage of the screws. This imaging assessment provided reassurance regarding the stability and integrity of the surgical construct.
+
+To enhance the comprehensibility of the case report, we compiled tomographic images that illustrate the placement of the screws. By consolidating these images, we aimed to provide a clearer visual representation of the precise positioning and alignment of the screws within the spinal structure.
+
+Within 24 hours of the procedure, the patient regained the ability to walk. The previously experienced weakness in the lower extremities and neurogenic claudication were resolved. Following a favorable recovery, the patient was discharged in good overall condition after 72 hours. A digital radiograph obtained four weeks post-surgery revealed the accurate positioning of the screws, indicating successful alignment and stability. At the four-month postoperative assessment, the patient’s Oswestry Disability Index (ODI) improved to 34%, indicating a significant reduction in disability. Prior to the surgery, the patient experienced nighttime pain disturbances, but after the procedure, he achieved uninterrupted sleep. The patient’s mobility has notably improved, enabling him to walk distances of up to 4 km without significant difficulties. However, he does report occasional paresthesias in his toes. Overall, the patient’s functional outcomes have significantly improved, demonstrating the positive impact of the surgical intervention.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3116_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3116_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0265c2c19c9a2639729cc89a0cc8611c9d993072
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3116_en.txt
@@ -0,0 +1,5 @@
+60-year-old male with a diagnosis of post-traumatic hydrocephalus who required the implantation of a DVP. The postoperative cranial computed tomography (CT) and the postoperative radiographs of the valve path confirmed the correct placement of the proximal catheter in the ventricle and a proper path of the distal catheter to the peritoneum, with immediate postoperative clinical improvement.
+
+Thirteen months later, the patient had a new clinical deterioration with gait, memory, and executive function impairments. X-rays of the valve tract were performed. The distal catheter was located in the right cavities and pulmonary artery on the chest X-ray, which was confirmed by a thoracic CT scan.
+
+The patient underwent surgery, reopening the previous retroauricular incision to remove the catheter by hand, without incident. A new catheter was implanted at the peritoneal level with immediate clinical improvement. The patient received enoxaparin at prophylactic doses during the five-day hospital admission, without developing thromboembolism. Two years later, the patient remains clinically stable and has not had any further complications.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3123_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3123_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..db5606a56eed8fcea3e7d7e40260c6a3a2b9ff0f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3123_en.txt
@@ -0,0 +1,15 @@
+A 65-year-old man on hemodialysis complained of malaise, lightheadedness, and confusion during one of his sessions. He did not report dyspnea, tachycardia, chest pain, or other symptoms. The patient had been previously diagnosed with hypertension, diabetes, morbid obesity, and cirrhosis secondary to non-alcoholic steatohepatitis. He was also on continuous use of allopurinol 100 mg/day, sertraline 50 mg/day, esomeprazole 40 mg/day, and sevelamer 2.4 g three times daily.
+
+The patient had been on hemodialysis for two years for diabetic nephropathy, but frequently missed sessions. He had no residual diuresis in addition to a long history of high interdialytic weight gain and low adherence to the prescribed diet. The individual had a radiocephalic arteriovenous fistula in his right upper limb. To deal with his frequent absences, he was prescribed hemodialysis six times a week, with 2.5 hour sessions. The dialyser was a high-flux polysulfone membrane with a surface area of 2.2 m2, and his hemodialysis prescription consisted of Qb: 370mL/min. Qb: 370 mL/min and Qd: 800 mL/min. Dialysate prescription: Ca: 2.5 mEq/L; K: 1 mEq/L; Na: 138 mEq/L; bicarbonate: 36 mmol/L; unfractionated heparin: 5000 IU/session. If the patient had attended his sessions as prescribed, his calculated standard Kt/V would have been 2.45. However, since he came to the clinic for only three or four sessions per week, his actual Kt/V was 1.5-2.
+
+The physical examination at admission showed the patient to be in poor general condition, pale and cyanotic. Pulmonary auscultation was normal. His respiratory rate was 16 bpm and his oxygen saturation was 88% in room air. Cardiac auscultation revealed hypophonic murmurs, no heart murmurs, a heart rate of 88 bpm, blood pressure of 50/30 mmHg with a prolonged capillary refill time and jugular venous stasis. His abdomen was normal and his legs showed no signs of oedema. He showed signs of confusion and slowness during the neurological examination. His electrocardiogram showed a sinus rhythm, low diffuse voltage of the QRS complex, and altered ventricular repolarization.
+
+The patient was anuric and in shock. Resuscitation was performed with 1,000 ml of crystalloid fluid, but his blood pressure did not recover to normal levels. Cultures were collected and vancomycin and ceftazidime were prescribed until the etiology of the shock was clarified. He was referred to the intensive care unit (ICU), where noradrenaline 0.2 mcg/kg/min was initiated. His clinical and neurological condition improved despite the presence of paradoxical pulse.
+
+The results of his examination were as follows: hemoglobin: 9.8 g/dL; hematocrit: 29.5%; leukocytes: 5,230/mm3; platelets: 98,000/mm3; C-reactive protein: 0.61 mg/dL; NUS: 66.82 mg/dL; creatinine: 7.94 mg/dL; Na: 134 mEq/L; K: 6.2 mEq/L; ionized calcium: 1.17 mmol/L; P: 7.8 mg/dL; ALT: 14 U/L; AST: 22 U/L; alkaline phosphatase: 81 U/L; total bilirubin: 0.51 mg/dL; albumin: 3.9 g/dL; INR: 1.3; and TAP: 1.29. The markers of myocardial ischemia and the subsequent blood cultures were negative.
+
+A transthoracic echocardiogram showed a mild enlargement of the left atrium. The ventricles had a systolic function with an ejection fraction of 67% despite abnormal septal motion. The patient had a thickened pericardium with no signs of effusion, along with areas of hyperechogenicity. His inferior vena cava (IVC) was dilated and showed no signs of inspiratory collapse. The association between the findings of tissue Doppler of the mitral annulus and the plethora of the IVC suggested constrictive pericarditis. A chest computed tomography showed a thickened pericardium with areas of coarse calcification. Cardiac catheterization showed equalization of diastolic pressures in all cardiac chambers and exhibited a square root signal, indicative of constrictive pericarditis. An echocardiogram performed ten months before admission showed no evidence of pericardial abnormalities.
+
+The individual underwent a pericardiectomy based on a diagnosis of constrictive pericarditis and cardiogenic shock. The cultures of pericardial fluid were negative for fungal and bacterial infection, and the adenosine deaminase (ADA) level was 23 U/L (normal range: <40U/L). The culture of pericardial fluid and the polymerase chain reaction (PCR) tests were negative for Mycobacterium tuberculosis. The histological analysis of the surgical specimen showed marked fibrosis, areas of dystrophic calcification and mild foci of mononuclear inflammation, with no signs of granuloma or infection. The investigation for neoplasms and autoimmune diseases, as well as tuberculin testing were negative.
+
+After ruling out additional secondary causes, the combination of findings of constrictive pericarditis led to the diagnosis of dialysis-induced constrictive pericarditis (DICP). The patient was prescribed a more intensive haemodialysis protocol and was discharged nine days later. Since then, he has been attending haemodialysis sessions rigorously and has been complying with his prescribed diet and fluid intake recommendations.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3159_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3159_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74c7aad02bfe38ff5fccf0458ff61caa8b690cd6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3159_en.txt
@@ -0,0 +1 @@
+A 49-year-old male was referred for sudden onset of right-side weakness and aphasia for 55 minutes, with an initial National Institute of Health Stroke Scale (NIHSS) score of 23 [(3 +2+2)+1+0+0+(0+4)+(0+4)+0+2+3+2+0] and a modified Rankin Scale (mRS) score 3. He had a history of rheumatic heart disease with atrial fibrillation and had been on oral warfarin anticoagulant therapy. AIS was considered after no bleeding was observed on emergency head computed tomography. Considering that the specific value of the patient’s international normalized ratio was unknown and given the risk of intravenous thrombolytic bleeding, we decided to perform MT directly after obtaining the consent of the patient’s family. The patient was then taken to the catheter room and prepared for an endovascular thrombectomy and the door-to-puncture time was 36 minutes. Digital subtraction angiography (DSA) in the posterior–anterior projection showed the bilateral A2 segments ACAs originating from the left A1 segment, and both bilateral A2 segments ACAs were occluded. Consider this rare anatomical variation and the fact that the existing aspiration catheter hardly reaches the occlusive site, MT then was performed by using a 4×20 stent retriever (RECO; Minitech Medical, Wuxi, China) to revascularize the bilateral ACAs. After the respective first thrombectomy trial with the stent retriever, the bilateral ACAs were completely reperfused with modified thrombolysis in cerebral ischemia 3, but secondary thrombi were found in the MCA bifurcation. Most thrombi were removed in the MCA bifurcation after the use of direct aspiration technique. Imaging was performed within the following 24 h using magnetic resonance imaging. A recent infarction in the bilateral ACA territory and part of the left MCA territory was found. The patient achieved an NIHSS of 4 and a mRS of 1 at the 3-month follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3174_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3174_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4ac75617037b04a85fee6c33824566b6cb8a072d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3174_en.txt
@@ -0,0 +1,27 @@
+A 61-year-old Bedouin man presented to a local hospital in September 2021 with a history of a black scorpion sting to his right eye, when he suddenly felt severe pain in his right eye and flanks along with loss of consciousness. He was subsequently admitted to the intensive care unit until his case improved. The scorpion was later found hidden within his clothes, identified as Androctonus crassicauda, commonly known as the Arabian fat-tailed scorpion, a type of arachnid that is widespread in the desert of Jordan.
+
+Initial Ocular Presentation: February–March 2022
+Two days after the bite, the patient described having severe tearing pain in the right eye, headache and loss of vision that lasted later for a month. Subsequently, he sought medical treatment from five different private ophthalmologists without improvement. Consequently, the patient was referred to our tertiary ophthalmic center, and he had been on atropine 1% eye drops twice daily, moxifloxacin eye drops 0.5% four times a day, acyclovir eye ointment 5% four times a day, oral acyclovir 400 mg four times a day, and oral Levofloxacin 500mg once a day.
+
+Upon examination at our center, the patient was presented with visual acuity of counting fingers close in the right eye, crescent-shaped epithelial defect, central corneal thinning surrounded by infiltrate (5mmx5mm), severe ciliary injection and hypopyon (3mm), all consistent with signs of keratitis. The treatment plan was modified as follows: the initial treatment plan was maintained with atropine 1% twice daily - and oral levofloxacin 500mg once a day, while the frequency of oral acyclovir 400 mg was increased to 5 times/day. Newly added medications included fortified vancomycin eye drops 5% every hour, fortified amikacin eye drop 2.5% every hour and lubricant eye drops every 1 hour. Topical moxifloxacin and acyclovir ointment were discontinued, and the patient was discharged with a follow-up appointment scheduled after 2 days.
+
+Two days later, the patient returned to the outpatient clinic with a deterioration in vision, presented with a visual acuity of hand motion. There was no improvement in clinical signs, including a hypopyon of 2.5 mm, a large central ulcer with thinning, ciliary injection, and mild eyelid swelling. Consequently, the patient was admitted to the inpatient department. After 3 days of no improvement, amphotericin-b fortified eye drops 0.15% were added every hour, alternating with fortified vancomycin 5% and amikacin 2.5% every hour. One-week post-admission, clinical examination revealed a 1.5 mm hypopyon and a corneal ulcer. Antibiotics were discontinued to obtain an eye swab and fungal cultures, which returned negative. Treatment was adjusted, changing the frequency of fortified antibiotics every 4 hours (amikacin 2.5%, vancomycin 5%, amphotericin b 0.15%). Loteprednol etabonate 0.5%, and chloramphenicol eye ointment 1% were then added to the treatment plan 1 week later.
+
+Three weeks after presentation, his exam revealed a visual acuity of counting fingers close in his right eye, hypopyon 2 mm, ciliary injection, and a large area of infiltrates with an overlying epithelial defect. All fortified antibiotics and antifungal eye drops were discontinued after the corneal ulcer improved, with a significant reduction in symptoms, including less pain. The patient was maintained on lubricant eye drops every 2 hours, moxifloxacin 0.5% eye drops 6 times/day, chloramphenicol eye ointment 1%, and atropine 1% every 12 hours. Despite the improvement, the patient was not yet discharged due to the need for continued monitoring and treatment.
+
+At discharge, the corneal ulcer continued to show signs of improvement, with resolved hypopyon, formation of a scar overlying the corneal infiltrate and reduced ciliary injection with a visual acuity of 20/60 for the patient was discharged on lubricants every hour, cyclopentolate 1% every 12 hours, loteprednol etabonate 0.5% every 12 hours, moxifloxacin 0.5% 4 times/day, and chloramphenicol ointment 1% at bed time.
+
+Six months later (August 2022), he returned for a follow-up appointment with opacity in the right eye and old vascularization, but no signs of infection. His visual acuity was 20/100. He was maintained on loteprednol etabonate 0.5%, moxifloxacin 0.5%, and lubricating eye drops.
+
+Last Presentation (July–September 2023)
+In July 2023, the patient reported a gradual loss of vision in his right eye exacerbated by one heat wave, accompanied by right-sided headaches, burning sensation, itching, diplopia, tears, tinnitus and heat-induced severe pain. On July 31st, 25 days after the onset of symptoms, he presented to the hospital with another attack of keratitis in the right eye.
+
+Ophthalmic examination of the right eye revealed visual acuity of Hand motion. Anterior segment exam revealed central scar with an overlying epithelial defect 3mm*4mm with corneal neovascularization in the right eye. Initially, the patient was treated with fortified vancomycin 5% every hour, alternating with fortified amikacin 2.5%.
+
+On the 3rd of August, he presented again for follow-up with a visual acuity of hand motion, a central corneal scar with an overlying epithelial defect measuring 3 mm × 5 mm, and 360-degree corneal vascularization. The patient complained of irritation attributed to the fortified antibiotic eye drops. Consequently, fortified vancomycin and amikacin were discontinued, moxifloxacin was increased to once every hour, and chloramphenicol ointment was added. Nonetheless, on August 7th, his visual acuity remained hand motion. He additionally had a 0.5 mm hypopyon, a large ring corneal abscess, and an epithelial defect measuring 3 mm × 5 mm. As a result of these findings, he was diagnosed with recurrent fungal keratitis. His treatment plan was adjusted accordingly to include lubricant eye drops every 2 hours and fortified voriconazole 1% eye drops four times a day, due to the unavailability of amphotericin B. On 11th of August, his visual acuity was still hand motion, and examination revealed a ciliary injection and an epithelial defect measuring 3 mm × 3mm. The hypopyon had increased to 2 mm. As a result, all antibiotics were held, and cultures were taken again, which also came back negative. After culture collection, the patient was restarted on fortified voriconazole eye drops 8 times a day, moxifloxacin eye drops every hour, and lubricants every hour. Moreover, oral fluconazole 400 mg was given as a loading dose, followed by 200 mg once daily as maintenance.
+
+On 25th of August, his visual acuity improved to counting fingers at 3 meters with resolution of the hypopyon and an ulcer size of 2 mm × 3mm. Oral doxycycline 100 mg once daily, and loteprednol etabonate eye drops 0.5% every 2 hours were added. Voriconazole and moxifloxacin eye drops were decreased to 4 times a day. The patient's case was monitored over 3 days.
+
+The patient’s case continued to improve until 27th September 2023 when he was discharged. Upon examination, his visual acuity was 20/125, and the ulcer had resolved, leaving a 3 mm*4 mm scar with no fluorescein uptake. Discharge medications included fortified voriconazole eye drops 1% twice a day, moxifloxacin eye drops 0.5% twice a day, lubricants eye drops every 2 hours, loteprednol etabonate eye drops 0.5% four times a day, cyclopentolate eye drops 1% twice a day, and oral doxycycline 100 mg once daily for 1 week, with eye drops administered only to his right eye. A follow-up appointment was scheduled 2 weeks later post-discharge.
+
+During the follow-up appointment, examination revealed a visual acuity 20/200. The patient had a central scar measuring 3 mm × 4mm, corneal thinning, and vascularization. Moxifloxacin 0.5% and loteprednol etabonate 0.5% eye drops were reduced to twice daily, while lubricants were continued. Cyclopentolate 1% and fortified voriconazole 1% eye drops were discontinued. The patient was planned for corneal transplantation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3187_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3187_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..876cbac42590f67ebbe267fd4b7c6e5cddefe200
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3187_en.txt
@@ -0,0 +1,5 @@
+n this case report, we presented an unusual cause of severe anemia in a 65-year-old male Amhara ethnicity patient resulting from oropharyngeal leech infestation. The patient, a farmer from a rural area in North Wollo, Raya Kobbo, Ethiopia, presented with a 2-week history of spitting blood-tinged saliva. The bleeding was intermittent and some time it became bright red. He also described experiencing a persistent foreign body sensation in his throat, which was accompanied by discomfort and a sensation of fullness in the oropharyngeal area, lightheadedness, and difficulty speaking; 1 week prior to the onset of these symptoms, he had consumed water from a nearby spring, primarily used for livestock. Notably, he had no history of other symptoms associated with upper respiratory or gastrointestinal issues, such as a cough, shortness of breath, vomiting, or bleeding from other sites.
+
+On thorough physical examination, the patient was stable. His vital signs included a pulse rate of 104 beats per minute, a respiratory rate of 32 breaths per minute, blood pressure of 100/70 mmHg, and a temperature of 37.2 °C. The elevated pulse and respiratory rates suggested tachycardia and mild tachypnea, possibly due to discomfort or partial respiratory obstruction caused by the foreign body. Eye examination revealed pale conjunctiva and nonicteric sclera. A detailed oropharyngeal examination uncovered a dark brown cylindrical worm attached to the posterior wall of the oropharynx, with clotted blood surrounding the site of attachment.
+
+The patient was thoroughly informed about the entire procedure to ensure his comfort and cooperation. He was positioned in the supine sniffing position (with neck hyperextension). The tongue was retracted outward using sponge forceps, allowing us to grasp and remove the foreign body, which was identified as a 9.6-cm live leech. After removal, the site of attachment was compressed with gauze to control bleeding, and any hematoma was removed. The patient was counseled and sent home with home-based iron supplements for 1 month. The counseling emphasized on using clean water and not drinking river water. In addition, he was informed on seeking healthcare early when experiencing health ill health.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_31_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_31_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4295a31c46680354c1d737a0b587535dbd6e58d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_31_en.txt
@@ -0,0 +1,2 @@
+A 13-year-old Moroccan boy with no medical history consulted with our department regarding a functional impairment of his left lower limb that developed after a football game. No particular sprain or accident had occurred. A clinical examination revealed slight lameness without visible muscular atrophy. Muscular testing showed paralysis of his tibialis anterior and extensor hallucis longus; his common extensor digitorum was also partially deficient. Stretching of the EPSN was diagnosed based on functional disability after the football match. However, subsequent examination in our Department of Physical Medicine and Rehabilitation revealed an asymptomatic minor soft tumefaction localized at the neck of his fibula. The Tinel sign was present with a sensory deficit on the back of his foot. An electromyographic study of the nerve revealed severe damage to the EPSN at the neck of his fibula with a slow nerve conduction velocity. An electromyographic study of the nerves of his right lower limb was normal, and X-rays showed no abnormalities. Ultrasound of the tumefaction revealed a tubulated, non-compressive, anechoic mass without a Doppler signal. Magnetic resonance imaging (MRI) showed low signal intensity on T1 images, high signal intensity on T2 images, and a heterogeneous pattern due to the presence of some fine regular partitions. The lesion was in contact with the EPSN at its proximal part and coursed downward externally, following the path of its external collateral. A gadolinium injection revealed regular peripheral enhancement of the lesion, defining a central cystic area with low signal intensity .
+An intraoperative examination revealed a mass at the origin of the fibular communicating branch and the lateral sural cutaneous nerves . The mass was compressing but not invading the EPSN; the mass originated from collaterals of the EPSN; electrostimulation of different nerves allowed us to differentiate the motor EPSN of the sensory collateral. Finally, we completely removed the tumor with the origin of the two collateral nerves. There were no postoperative complications. A pathologic examination confirmed a neurofibroma. Our patient underwent several rehabilitation sessions, but his steppage gait persisted. Nerve grafting may eventually be conducted to address his steppage gait.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3216_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3216_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..155cded465d72b0e3b76af52ef2eba2b1ef309b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3216_en.txt
@@ -0,0 +1,11 @@
+A male neonate with a birth weight of 2800g, body length of 47cm, and Apgar scores of 9–10-10 was born via cesarean section delivery to a 33-year-old G4P2+1L1 mother at 38+5-week gestation in hospital in a nonconsanguineous marriage with 4000mL of II° meconium-stained amniotic fluid in a tertiary first-class hospital in Chengdu, western China, in 2019.
+
+The mother had a history of one intrauterine fetal loss at 7 months’ gestation for undetermined cause, gave birth to a healthy male infant two years previously, and experienced a spontaneous abortion during her third pregnancy with specific details unavailable. This was her fourth pregnancy, and she underwent routine prenatal examination in the local county-level hospital during the mid-term of pregnancy. Given the history of previous stillbirths, the pregnant woman underwent comprehensive genetic screenings, including thalassemia gene screening, amniocentesis, and examinations of fetal chromosomal number chromosomal aneuploidy, and gene copy number variations at gestational age of 22+5 weeks at the most authoritative hospital in the province. However, all these investigations failed to reveal any abnormalities. At 35+6-week gestation, the local hospital detected a serum alpha-fetoprotein (AFP) level in the pregnant women exceeding 1000 ng/mL. At 36+5-week gestation, upon transferring to our hospital in preparation for delivery, ultrasound revealed mild polyhydramnios (Amniotic fluid index of 33.5 cm.), chorioamniotic membrane separation(CMS), and an enlarged fetal gastric bubble (7.2cm×3.0cm), and the pregnant woman was diagnosed with gestational diabetes (GDM) and suspected fetal digestive tract obstruction by the outpatient obstetrician.
+
+On physical examination, the neonate was found tachypnea (with respiration rate of 55/min) and absence of skin along Blaschko’s lines over the anteromedial aspect of both lower legs almost symmetrically, and also skin absence on the nasal tip, ears, right neck, the right hip, and mucosa absence in the oral cavity, and totally the skin missing covered about 17% of the whole body surface (Roughly, calves, feet, buttocks, and neck accounted for 10%, 3.5%, 2.5%, and 1% respectively), with scattered blisters. The skin and mucous membrane adjacent to these defects appeared “normal” but showed a strongly positive Nikolsky test. Moreover, there was bilateral ear maldevelopment.
+
+Right after the delivery, routine airway sputum suctioning was performed on the neonate. Subsequently, the neonate was transferred to the Neonatal Intensive Care Unit (NICU) laminar flow ward due to extensive skin lesion and pneumonia, placed in reverse isolation in a 34°C temperature-controlled incubator with humidity of 55%, aiming to minimize insensible water loss. The neonate received immediate thermoregulation and total parenteral nutrition, along with vitamin K1 for vitamin K deficiency bleeding (VKDB) prevention, analgesia, sedation, and cefuroxime anti-infective treatment. In terms of care, continuous electrocardiographic monitoring, oxygen inhalation, and fasting were initiated promptly.
+
+For skin care, given the extensive abnormal skin area of the patient, to alleviate pain and reduce the duration of dressing changes, we planned an alternate-day dressing change strategy, alternating between the trunk and limbs. The dressing sequence involved moistening and softening, wound cleaning, medication application, covering with petrolatum gauze, non-adherent foam dressing, and self-adhesive elastic bandage wrapping.
+
+The neonatologist requested urgent consultations. Given absence of skin and scattered blisters of the skin, the dermatologist suspected “Bart Syndrome”. A subsequent plain abdominal radiograph was performed and it revealed a large gastric air bubble with no gas distally, indicating PA. Consequently, the pediatric surgeon made a supplementary diagnosis of CPA. After 26 hours and 53 minutes of hospitalization, the neonate’s family decided to discontinue treatment, and the neonate passed away approximately 30 hours after birth. Despite departmental discussions mentioning the possibility of EB and/or ACC in the neonate and proposing the need for pathological and genetic examinations, these planned investigations were not implemented due to the neonate’s short lifespan, lack of family support, and other factors.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3218_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3218_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2cc791c63a7fc83d2994832ca6238e34cc062960
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3218_en.txt
@@ -0,0 +1,5 @@
+A 69-year-old female had received antihypertensive drugs (azilsartan [20 mg/day] and amlodipine [10 mg/day]) for over 15 years. The patient previously had non-Hodgkin’s lymphoma (stage IV) and underwent repeated courses of chemotherapy for each relapse between the ages of 35–49 years, resulting in complete remission (chemotherapy drug/cumulative dose [mg/m2]: doxorubicin [DOX]/218; pirarubicin/830; mitoxantrone/33; cyclophosphamide/23,758; vincristine/72; etoposide/333; and carboplatin/85; and rituximab/1,358; the equivalent DOX dose to assess ATC cardiotoxicity was 691 mg/m2). Furthermore, the patient received endoscopic submucosal dissection for early-stage rectal cancer and a right hemicolectomy for colon cancer at the age of 65 years.
+
+The patient subsequently presented with exertional dyspnea and abdominal distention and was hospitalized for acute HF in August X, 1.5 months after symptom onset (this admission date was considered the reference date). Upon admission, the patient was in clinical scenario 2, with chest X-ray (CXR) findings of a pleural effusion, cardiac enlargement, and moderate pulmonary congestion (CXR2). An electrocardiogram (ECG) revealed sinus tachycardia (E2). A systolic murmur was heard, suggesting aortic stenosis (AS). Initial oxygen and intravenous diuretic therapies relieved the HF symptoms. Azilsartan was titrated to 40 mg/day, and azosemide (30 mg/day) and carvedilol (5 mg/day) were added early in the treatment course. A two-dimensional echocardiogram (2DE) revealed left ventricular (LV) and left atrial (LA) enlargement, reduced left ventricular wall motion (LVWM) with an 18% left ventricular ejection fraction (LVEF), and an elevated tricuspid regurgitant maximum pressure gradient (TRmaxPG) of 41 mmHg. All three calcified aortic valve leaflets had restricted openings, with a 30-mmHg aortic valve pressure gradient (AVPG) (#1 in Table 1). Dobutamine Stress 2DE ruled out severe AS. Computed tomography (CT) revealed an aortic valve calcium score of 1,189 Agatston units (AU). Coronary angiography (CAG) demonstrated no significant stenosis. Cardiac catheterization revealed increased pulmonary artery wedge pressure, increased LV end-diastolic pressure, pulmonary hypertension (PH), decreased cardiac output index, and low AVPG. Brain natriuretic peptide (BNP) levels declined from 1,183 pg/mL at admission to 710 pg/mL at discharge. In January X + 1, five months after reference date and four months post-discharge, weight gain was observed, and the BNP level increased to 2,986 pg/mL, indicating WHF. Azosemide was titrated to 45 mg/day, slow-release nifedipine at 20 mg/day was added to control blood pressure below 120 mmHg, and carvedilol was titrated to 7.5 mg/day. The patient remained stable at New York Heart Association (NYHA) class 2, with BNP levels of 1,100–1,900 pg/mL over the following year.
+
+In March X + 2, one year and seven months after the reference date, the patient was suspected of having WHF with possible progression toward severe AS. This suspicion was based on an ECG in February X + 2 (one year and six months after the reference date) demonstrating LV strain (E4) and a CXR in March X + 2 (one year and seven months after the reference date) demonstrating cardiac enlargement (CXR4). Azilsartan was substituted with empagliflozin at 10 mg/day and sacubitril/valsartan at 200 mg/day (titrated to 400 mg/day over four weeks). Approximately three months later (one year and 11 months after the reference date), the patient rapidly experienced WHF symptoms, including dyspnea and abdominal distention, classified as NYHA class III. The symptom progression coincided with physical exertion, as the patient’s partner had undergone surgery and required care. Ivabradine was added to achieve heart rate control between 50–60 bpm, and a diuretic was used as needed to achieve target morning weight maintenance. Cardiac status subsequently improved to NYHA class II moderate limitation of physical activity (NYHA class IIm). The 2DE in October (two years and two months after the reference date) revealed a slight decrease in LV systolic dimension, slight LVEF improvement to 29%, and AS progression. Therefore, spironolactone at 25 mg/day was started as quadruple therapy. BNP levels decreased to 2,902 pg/mL in early February X + 3 (two years and six months after the reference date). Vericiguat was started in late February after receiving quadruple therapy and ivabradine treatment, without a 2DE evaluation. HF symptoms improved with weight loss owing to increased urine output, and the BNP level decreased below 650 pg/dL. The 2DE in March X + 3 (two years and seven months after the reference date) revealed the same LVEF and AVPG as in October X + 2 (two years and two months after the reference date), in addition to decreasing LV dimensions and a normalized TRmaxPG. Paroxysmal supraventricular tachycardia with hypotension frequently occurred, and the patient was readmitted in June (two years and 10 months after the reference date) for an electrophysiological study and right heart catheterization (RHC). RHC revealed mild PH, and right ventricular myocardial biopsies demonstrated drug-induced myocardial damage: the cardiomyocyte diameter was mildly enlarged, with noticeable anisokaryosis of the cardiomyocyte nuclei, some cardiomyocytes exhibited giant nuclei, and cytoplasmic vacuolar degeneration was observed. Mallory staining revealed fibrosis unrelated to the vascular structure between the cardiomyocytes, with the replacement of the myocardium by fibrous tissue. The 2DE in June (two years and 10 months after the reference date) revealed normalized LV diameter, a moderate reduction in LA enlargement, improved LVWM (52% LVEF), and a normalized TRmaxPG; however, the AVPG increased to 77 mmHg, with a Vmax of 4.4 m/s and aortic valve orifice area of 0.55 cm2, which was diagnosed as severe AS. The restricted openings of all calcified aortic valve leaflets were unchanged; however, all leaflets appeared slightly thickened and brightened. CT revealed that the aortic valve calcium score increased to 2,468 AU. Amlodipine was discontinued, and sacubitril/valsartan was tapered to mid-dose owing to persistent hypotensive symptoms. Spironolactone was discontinued due to hyperkalemia. The patient was stable at NYHA class II with a slight limitation of physical activity (NYHA class IIs) on sacubitril/valsartan at 200 mg/day, empagliflozin at 10 mg/day, carvedilol at 7.5 mg/day, azosemide at 30 mg/day, ivabradine at 15 mg/day, and vericiguat at 10 mg/day. An aortic valve replacement (AVR) for severe AS was successfully performed in September (three years and one month after the reference date), with good subsequent clinical outcomes.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3222_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3222_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b7833a9ae29702e04dd4ed556d0923899845b17
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3222_en.txt
@@ -0,0 +1 @@
+A 73-year-old male patient without any comorbidities presented with breathlessness for the last 12 h along with bipedal pitting edema and scrotal edema for the last 1 month with no features suggesting orthopnea or paroxysmal nocturnal dyspnea. There was no history of any medication intake, prolonged steroid abuse, altered bowel habits, recent surgery, or prolonged immobilization. Physical examination revealed tachypnea (respiratory rate—44/min), tachycardia (heart rate—140 beats/min), mild pallor, hypotension (BP 70/40 mmHg) with SpO2 80% in room air and 96% with 8 liters of O2/min via face mask. Peripheral extremities were cold and clammy. Bilateral pitting pedal edema, and scrotal edema along with leukonychia were present. Jugular venous pressure was not raised. Cardiovascular, respiratory, gastrointestinal, and lymphoreticular system examinations were within normal limits. For shock, vasopressor (noradrenaline) support and intravenous fluid resuscitation were carried on. The patient survived the episode of shock. 12-lead electrocardiogram showing sinus tachycardia and negative cardiac biomarkers ruled out acute coronary syndrome. Chest X-ray was performed which was normal. 8 a.m. serum cortisol was found to be normal (11.2 mcg/dl). On evaluation, the patient was found to have iron deficiency anemia (transferrin saturation 10%) with normal vitamin B12 levels. Fasting blood glucose was 93 mg/dl with a Glycated hemoglobin (HbA1C) of 5.4. Serology for Human Immunodeficiency virus (HIV)- 1,2; Hepatitis C virus (HCV); and Hepatitis B virus (HBV) was non-reactive. The Mantoux test was negative. Hypoproteinemia (4.4 mg/dl) along with hypoalbuminemia (2.4 mg/dl) was evident with normal renal function test. Markers of inflammation were elevated [erythrocyte sedimentation rate (ESR)-64, Ferritin-732 mcg/L, C-reactive protein (CRP)-12.6 mg/dl]. 24 h of urinary protein was 119 mg/24-h urine. No dyslipidemia was present. Ultrasonography of the whole abdomen revealed no evidence of chronic liver disease or any kidney disease. 2D echocardiography revealed an ejection fraction of 60% with right ventricular free wall hypokinesia without any pericardial effusion. Raising the suspicion of pulmonary thromboembolism, computed tomography of pulmonary angiography was performed where pulmonary thromboembolism was noted in bilateral lower lobe pulmonary arterial branches and right-sided upper lobe pulmonary arterial branches with dilated pulmonary trunk and both main pulmonary artery (MPA) [MPA 29 mm, right-22 mm, left-18 mm]. During the hospital stay, the patient was gradually developing asymmetrical right leg swelling for which an ultrasonography color doppler of bilateral lower limbs was performed where a long segment thrombus was noted extending from the popliteal vein to complete involvement of the external iliac vein. Antiphospholipid syndrome was ruled out. Protein, C, S, antithrombin III, and Serum homocysteine were within normal limits. Factor V mutation was not detected. Paroxysmal Nocturnal Hemoglobinuria (PNH) profile was negative. No Monoclonal protein band was detected on serum protein electrophoresis (SPEP). A computed tomography scan of the neck, thorax, and abdomen revealed no evidence of internal solid organ malignancy. Anticoagulation was started with low molecular weight Heparin (LMWH) and Warfarin and INR were monitored. To unveil the etiology of iron deficiency anemia and hypoproteinemia, stool examination, and upper gastrointestinal endoscopy were planned which revealed erythematous duodenal mucosa. D2 biopsy was taken which revealed chronic inflammatory cell infiltration in lamina propria consisting of eosinophils, plasma cells, and lymphocytes along with the presence of a parasite within the lumen of duodenal crypts morphologically resembling Strongyloides stercoralis. The stool was positive for occult blood and Strongyloides stercoralis larva was seen on wet moun. Bronchoscopy was done where the larval stage of the parasite was seen. Ivermectin (200 μg/kg orally) was started with Albendazole (400 mg orally two times a day). On continuation of the treatment with anticoagulant and anthelmintic, target INR was achieved (INR 2.2). The patient’s general well-being and appetite were improved within 2 days of therapy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3228_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3228_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b7ae45bc7f2e7a793392893ecabb85993438729d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3228_en.txt
@@ -0,0 +1 @@
+A 30-year-old male presented with grade 3 phimosis with no other relevant personal or family history. On physical examination, a mobile, painless, elastic, 20 mm diameter, solid, nodular mass was found in the right scrotum, with a one-year history. On ultrasound, a right paratesticular solid mass was found, 20 mm in diameter, predominantly hypoechoic, heterogeneous, with well-defined borders. Surgical resection was performed and the material was sent to the pathology department, fixed in 10% formalin. Macroscopically, a 2.5 x 1.5 x 0.7 cm skin fragment was received, which showed a 2 cm diameter nodule, poorly circumscribed, brown-grey, soft, gelatinous. Total processing of the sample was decided according to the routine protocol. Histological examination showed a dermo-hypodermic multilobulated proliferation, poorly circumscribed, partially subdivided by fibrous septa, consisting of a vascularised myxoid matrix with the presence of stromal cells of spindle-shaped fibroblasts and some stellate cells. The vascular structures had a thin wall and formed a tree-like network in some areas. A mononuclear inflammatory infiltrate and isolated polymorphonuclear neutrophils were detected at the intra-lesional level. In addition, there were elongated epithelial cords located in the periphery, but no mitosis or atypia was observed. Complementary histochemical (periodic acid-Schiff PAS; alcian blue and mucicarmine) and immunohistochemical techniques were used. The first highlighted the myxoid stromal matrix rich in mucin. The immunomarking profile was positive for vimentin and CD34 in some stromal cells and blood vessels, and negative for pan-keratin, S-100 protein, desmin, smooth muscle actin and estrogen and progesterone receptors. Clinical and morphological findings allowed the diagnosis of AS to be made. The section margins contacted the lesion. To rule out the Carney complex, extensive consultations and evaluations were performed. A detailed medical history and physical examination was performed, including a review of personal and family medical history. An echocardiogram ruled out the presence of cardiac myxoma. Possible skin lesions and laboratory blood tests were investigated. After these studies, no lesions or findings characteristic of the Carney complex were found, so this entity was ruled out. The patient signed the corresponding informed consent for the publication of the case.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3249_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3249_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d392fa964678ddfa5ce0e4a681e553b1fbb62baa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3249_en.txt
@@ -0,0 +1 @@
+52-year-old female patient, without comorbidities. Two years of disease evolution with localized pain (visual analogue scale [VAS] 9) on the distal phalanx of the left thumb, of a burning type, which increased with movement and with changes in temperature. Physical examination showed subungual pain, with mild volume increase and palpation of a radial-sided tumour. Ultrasound reported a highly vascularised nodular lesion without shadow or posterior reinforcement, circumscribed, hypoechoic and homogeneous of 3.00 × 2.10 mm on the medial edge of the distal phalanx of the first finger plus thickening of the synovial sheath; these are characteristic findings of glomus tumours. Surgical treatment was decided, which required glasses with two-fold magnification, regional block anaesthesia and ischaemia and H approach to the distal phalanx and transverse subungual. The nail tumour was removed and a white-yellowish tumour, well encapsulated and of the described dimensions, could be visualised. After exeresis, bone curettage and cauterisation of the vascular bed was performed to finally suture with monofilament nylon 4/0. A piece was sent for histopathological study. She attended the two-week follow-up appointment in the outpatient department, where surgical wound stitches were removed with adequate healing. Physical examination with ability to mobilise the distal interphalangeal joint (IFD) and 1-point VAS. The result of the histopathological study reported a glomus tumours of 3 × 2 mm.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3267_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3267_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fed42cf8a3940d5d42da80bc08734fa992600bd8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3267_en.txt
@@ -0,0 +1,9 @@
+30-year-old male patient, resident of the city of Santa Cruz de la Sierra in Bolivia, engineer, man who has sex with man (HSH), promiscuous and with personal pathological history of HIV infection, diagnosed seven years ago, with adherence to antiretroviral therapy of great activity (TARGA, dolutegravir, lamivudine and tenofovir), since the beginning of 2018.
+
+On August 8, 2022, he reported unprotected sexual activity (without condom) with a stranger, then four days later he presented a papule with well-defined edges in the left gluteal region, near the intergluteal cleft and three centimeters from the gluteal groove (first day, August 12), with pruritus. In addition, he presented rectal tenesmus and tenesmus, with non-fetid mucopurulent discharge and pain during defecation. For this reason, he decided to go to the National Center for Tropical Diseases (CENETROP) on August 15, 2022.
+
+On physical examination (day 3), 15 lesions, including papules and pustules, were observed in the gluteal region of varying sizes, less than 1 cm. In addition, an erythematous papule was identified in the lower third of the left thigh (sartorius) and a pustule in the neck. There were also bilateral, symmetric, painless, mobile, and slightly indurated superficial and deep cervical lymphadenopathies. The dermatological lesions were sampled, with pharyngeal and anal swabs, the latter to rule out sexually transmitted infections. The diagnosis of VS was confirmed by real-time polymerase chain reaction (RT-PCR). He was referred to his corresponding health center, and blood chemistry, serological, and other tests were performed.
+
+Isolation and home monitoring twice a week (Monday and Thursday) was decided. On the seventh day, two solitary lesions appeared: a pustule in the left lateral region of the neck and an erythematous papule in the left costal rib. On the eleventh day, all lesions were erythematous-pustular in the gluteal region and neck, and some pustules were observed umbilicated. In addition, the patient reported that the lesions in the gluteal region were painful. On the fourteenth day, most lesions were in the scab phase and painless. A papule appeared near the gluteal cleft. On the eighteenth day, several scabs were observed. On the twenty-first day, all scabs fell off and discharge was decided.
+
+In view of these findings, the following nosological entities were proposed: VS with HIV, gonorrhea, latent syphilis and infectious proctitis (IP). From the fifth day, general measures were indicated such as home isolation, frequent disinfection, daily washing of towels, clothing and bed at a temperature of 60°C, drying of lesions with a towel specific for the affected areas, and another towel for the rest of the body. Empirical and symptomatic pharmacological treatment was indicated with ceftriaxone 1 g single dose intramuscularly (IM); benzathine penicillin G 2.4 million IU, once a week for three weeks IM; transfer factor (HEBERTRANS®) twice a week IM for eight weeks; doxycycline 100 mg twice daily orally (VO) for seven days; vitamin D3 150 000 IU single dose orally; vitamin C 1 g every eight hours orally; fexofenadine 180 mg once a day orally; tramadol 325 mg/paracetamol 37.5 mg three times a day orally; Roydil (calcium dobesilate, lidocaine anhydride, hydrocortisone acetate and zinc oxide) once a day rectally. After three days of the application of ceftriaxone, the patient had improvement of the tenesmus and straining.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3271_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3271_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a6c358d2c27533b56a9bd8dd5520bb575005d3cf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3271_en.txt
@@ -0,0 +1,20 @@
+Patient background
+Our patient was a 73-year-old male diagnosed with localized prostatic cancer on a background of long-standing metabolic syndrome, osteoarthritis, peptic ulcer disease and two previous cerebrovascular accidents (CVA). His regular medications were aspirin, telmisartan, rosuvastatin, esomeprazole, empagliflozin and metformin. He had no known allergies. He was an ex-smoker and drank one bottle of wine a night.
+
+Prostate cancer diagnosis
+The patient was referred to urology with an elevated PSA of 15.4 ng/ml, which was an increase from 8.13 ng/ml performed the year prior. Multiparametric MRI (mpMRI) demonstrated no lesion and a transperineal prostate biopsy (TPB) revealed Gleason 9 (G4+5), grade group 5 prostate cancer of the right posterior lobe. A staging PSMA PET scan confirmed high local prostate avidity and no metastasis. The final histopathology demonstrated a pT3a stage cancer with clear surgical margins.
+
+RALP and discharge
+RALP was performed under general anesthetic in the 27-degrees trendelenburg position with a zero-degree telescope. A 24F rectal tube and 18F indwelling catheter (IDC) were inserted during the procedure. Hasson port was passed supraumbilically and insufflated to 10 mmHg with the remaining ports inserted under vision. The sigmoid colon was minimally released laterally to drop the bowel away from the working peritoneal space. There were no adhesions observed and the sigmoid was normal in appearance and attachment. The space of retzius was accessed and a routine prostatectomy was performed. Bladder neck was spared, bilateral nerve sparing was not performed, dorsal venous complex was cut and oversewn. Prior to vesicourethral anastomosis a negative rectal leak test with 60ml air was performed via a syringe, with insufflated air then removed and the rectal tube left open at the end till removal at case completion. The anastomosis was watertight with a negative 180 ml leak test. Total operative time was 160 minutes and estimated blood loss measured at 250 ml. The patient was discharged after two days and postoperative care included analgesia on demand, laxatives for three-days and enoxaparin venous thromboembolism (VTE) prophylaxis.
+
+ED presentation
+19-days following RALP the patient presented to the emergency department (ED) with a three-day history of obstipation and reduced oral intake. He also presented with a two-day history of nausea, one episode of vomiting and back pain relieved by lying supine. He denied any abdominal pain, urinary symptoms, fevers or chills. He also denied any recent opioid use and was using paracetamol when required following RALP.
+
+On examination his vitals were normal. His abdomen appeared very distended, however non-tender to light and deep palpation. There was no guarding or peritonism. Bowel sounds were hyperactive on auscultation. Digital rectal examination revealed an empty rectum with no blood or fecal matter.
+
+Sigmoid volvulus diagnosis & management
+The patient was admitted, and an abdominal & pelvis contrast-enhanced CT was performed revealing volvulus of the sigmoid colon. Flexible sigmoidoscopy confirmed a sigmoid volvulus 30 cm of insertion of the scope. There was no masses or blood, and the mucosa appeared normal and healthy. The patient underwent sigmoid detorsion and the colon was decompressed with insertion of a rectal tube. There were no procedural complications during the flexible sigmoidoscope. Postoperatively, he was commenced on regular metoclopramide, cetirizine, analgesia and osmotic laxatives. Postoperative stay was complicated by euglycemic ketoacidosis thus, seven days later the patient was discharged.
+
+Two months after discharge, the patient presented again to ED with a similar three-day history of obstipation, progressive abdominal distension, reduced oral intake for two days, and dull generalized abdominal pain worse centrally. On examination his abdomen was very distended again, bowel loops were palpable and there was mild generalized tenderness with no guarding or rigidity.
+
+Abdominal & pelvis contrast-enhanced CT revealed another sigmoid volvulus, thus the decision was made to perform flexible sigmoidoscopy, detorsion and decompression of the volvulus and insertion of the rectal tube again. One month following his second episode of sigmoid volvulus, an elective anterior resection of the sigmoid colon was performed to prevent recurrence of symptoms following his urological procedure. No operative comment was made about abnormal clinical findings such as a narrow mesentery or large redundant sigmoid colon.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3286_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3286_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..142eed244a9080ac72e9e928f0ae0abbc6a30678
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3286_en.txt
@@ -0,0 +1,17 @@
+History of Presentation
+A 53-year-old man with a history of multiple previous percutaneous coronary intervention (PCI) treatments had an angina on effort with Canadian Cardiovascular Society class II. Coronary angiography (CAG) revealed 90% stenosis in the stent implanted 4 years before, and he was admitted for revascularization.
+
+Past Medical History
+Four years before, the patient underwent catheter ablation for symptomatic paroxysmal atrial fibrillation. At the same time, he was also aware of angina on effort, and CAG performed during the ablation procedure showed 90% stenosis with severe calcification in the proximal segment of the left anterior descending artery (LAD). He then underwent PCI. Despite extensive preparation with rotational atherectomy of 1.25-mm burr and predilatation by 2.5-mm cutting balloon, a 2.75- × 20-mm drug-eluting stent was insufficiently expanded even after postdilatation with a 2.75-mm noncompliant balloon. Two years before, the patient complained of angina symptoms and CAG showed in-stent restenosis (ISR) of 90% stenosis. We performed revascularization, but high-pressure dilation of 12 atm with a 2.75-mm cutting balloon and 25 atm with a 3.0-mm noncompliant balloon did not provide sufficient dilation eventually.
+
+Differential Diagnosis
+Other causes of chest pain were ruled out. Chest radiography did not show any signs of heart failure or respiratory disease. Despite a history of catheter ablation for paroxysmal atrial fibrillation, he had been in sinus rhythm and there was no evidence of tachycardia event. His chest pain was similar to the symptoms which he felt at previous PCIs.
+
+Investigations
+The 12-lead electrocardiogram showed sinus rhythm and no significant ST-segment changes, and transthoracic echocardiogram showed no significant asynergy and preserved left ventricular systolic function with an ejection fraction of 74%. Moreover, myocardial perfusion single photon emission computed tomography implied anterior ischemia and CAG showed 90% ISR with severe calcification in the proximal LAD.
+
+Management
+Via a right distal radial artery approach with a 6-F Judkins Left 4.0 guide catheter (Mach 1; Boston Scientific) a guidewire (SION blue; Asahi Intecc) was crossed into the distal LAD successfully. Supported with a guide extension catheter (GUIDEPLUS, NIPRO), optical coherence tomography (OCT) (Dragonfly OPTIS, Abbott Vascular) examination was performed and we found circumferential thick calcification outside of the stent. Even though 3.0-mm scoring balloon inflation with up to 24 atm, the lesion proved resistant to expansion. Then, we exchanged to 7-F SPB 3.5 guide catheter (Hyperion, Asahi Intecc) to enforce the backup power and 1.75-mm burr rotational atherectomy was performed. Even after rotational atherectomy, high-pressure dilatation with a 3.0-mm scoring balloon up to 24 atm again did not provide adequate stent expansion. Therefore, we decided on a strategy of treatment by intravascular lithotripsy (IVL). A lithotripsy balloon 3.0 × 12 mm (Shockwave Medical) was positioned across the underexpanded segment of the stent. The balloon was inflated to 4 atm and 10 shockwave pulses were delivered at a rate of 1 pulse per second, following which the balloon was inflated further to 6 atm for 5 to 10 seconds, which was repeated multiple times, and then excellent dilation was seen at the second 10 pulses. Additional 40 pulses were delivered eventually, and the stent appeared to have expanded fully on repeat angiography and OCT observation. Finally, the lesion was dilated with a 3.0-mm drug-coated balloon (SeQuent Please NEO, NIPRO) up to 6 atm. We confirmed sufficient stent and lumen expansion on angiogram and OCT with the final lumen area of 7.08 mm2 at underexpanded stent segment. Therefore, we finished the PCI procedure without any complications, and the patient was discharged 2 days after PCI.
+
+Follow-Up
+During the outpatient clinic follow-up, there were no clinical events and the patient did not complain of angina symptoms. Seven months later, follow-up CAG accompanied with OCT and coronary angioscopy (CAS) imaging were conducted. On CAG, there was no stent restenosis with patent stent. OCT revealed homogeneous neointimal coverage of stent struts with sustained acute lumen gain and no evidence of stent recoil or ISR. Notably, post-PCI fractured thick calcium outside the stent at the index PCI had disappeared. In addition, CAS showed the stable white color neointima and a few stent struts with dull light reflection
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3378_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3378_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..becfa670973c0c21697c377434630a0f6a4d31ce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3378_en.txt
@@ -0,0 +1,13 @@
+The patient is a 46-year-old male with a three months’ history of progressive dyspnea on exertion. His past medical history was significant testicular cancer involving the right testes 32 years prior with pulmonary and widespread lymph nodal metastasis. He was treated at that time with orchiectomy, and chemotherapy along with radiation to the brachial plexus for distant metastasis. Eight years later, the patient was found to have a pulmonary nodule on chest x-ray that was treated surgically and was a teratoma. Since then the patient had remained asymptomatic.
+
+As a part of a dyspnea workup, the patient underwent a transthoracic echocardiogram (TTE) that showed two large, well circumscribed, partially mobile right ventricular masses. One was in the right ventricular outflow tract (RVOT) measuring 2.8×2.0 cm) and the other was toward the RV apical free wall (3.3×2.9 cm). The RV and left ventricle (LV) systolic function was normal though the RV was mildly dilated. There was color flow turbulence across the RVOT indicating some obstruction to flow, though velocity was not elevated. The patient was subsequently admitted to the hospital with Cardiothoracic Surgery and Oncology consults for further workup of his RV masses.
+
+Cardiac magnetic resonance imaging (MRI) also showed these two intra-cardiac masses in the RV. One was located in the RVOT and the other in the diaphragmatic wall of the RV. Dynamic perfusion MRI demonstrated central delayed hyper-enhancement suggesting necrosis. These findings were thought to be suggestive of tumor. RV systolic function was low normal. Chest computerized tomography (CT) re-demonstrated the RV masses but also showed scattered areas of nodularity in the peripheral pulmonary arteries with areas of peripheral wedge-shaped consolidation and ground glass opacity likely related to tumor emboli and associated pulmonary infarcts. Supraclavicular and gastro-hepatic adenopathy was noted that was concerning for metastatic disease. These findings were new compared to prior CT from two years ago. Testicular ultrasound was negative for recurrence of cancer in the solitary remaining testicle.
+
+Laboratory data demonstrated elevated brain natriuretic peptide at 466 pg/mL (normal 0–100 pg/mL), minimal elevations in α-fetoprotein (AFP) to 32 ng/mL (normal 0–15 ng/mL), and LDH to 300 U/L (normal 100–210 U/L). B-HCG was negative. Mild thrombocytopenia was also noted with a platelet count of 132,000 U/mL. Troponin was negative at <0.02 ng/mL (normal 0.00–0.07 ng/mL).
+
+Given concerns for RVOT obstruction, early RV failure and multiple tumor emboli to the lungs, patient was taken to the operating room by Cardiothoracic Surgery team for resection of the masses. On intra-operative gross visualization, the first mass was noted to be a pedunculated mass with a thin stalk while the second mass was a sessile mass imbedded in the wall of the ventricle. The pedunculated mass was easily resected in total. The sessile mass was debulked so as to not compromise the ventricular wall or damage the tricuspid valve.
+
+The specimens were sent to pathology. Both tumors were positive for glypican 3, pancytokeratin, antibody to CDX2, and AFP. They were negative for OCT4, TTF-1, PAX-8, vimentin, WT-1, and podoplanin. Ki-67 showed a high proliferative index. Several histological features of these masses were consistent with yolk sac carcinoma with endodermal differentiation. The first finding consistent with yolk sac carcinoma was presence of periodic acid Schiff positive hyaline bodies known as Schiller-Duval bodies. Second was the presence of mixed mesenchymal and epithelial cells, tubular and papillary structures and possibly an eosinophilic basement membrane known as Reichert’s membrane. Lastly, immunochemical staining for AFP was used to confirm the diagnosis.
+
+Post procedure the patient continued to deteriorate clinically with worsening right-sided heart failure, requiring multiple vasopressor medications. Initial plan was for PET/CT of the abdomen/pelvis for identification of primary tumor and staging followed by chemotherapy. However, the patient was never hemodynamically stable to undergo further testing and unfortunately passed away 14 days after the surgery. The family opted to forgo an autopsy so complete staging of the cancer was left incomplete.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3382_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3382_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ef323b0ed3ec01479bf04324b049438bb46550f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3382_en.txt
@@ -0,0 +1,34 @@
+A 30-year-old man was admitted to our hospital on June 6, 2020, presenting with abdominal distension that had developed over the preceding 2 weeks. Initially, the patient noted abdominal distension without any accompanying symptoms such as pain, diarrhea, nausea, vomiting, or fever and, thus, did not seek immediate medical attention. As the distension worsened, he sought evaluation at our outpatient department. An abdominal ultrasound revealed ascites, leading to his admission.
+
+On physical examination, the patient’s temperature was 38.2 °C, with clear consciousness and overall good condition. Heart and lung examinations revealed no abnormalities. Abdominal examination showed distension with slight tenderness in the right lower quadrant, positive moving dullness, and no muscle rigidity or rebound tenderness.
+
+The differential diagnosis included tuberculous peritonitis, purulent peritonitis, and cirrhosis-associated ascites. Laboratory tests at admission revealed the following.
+
+Complete blood count: White blood cell count of 11.7 × 109/L, neutrophil percentage of 83.2%, lymphocyte percentage of 11.7%, hemoglobin of 162 g/L, and platelet count of 423 × 109/L.
+
+Biochemistry: Alanine aminotransferase of 40.0 U/L, aspartate aminotransferase of 33.0 U/L, phosphocreatine kinase of 60.0 U/L, albumin of 39.8 g/L, glutamyl transpeptidase of 16.0 U/L, total bilirubin of 6.4 µmol/L, direct bilirubin of 1.7 µmol/L, C-reactive protein of 10.2 mg/L, and procalcitonin of 0.077 ng/L.
+
+Infection screenings for hepatitis B virus, hepatitis C virus, human immunodeficiency virus, and syphilis were negative. Liver stiffness testing was normal. Abdominal computed tomography (CT) showed thickening of the small intestine and ileocecal wall, disorganization of intestinal structure, thickening of the greater omentum, and an increased number of lymph nodes in the abdominal cavity, suggesting peritonitis.
+
+Diagnostic procedures and initial management
+An abdominal puncture was performed, yielding turbid ascitic fluid with a leukocyte count of 139 × 109/L, predominantly multinucleated cells (98%). Biochemical analysis of the ascitic fluid revealed: albumin of 33.0 g/L, lactate dehydrogenase of 3554.0 U/L, total protein of 48.8 g/L, glucose of 0.07 mmol/L, chloride of 105.6 mmol/L, and adenosine deaminase of 39.5 U/L. Interferon levels in ascitic fluid were normal, and cultures were negative. The initial diagnosis was suppurative peritonitis. Treatment with cefotaxime and sulbactam (4.5 g, intravenous drip, twice a day) was initiated to target common gram-negative bacilli of intestinal origin.
+
+Further evaluations, including purified protein derivative and T-spot tuberculosis tests, were negative, and normal interferon levels in ascitic fluid did not support tuberculous peritonitis. Continued investigation revealed ileocecal lesions that were suspected to cause purulent peritonitis. The gastrointestinal surgeon noted the presence of lesions in the ileocecal area and potential appendix perforation but recommended against surgery. Instead, they advised continued antibacterial therapy.
+
+Despite the addition of etimicin (0.3 g, intravenous drip, once a day) on June 15, the patient’s condition did not improve. The antibiotic regimen was adjusted to imipenem and cilastatin sodium (2.0 g, intravenous drip, once every 8 hours) on the same date. While the patient’s fever resolved, ascites persisted. Nutritional support was provided, and additional ascitic fluid analyses were performed, consistently showing no tumor cells or evidence of tuberculosis. The patient and his family chose to discharge him against medical advice on June 22.
+
+After discharge, the patient continued to experience ascites and fever but did not seek further treatment. Despite recommendations for further evaluation at a larger facility, the patient refused additional care. On August 24, 2020, he was readmitted to Nanjing First Hospital. A repeat abdominal CT showed multiple enlarged lymph nodes in the abdomen, raising suspicion of a hematological malignancy. Bone marrow aspiration confirmed the diagnosis of ALL.
+
+Differential diagnosis
+
+Tuberculous peritonitis
+The patient, a young male with fever and ascites, underwent several tests to rule out tuberculous peritonitis. Acid-fast staining of the ascitic fluid was negative, and the concentration of interferon-γ in the ascitic fluid was not elevated. In addition, the peripheral blood T-spot tuberculosis test was negative. These findings collectively excluded tuberculous peritonitis.
+
+Purulent peritonitis
+The patient presented with fever and ascites. Routine analysis of the ascitic fluid revealed a significant increase in white blood cells and a predominance of neutrophils. Although bacterial cultures were inconclusive, the patient’s fever subsided and the white blood cell count in the ascitic fluid decreased following antibacterial treatment. These clinical responses support the diagnosis of purulent peritonitis.
+
+Cirrhosis-associated ascites
+The patient, a young male, underwent liver stiffness measurement using fibro touch, which indicated normal liver hardness. In addition, abdominal CT did not show signs of cirrhosis. Therefore, cirrhosis-associated ascites was excluded.
+
+Outcome and follow-up
+The patient was admitted to the hematology department for further treatment. Unfortunately, despite intervention, the patient’s condition deteriorated, and he eventually passed away.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3388_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3388_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..474da8912cb7c49bef16fa55e6d1528137ff173d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3388_en.txt
@@ -0,0 +1,13 @@
+A 13-year-old-male with no known past medical history presented after being struck by a car. He presented with several orthopedic injuries: an open left humeral shaft fracture, left knee osteochondral fracture, and left open patella fracture. The patient was intubated and sedated on presentation to the emergency department, and therefore, a thorough neurovascular assessment could not be made. However, the patient had a palpable radial pulse. He was taken for open treatment of left patella fracture, irrigation and debridement to left open humeral wound, and surgical stabilization of left humerus fracture.
+
+As for his left open humeral shaft fracture, the wound and constituent soft tissues were copiously irrigated and debrided. Intraoperatively, a mid-substance, complete intramuscular biceps tear was noted. The radial nerve was identified to be contused where it passed beyond the fracture site posteriorly; however, it was in full continuity throughout the course of the nerve. Next, the fracture was reduced and stabilized with a 4.5 mm narrow large fragment plate.
+
+Attention then was directed at open repair of the intramuscular, mid-substance biceps rupture. Proximal and distal ends were identified. Ethibond sutures were used in a running Krackow fashion while the elbow was held in hyperflexion. All six sutures were then tied with the proximal corresponding limb repaired to the distal corresponding limb. Once all six suture tails had been fully tensioned and tightened, the elbow was taken through a gentle range of motion from approximately 80 degrees short of full extension to full flexion with no noted gapping about the biceps repair site. Wound closure ensued, followed by placement into a splint in 100 degrees of flexion. Postoperatively, the patient was extubated and was observed to be distally neurovascularly intact in radial, ulnar, and median nerve distributions.
+
+Nine days after the index surgery, the patient presented due to purulent drainage from the surgical wound. He was taken to the operating room for wound exploration and irrigation and debridement. Intraoperatively, it was noted that the biceps repair had failed. Deep tissue samples were sent for culture. The area was debrided, leaving a large soft tissue defect. A wound vac was then placed. He was placed on antibiotics postoperatively that were narrowed to ciprofloxacin once cultures speciated to Enterobacter and Citrobacter.
+
+He was taken back to the operating room three days afterwards for a repeat wound exploration, repeat irrigation and debridement, revision open biceps repair, and wound closure. He was treated with oral ciprofloxacin per the pediatric infectious disease recommendations. He was made platform weight-bearing to the left upper extremity in a splint with a lateral side strut, with the arm flexed to 100 degrees to protect the intact brachialis muscle. At twelve days postoperatively, his wound was healing appropriately.
+
+At his first postoperative visit 2.5 weeks after his first surgery (six days after the repeat debridement and revision open biceps repair), the surgical incision was healing well. At seven weeks after his first surgery (5.5 weeks since the repeat debridement and revision open biceps repair), plain film radiographs showed fracture healing and no hardware complications. At this time, his weight bearing status was advanced to weight bearing as tolerated for activities for daily living, and he began gentle active and passive range of motion exercises; occupational therapy for static dynamic extension splinting was also initiated. The patient returned at 14 weeks after his first surgery (12.5 weeks since the repeat debridement and revision open biceps repair) and was able to actively range his left elbow from full flexion to 10 degrees shy of full extension; he had full pronation and supination. At this visit, his weight bearing status was advanced to weight bearing as tolerated, except for heavy lifting.
+
+He completed five total months of oral antibiotic therapy with ciprofloxacin. He was advanced to full weight bearing with no restrictions nine months after his index surgery. At this clinical visit, he lacked two degrees of terminal extension. Subsequently, at his most recent clinic visit (one year after his index surgery), he had full flexion/extension to the left elbow, 5/5 biceps, supination, and pronation strength, and was playing sports without limitation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_34_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_34_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1fa188745d8002c8651bd83c1d9ec8850542025a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_34_en.txt
@@ -0,0 +1,6 @@
+Rectal bleeding.
+A 79-year-old male who presented with rectal bleeding and discovery of large thrombosed internal hemorrhoids during screening colonoscopy. He reported intermittent hematochezia and denied rectal pain or changes in the frequency, consistency or caliber of bowel movements. He is a self-reported never smoker who adheres to a high-fiber diet. The patient subsequently underwent an uneventful three-column hemorrhoidectomy. The internal hemorrhoids were identified, excised, and sent for routine pathologic evaluation. Pathologic analysis revealed the left lateral hemorrhoid column positive for a 1.5 cm moderate-to-poorly differentiated adenocarcinoma. The tumor showed superficial invasion into the submucosa along with a focus that was suspicious for lymphatic invasion .
+The patient has a history of atrial fibrillation, diabetes, and remote history of hemorrhoids. The patient underwent a previous laser ablation 10 years prior for bleeding internal hemorrhoids. However, there was no procedure note to denote the location of the bleeding hemorrhoid or pathology report to suggest biopsy in the electronic medical record.
+Digital rectal examination prior to hemorrhoidectomy revealed one small skin tag, but was otherwise unremarkable. He had no inguinal lymphadenopathy. Anoscopy revealed a single large inflamed and prolapsing internal hemorrhoid.
+Hemoglobin A1c (HbA1c), 6.3%; and albumin, 4.4 g/dL.
+Computed tomography (CT) chest/abdomen/pelvis-negative, endorectal ultrasound-negative.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_372_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_372_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7ae2a3d69ad9e6a462f888f3f87dac103d305779
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_372_en.txt
@@ -0,0 +1,8 @@
+A 64-year-old Chinese man with weekly BCG instillation visited our center in January 2022 for routinely examination of bladder cancer complaining of rising total PSA level (9.14 ng/mL) and decreasing free PSA/total PSA (0.09) with no symptom.
+The patient was diagnosed with high-grade NMIBC in March 2020 and scheduled for gemcitabine intravesical chemotherapy. Owing to a pathologically T1G3 bladder carcinoma on histopathology, TURBT was repeated 3 mo later. Cystoscopy showed necrosis attached to the surface of the scar, and pathology suggested inflammatory necrosis with no tumor. Two months after the second TURBT, weekly BCG instillations were recommended to replace the gemcitabine intravesical chemotherapy. Three days after the first BCG instillation, the patient experienced fever up to 39 °C, gross hematuria, lower abdomen pain, and perineal pain. The physical examination and scrotal B-ultrasound indicated left hydrocele testis and epididymitis. Routine laboratory blood results indicated that total leukocyte counts were elevated to 18.25 × 109/L with increasing neutrophil granulocyte count (10.62 × 109/L) and decreasing hemoglobin levels (114 g/L). In addition, urinary testing revealed pyuria, hematuria, and bacteriuria. The patient was diagnosed with a urinary tract infection and received piperacillin and tazobactam as anti-infective therapy for 6 d until his temperature returned to normal. His urinary testing also became normal 1 wk later. He stopped BCG instillation and restarted gemcitabine intravesical chemotherapy. Following the second TURBT, cystoscopies and urinary B-ultrasounds were performed every 3 mo. The results showed no evidence of tumor recurrence. Sixteen months after the second TURBT, BCG intravesical immunotherapy was restarted.
+The patient had no history of tuberculosis.
+The patient and his family had no history of prostate cancer.
+Digital rectal examination revealed a moderately enlarged, non-painful prostate gland with shallow central sulcus and normal density.
+Laboratory tests revealed a rising serum total PSA level (9.14 ng/mL) and a decreasing serum ratio of free PSA/total PSA (0.09).
+MP-MRI was performed. Axial T2-weighted images showed a 28 mm × 20 mm low-signal, diffuse abnormality in the right peripheral zone . On diffusion-weighted MRI with a b-value at 1500, the lesion was seen as a markedly hyperintense focus , which was consistent with a lesion with a Prostate Imaging Reporting and Data System (PI-RADS) score of 5, with hypointense signal on an apparent diffusion coefficient map image .
+Considering the increasing PSA results and abnormal focus in MP-MRI, the patient was primarily diagnosed with prostate cancer. A transperineal prostate needle biopsy was conducted. Levofloxacin was used as antibiotic prophylaxis. However, the histopathological findings showed benign prostate tissue with typical features of granulomatous prostatitis with multinucleated giant cells, epithelioid cells, fibroblasts, and infiltration lymphocytes . A nucleic acid test of tuberculosis was subsequently performed and the result was positive (Ct = 37.18).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_376_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_376_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..946c28adc3beb78e14372ea4bc03fb492321aad6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_376_en.txt
@@ -0,0 +1,2 @@
+A 61-year-old female patient was referred to our hospital to undergo surgical resection of colon cancer. She underwent bilateral mastectomy for breast cancer and implantation of a central venous port system via the left subclavian vein for chemotherapy 16 years ago in another institution. In addition, she has been suffering from pulmonary hypertension for 10 years. At the preoperative workup, a chest radiograph revealed a broken central venous catheter fragment in the heart. According to a retrospective review of the chest radiographs, disruption of the catheter occurred at least 3.5 years ago. The catheter fragment was found to be lodged mainly in the right atrium on computed tomography (CT), and both ends located in the right atrial appendage and the left hepatic vein were inaccessible .
+Percutaneous retrieval of the catheter fragment was performed as follows: under local anesthesia, the right femoral vein was punctured and a 10-Fr sheath 25 cm in length (Supersheath®, Medikit Co. Ltd., Tokyo, Japan) was placed in the inferior vena cava (IVC). A 6-F snare catheter with a 25-mm-diameter loop (Amplatz Gooseneck Snare™, Medtronic, Minneapolis, MN, USA) was advanced into the hepatic segment of the IVC and opened in advance. Then, an angled 4-F pigtail catheter (Optiflash®, Terumo Co., Tokyo, Japan) was inserted over a 0.035-in guidewire (Radifocus®, Terumo Co., Tokyo, Japan) into the sheath side-by-side with the snare catheter. The pigtail catheter was advanced into the right atrium passing through the snare loop under multi-directional fluoroscopic guidance . The catheter fragment was then hooked and pulled inferiorly by the pigtail catheter . As a result, the inferior end of the catheter fragment disengaged from the left hepatic vein and fell into the IVC through the snare loop . Instantly, the snare loop tightened the catheter fragment at the initial position . Repositioning of the snare catheter was not necessary throughout the procedure. When the catheter fragment was being removed from the body, the pigtail catheter was first pulled into the sheath to ensure sufficient clearance to pull the folded catheter fragment into the sheath. The administration of local anesthesia to the withdrawal of the sheath took 26 min. Fluoroscopy time was 4.6 min. The dose area product was 8640 mGycm2 and air kerma was 68.12 mGy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_382_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_382_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec17a02ee67ae5de51630aa7fedabbefc13dfde0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_382_en.txt
@@ -0,0 +1,7 @@
+A 63-year-old woman with advanced pancreatic cancer was referred for a psycho-oncology consultation due to her response, which seemed like sudden onset of loss of consciousness.
+On visiting her, we found her bedridden, staring at the ceiling without blinking, and responding minimally but correctly to our questions, including orientation-related ones such as date and location. Her family said that she suddenly became absentminded and stated to her husband, “It is over and I will probably die soon.”
+Her clinical findings were as follows: blood pressure, 109/70 mmHg; heart rate, 78 beats/min; oxygen saturation, 98%; body temperature, 36.7 °C. Laboratory findings revealed that alkaline phosphatase and amylase values were slightly increased, but these could not explain her psychiatric symptoms. By electroencephalography, the basic rhythm was 8–10 Hz and slow waves were not evident, findings that did not suggest reduced consciousness. Neurological examination demonstrated that she maintained the position when the psycho-oncologist raised her hand (catalepsy).
+She had no medical history of psychiatric illness or alcohol or drug abuse, and she was very kind to others. Her husband said that she was very shocked at her diagnosis of pancreatic cancer, and became anxious about treatment and admission to hospital. She had been afraid of cancer because her grandfather had died of cancer after a long period of suffering.
+She had been diagnosed with advanced pancreatic cancer accompanied by multiple liver metastasis 4 months before the event, and gemcitabine was administered. Three weeks before the event she had been admitted to our emergency department with thrombosis of both pulmonary arteries and stenosis of the third portion of the duodenum due to disease progression. She frequently vomited. Insomnia and anxiety reappeared, and after much agonizing, she decided to undergo a gastrointestinal bypass. The surgery proceeded 3 days before the event, without complication and post-operative delirium was not evident.
+Based on physical, neurological, and psychiatric assessment, we suspected brief psychotic disorder with catalepsy and substupor, and she was administered 2.5 mg of intravenous haloperidol.
+On the following day, she could sit on the bed and respond to our questions more clearly. Two days later, she was able to make expressions and smiled at us. The symptoms disappeared 4 days later and did not reappear. One week later, she told us about this experience and said that it was very scary. We diagnosed a brief psychotic disorder based on these findings, and its features fulfilled the Diagnostic and Statistical Manual of Mental Disorders 5th edition .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_405_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_405_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..768b99274e38141710e7d9cb59543dd3395eaccc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_405_en.txt
@@ -0,0 +1,6 @@
+A 43-year-old man with mild type 2 diabetes mellitus visited the hospital where he received his medications for diabetes mellitus, owing to persistent dizziness, anorexia and general fatigue for 1 month before the consultation. He showed significant weight loss of 15 kg during that 1 month. Approximately 2 weeks before the emergence of his clinical symptoms, he walked around a cave where he encountered a lot of bird droppings and feathers. Since abdominal CT revealed bilateral adrenal masses, he was introduced to a larger hospital for advanced examination. On admission, physical examination revealed a height of 167 cm and a weight of 62 kg. The remainder of the examination findings were normal without signs of meningitis. Laboratory data included white blood cell count of 7,390/μL with 61.7% neutrophils, 23.9% lymphocytes, 2.4% eosinophils, 0.5% basophils and 9.4% monocytes, hemoglobin of 12.6 g/dL and platelet count of 313,000/μL. Although the serum sodium level (133 mEq/L) was slightly decreased, the serum levels of potassium, chloride, creatinine and fasting glucose were normal. The HbA1c was 6.2%. The level of γ-gamma glutamyl transpeptidase was elevated to 116 U/L without increased levels of aspartate aminotransferase, alanine aminotransferase and alkaline phosphatase. The serum C-reactive protein level was elevated (5.04 mg/dL). On endocrinological examination, low basal serum cortisol (2.3 μg/dL; normal: 4.0-18.3) with high serum adrenocorticotropic hormone (ACTH) (843 pg/mL; normal: 7.2-63.3) was observed, indicating primary adrenal insufficiency. In addition to the low blood levels of aldosterone (28.5 pg/mL; normal: 38.9-307) and dehydroepiandrosterone sulfate (55 μg/dL; normal: 70-495) synthesized and released by the adrenal cortex, the 24-hour urine adrenaline (1.6 μg/day: normal: 3.4-26.9) and epinephrine (< 0.01 mg/day; normal: 0.04-0.19) levels were markedly reduced, indicating that the adrenal medulla was also devastated. Rapid ACTH (Cortrosyn) stimulation revealed the absence of a serum cortisol response (baselines of 1.1 μg/dL to 1.1 μg/dL and 1.1 μg/dL at 30 and 60 minutes after the ACTH challenge, respectively). Primary adrenal insufficiency was diagnosed and a regimen of oral hydrocortisone (20 mg/day) was prescribed.
+Contrast-enhanced abdominal CT showed bilateral adrenal masses (right: 5.2 × 2.7 cm; left: 3.7 × 3.6 cm) . The differential diagnosis of the adrenal masses included metastatic carcinoma, tuberculosis, fungal infections, bilateral adrenal hyperplasia and sarcoidosis. An intensive whole-body examination failed to detect a primary lesion for malignancy. The QuantiFERON-TB test and serum human immunodeficiency virus (HIV) antibody enzyme immunoassay were negative. Re-examination of the abdominal CT at 1 month after admission revealed a liver abscess that was thought to be an invasion from the right adrenal mass . Whole-body 18 F-FDG PET showed intense uptake by the bilateral adrenal glands and liver.
+To make a diagnosis, a fine-needle aspiration biopsy of the liver mass was performed. The pathological diagnosis of the liver abscess showed multiple foci of necrotic and degenerative cells with infiltration of neutrophils. No malignant cells or epithelioid granulomas were observed in this specimen. Alcian blue staining demonstrated the presence of 5-μm spherical yeast-like organisms, such as Cryptococcus spp., interspersed within the foci. Since the serum cryptococcal antigen titer was 1:256, cryptococcosis of the bilateral adrenal glands and liver was diagnosed. A lumbar puncture revealed clear cerebrospinal fluid with a white blood cell count of 1/μL, normal levels of protein and glucose and negative cryptococcal antigen titer.
+After 4 months of fluconazole treatment at a daily dose of 400 mg, the size of the liver abscess was reduced, but no significant changes were observed in the bilateral adrenal masses and the serum cryptococcal antigen titer was still elevated at 1:128. Additional treatment with liposomal amphotericin B at 150 mg daily for 6 weeks (a cumulative dose of 6.3 g) was not effective.
+Since it was conceivable that the bilateral adrenal glands were the apparent foci of the persistent fungemia, the patient was referred to our hospital and a laparoscopic left adrenalectomy was performed to control the cryptococcosis. Resection of the right adrenal mass was not executed as the first operation to avoid injury to the adjacent liver. The size of the resected mass was 5 × 4 cm . Histological analysis revealed that the adrenal tissue was widely replaced by massively necrotizing granulomas and fibrous tissue. Many fungi structures, similar to Cryptococcus spp. cells were detected by PAS and Grocott staining .
+Fluconazole therapy was continued after the adrenalectomy. At 3 months after the adrenalectomy, a significant size reduction of the right adrenal mass was observed by abdominal CT . The serum cryptococcal antigen titer also decreased to 1:16 at 2 months after the adrenalectomy, and 1:4 at 5 months after the operation. There were no signs of relapse in imaging analyses and the serum cryptococcal antigen titer remained at 1:4 for the subsequent 9 months .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_407_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_407_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..72ad178de18d0786c27821fc271c3283dc6395f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_407_en.txt
@@ -0,0 +1,6 @@
+We report on a fifty-year-old man who had been suffering from increasing neck pain, burning, and stinging since he was 18 years old. Rotation of the cervical spine to the left or right increased the pain up to a peak level of 6 on the Visual Analog Scale (VAS). Sitting (at the computer) was worst.
+The patient had been given chiropractic therapy, physiotherapy, and non-steroidal antirheumatics (diclofenac) without success. There was no other illness known, and he did not take any other medication. In this situation, the patient was referred to our pain center by his family doctor.
+All movements of the cervical spine were limited between 10 and 30°, and at the maximum of the movements, the pain increased. The muscles were in higher tension (especially the levator scapulae and the splenius capitis muscle on both sides). We also found myofascial trigger points in these muscles on both sides. Clinical neurological findings were symmetrical and in order.
+The X-ray showed a light generalized spondylosis and spondylarthrosis as well as a light chondrosis C5/C6 (that could not explain his pain). Laboratory findings showed no signs of a general inflammation or of any disease.
+In the first session, we treated the myofascial trigger points and the increased tonus of the muscles mentioned with a well-directed injection of LA procaine 1% (according to neural therapy). These local interventions were not successful. As a routine in such cases, we ordered an orthopantomogram of the teeth, although the patient had no tooth pain. We found 3 M with a space problem at positions 2.8 and 3.8 (ascending mandibular ramus), and an impacted tooth with perifocal inflammation at 4.8 . As a diagnostic test (with the question of an influence on the neck pain, see Discussion), we infiltrated the periodontal tissue of these three teeth with LA procaine 1%. Minutes after these interventions, the patient was nearly free of pain in the neck for the first time since many years. After 1 week, the pain in the neck appeared again, reaching the same level.
+With this “positive” test, we made the indication for extraction of the teeth 2.8, 3.8, and 4.8. Afterward, the patient was nearly pain free in the neck. Half a year later, his neck pain appeared again to a slight degree (VAS 2–3). Subsequently, we infiltrated the scars of the teeth extractions with procaine 1% in the regions 2.8, 3.8, and 4.8. After this last intervention, the patient was pain free, and he showed almost normal mobility of the cervical spine without increased muscle tone. The freedom from neck pain has lasted for over 3 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_422_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_422_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e7304eb83bae7293629f53aba5decb2178d0b98
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_422_en.txt
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+A 60-year-old denture-wearing Malaysian woman was referred to the Oral Medicine Clinic, Universiti Malaya, in February 2020, with the complaint of a painless swelling on her lower right cheek for a month. She also had moderate xerostomia, with a Clinical Oral Dryness Score of five [, ]. Upon examination, the patient was partially edentulous with no obvious facial swelling or palpable lymph nodes. Slight erythema was noted at the bilateral angle of her mouth, suggestive of angular cheilitis. A non-tender, non-indurated lump measuring 0.5 × 0.5 cm resembling an irritation fibroma, most likely caused by an ill-fitting denture, was observed on her lower right buccal sulcus over the premolar region.
+An oral swab was collected from the bilateral angle of her mouth for Gram staining and cultured for Candida yeasts on Brilliance Candida agar™ (BCA) (Oxoid, UK). An expectorated oral rinse sample collected from gargling 20 ml of saline was also obtained and centrifuged at 9600 revolutions per minute at 4 ºC for 10 min. The pellet (100 μl) was cultured for isolation of Candida yeasts. Gram-stained smear of the oral swab showed presence of scanty Gram-positive and Gram-negative bacteria and epithelial cells. Blastoconidia or hyphal filaments were not observed. Primary cultures from the oral swab and oral rinse samples grew dark blue colonies along the initial streak lines on BCA upon incubation at 37 °C after 48 h of incubation. The colonies were subcultured onto fresh BCA and Sabouraud’s dextrose agar (SDA) plates for incubation at room temperature and 37 °C. Smooth, mucoidal, and light orange or beige colonies were observed on SDA at both temperatures. Similar colonies were observed on BCA at room temperature; however, dark blue colonies were observed on BCA at 37 °C. The yeast growth was generally faster at room temperature compared to 37 ºC on both agar media. Gram stain examination of a pure culture showed round-to-oval yeast morphology. The yeast isolated was assigned as C. calyptogenae strain D1.
+The yeast was identified to the species level through polymerase chain reaction (PCR) amplification and sequence determination of the internal transcribed spacer (ITS) gene and D1/D2 domain of the large subunit (LSU) ribosomal DNA (rDNA) of the yeast. The freeze–thaw method as described by Silva et al. was used to extract yeast DNA. Two sets of primers, ITS1 (5ʹ-TCC GTA GGT GAA CCT GCG G-3ʹ) and ITS4 (5ʹ-TCC TCC GCT TAT TGA TAT GC-3ʹ) , and primer pair NL1 (5ʹ- GCA TAT CAA TAA GCG GAG GAA AAG-3ʹ) and NL4 (5ʹ-GGT CCG TGT TTC AAG ACG G-3ʹ) were used for species identification. The PCR reaction mixture (25 μl) contained 2 μl (16 ng) of DNA extract, 1 μM of each primer, 12.5 μl of exTen 2 × PCR Master Mix (1st Base, Singapore). The PCR amplification conditions included 5 min denaturation at 95 ºC for 1 cycle, followed by 35 cycles of 95 ºC for 1 min, 52 ºC for 1 min, 72 ºC for 1 min and one final extension step of 72 ºC for 10 min. The nucleotide sequences of the amplified products were determined by a commercial sequencing provider (Apical Scientific, Malaysia), using forward and reverse PCR primers. The sequences were assembled on the Biological Sequence Alignment Editing (Bioedit) software (RRID: SCR_007361) and searched for the highest sequence similarity using the GenBank Basic Local Alignment Search Tool (BLASTn) (RRID: SCR_004870) against the National Centre for Biotechnology Information (NCBI) nucleotide database (RRID: SCR_004860). A phylogenetic tree was constructed on the Molecular Evolutionary Genetics Analysis (MEGA) software (RRID: SCR_000667) using ITS gene sequences of C. calyptogenae strains retrieved from the GenBank database. Erythrobasidium hasegawianum strain CBS 8253 (AF444522) was used as an outgroup.
+The yeast D1/D2 domain sequence (GenBank accession no. OK147747) was 100% (558/558 nucleotides) similar to the C. calyptogenae CBS 9125 type strain, which was first isolated from a giant white clam (AB025996) . Other strains demonstrating 100% sequence similarity include C. calyptogenae strain 4107 (EU669877) , which was isolated from seawater in Taiwan, and strain CBS 11058 from a culture collection . Meanwhile, the yeast ITS sequence (GenBank accession no. OK147742) exhibited 100% (463/463 nucleotides) similarity to C. calyptogenae strain 4107 (EU669877) , and CBS 11134 (KY103129) but 99.5% (2 nucleotide difference) to C. calyptogenae CBS 9125 type strain. Figure shows the phylogenetic tree constructed based on ITS sequences of various Cystobasidium reference strains. Strain D1 was clustered with C. calyptogenae CBS 9125 type strain, and other known C. calyptogenae strains in the same branch with high bootstrap value (100%). Based on phylogenetic analysis, the identity of strain D1 was thus confirmed as C. calyptogenae.
+The patient was given topical treatment with 2% miconazole and fusidic acid, once daily, for the management of angular cheilitis. Mouthwash (Oral-7) was provided to improve oral dryness. The patient was also scheduled for the construction of a new lower denture to increase the vertical dimension of the mouth to prevent recurrence of angular cheilitis. The clinical condition of the patient improved during a follow-up visit 2 weeks later, with mild erythema observed on the affected area. Repeat oral swab and oral rinse cultures were negative for C. calyptogenae. However, a mixed growth of yeasts (Trichosporon asahii, Candida dubliniensis, and Candida parapsilosis) was noted in the oral rinse sample. Similar treatment was thus continued for another 2 weeks and the patient was placed on an open appointment that required her to come to the clinic only if the symptoms persisted.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_424_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_424_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3e2763cfaf58175e21cf606e0f350d84357b924
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_424_en.txt
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+An asymptomatic 23-month-old boy, weighed 10.5 kg, was incidentally diagnosed with congenital heart disease while presenting to the hospital for another illness. Transthoracic echocardiography (TTE) revealed one 18-mm ASD located in the inferior portion of the atrial septum that resulted in an overriding inferior vena cava (IVC), and the right inferior pulmonary vein (RIPV) partially returned to the right atrium (RA) near the orifice of the IVC. TTE also showed a complete left-to-right atrial shunt, no tricuspid regurgitation, and right ventricular dilation (with a diameter of 15 mm). Cardiac catheterization confirmed a normal anatomy of coronary arteries and a pulmonary to systemic flow ratio (Qp/Qs) of 3.2:1.
+The patient was placed in a supine position with the right side of the body elevated to 30°. Two arms were placed along the body and the patient was under general anesthesia with a single-lumen endotracheal tube. One 14F-arterial cannula (Medtronic, Inc., Minneapolis, Minn, USA) used as a superior vena cava (SVC) cannula was inserted through the right internal jugular vein with Seldinger technique. Four trocars were set up on the right chest wall, included the following: one 12 mm trocar in the 5th intercostal space (ICS) at the anterior axillary line as the main working port, one 5 mm trocar in the 4th ICS at the mid-axillary line as the secondary working port, one 5 mm trocar in the 5th ICS at the mid-axillary line as the camera port and one 5 mm trocar in the 6th ICS at the mid-axillary line for right heart sucker.
+The ventilation volume was reduced to 50%–75% compared with conventional practice. The anesthetist continuously monitored the oxygen saturation with a finger pulse oximeter and maintained it ≥95% throughout the operation. With this ventilation technique, the lungs were collapsed enough for the surgeon to open and hang up the pericardium. The large right lobe of the thymus covered the majority of the pericardium surrounding the aorta and the SVC. Therefore, we dissected this lobe from the pericardium (while preserving the tissue and supplying vessels) and hung it on to the anterior chest wall with a suture. The pericardium was opened parallel to and at 1.5 cm away from the anterior chest wall. The inferior edge of the pericardium was hung up to the diaphragm (the caudal end) and through the trocar (the cephalic end) by some sutures to expose the surgical field (Video 1). At this stage, respiratory ventilation was continued as usual.
+To expose the ascending aorta, the top of the right atrial appendage was sutured and pulled down through a trocar. A 2–0, 17 mm braided suture (ETHIBOND EXCEL® Polyester Suture, ETHICON, JOHNSON & JOHNSON, Shanghai, China) was used to make a purse-string suture on the anterior wall of the ascending aorta, right beneath the semicircular fat plica (A) (Video 2). A 12F-arterial cannula (Medtronic, Inc., Minneapolis, Minn, USA) was placed superiorly through right anterior chest wall in the 4th ICS, 1 cm away from the right border of the sternum. This process was performed from the outside combined with endoscopic visualization from inside to avoid injury to the internal thoracic artery and ensure that the cannula was best directed to the purse-string suture . We placed a piece of a 10 F rubber catheter (Red Rubber Latex All-Purpose Intermittent Catheters, Medline, USA) about 1.3 to 1.5 cm away from the tip of the arterial cannula to work as a brake. Subsequently, a surgical scalpel blade No.11 (Aesculap, Inc.) was used to open the ascending aorta inside the purse-string suture. The arterial cannula was then introduced via this ostium into the ascending aorta until the brake on the cannula reached the aortic wall (B, C) (Video 3). The arterial cannula was fixed and the cardiopulmonary bypass (CPB) was started.
+A CO2-pump line connecting to the camera port was used to fill the pericardial and pleural spaces with CO2. Initially, CO2 was pumped with a rate of 0.5 l/min, and then the pump rate was adjusted to maintain the partial pressure of CO2 in arterial blood ranging from 35 to 40 mmHg. Arterial line pressure was maintained >50 mmHg during the operation.
+A loop was placed around the SVC to act as a tourniquet but not snaring. The patient was placed in the Trendelenburg position. The tourniquet on the SVC was tightened after opening the RA (Video 4). The blood returning to the RA from the IVC was drained by a stiff sucker, which also acted as an atrial retractor to expose the lesion. The edges of RA were hung to the pericardium by stitches to expose structures inside the RA. After determining the location, size of the ASD, as well as the anatomical correlation between the IVC and the RIPV, an artificial patch was used to close the ASD and form a canal to drain blood from the RIPV to the LA through the ASD (A, B) (Video 5). Right before completing the ASD closure, the lung was inflated to remove air from the left atrium. The RA was closed in a two-layer fashion using continuous stitches. The extracorporeal circulation was stopped and the surgery was finished uneventfully. The operative and cardiopulmonary bypass times were 259 and 133 min, respectively. The patient stayed in the intensive care unit for 18 h and was discharged on postoperative-day 7 without neurological complication or blood transfusion. TTE prior to discharge revealed a completely closed ASD, patent IVC, and RIPV ostia. Both the patient and his family were extremely satisfied with the cosmetic results of surgical scars (C).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_430_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_430_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6bf6ad656d96f3b79f4c613a8576ac359af6eb06
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_430_en.txt
@@ -0,0 +1,4 @@
+A previously healthy 12-year-old boy was admitted to the hospital with vision loss, headache and dizziness over 1 month, which was aggravated in the last 5 days. Magnetic resonance imaging (MRI) of the head revealed a large (19.8 mm*18.5 mm*23.5 mm) irregular mass located in the suprasellar region abutting the left aspect of the optic chiasm. It appeared isointense on T1-weighted imaging (T1WI) and homogenously hyperintense on T2-weighted imaging (T2WI). After gadolinium administration, a well-circumscribed enhancing lesion was observed . A small cerebellar lesion was also confirmed.
+The mother of the patient underwent surgery for HGB in the CNS (spine, cerebellum) and had pheochromocytomas and pancreatic cysts. On the basis of the mother’s medical history, clinical manifestations and imaging examinations, she was diagnosed with VHL disease, although she refused genetic sequencing. Therefore, the patient was examined for VHL disease before surgery. Sequencing of exon 1 of the VHL gene revealed a c.257C>T mutation (amino acid p.P86L). Ophthalmological examination revealed that the boundary of the optic disc in the left eye was pale and that there were no abnormalities in the right eye. Abdominal computed tomography (CT) was also performed to identify associated lesions and pancreatic cysts . Based on these findings, the patient was definitely diagnosed with VHL syndrome.
+He underwent surgery to remove the tumor from the suprasellar region at our neurosurgical department, and histology confirmed the diagnosis of HGB ( and ). The cerebellar lesion was not in the same surgical field as the suprasellar tumor and had no obvious mass effect, so they were not treated at the same time. Immunohistochemical analysis indicated that the Ki-67 index was approximately 2%. Furthermore, the neoplasm was positive for EGFR, NSE, CD34 and vimentin and negative for CK-pan, Pax-8, CD10, CD56, S-100, glial fibrillary acidic protein, inhibin, SSTR2, and epithelial membrane antigen .
+The patient was transferred to the neurosurgery intensive care unit for postoperative monitoring and was ambulatory on postoperative day 1. Postoperative MRI demonstrated that the lesion in the suprasellar region was completely removed. He was discharged on postoperative day 7, and regular follow-up was performed. Unfortunately, the patient lost vision completely in the left eye after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_438_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_438_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c05f9ec1d5ac82c40f6a18167f81e2cd6d2148dc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_438_en.txt
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+A 71 years old male came to our attention because of dyspnea during the last three months.
+A chest computed tomography scan showed a 35 × 25 mm central pulmonary nodule of the lower left lobe with no evidence of thoracic lymphoadenopaties.
+A positron emission tomography (PET) scan demonstrated the concentration of fluorodeoxyglucose (FDG) in that nodule, with a peripheral rim of hyperfixation (standard uptake value max 6.9).
+The patient underwent a left lower lobectomy with omolateral mediastinal lymphoadenectomy; gross examination of the specimen showed a 3.8 cm greyish nodule, with stellate margins and no involvement of the visceral pleura.
+Light microscopy showed a moderately-differentiated (G2) acinar adenocarcinoma, with marked stromal fibrosis. Necrosis was not found .
+A massive lymphocytic reaction, with a diffuse pattern of growth and several aspects of infiltration of neoplastic glands was present in the tumoral stroma. No germinal centers were highlighted. Immunohistochemistry revealed a strong positivity of the tumoral cells for TTF-1 (DAKO, clone 86763/1) and Napsin-A (DAKO, policlonal) antibodies, confirming the glandular histogenesis and the pulmonary primitivity .
+The lymphoid component was found to be policlonal and made up mainly by CD3+ (DAKO, clone 2GV6, Rabbit) T-cells. Cytotoxic (CD8+, DAKO, clone C8/144B) T-lymphocytes were more represented than helper (CD4+, DAKO, clone 5835) cells . EBV infection was excluded by an EBV Encoded Small RNAs (EBER) probe negative in situ hybridization.
+According to these histological findings, we made a diagnosis of pulmonary adenocarcinoma with massive lymphocytic infiltration.
+All the mediastinal lymphnodes showed antracosis and sinus hystiocitosis without evidence of metastasis.
+Molecular testing of the EGFR gene (regions investigated: exon 18 codon 719, exon 19 codon 746–750, exon 21 codons 858 and 861) performed by pyrosequencing, using the "Pyromark Q96 ID System" with the diagnostic kit IVD / CE EGFR TKI response (Diatech Pharmacogenetics srl) showed no mutations.
+Molecular testing of the KRAS gene (regions investigated: codon 12, 13, 61 and 146) performed by pyrosequencing using the "Pyromark Q96 ID System" with the diagnostic kit IVD / CE Anti-EGFR mAb response (KRAS status) [Diatech Pharmacogenetics Srl] showed a wild type phenotype.
+Lastly, immunostaining for ALK (Novocastra, clone 5A4) resulted negative.
+After a follow up period of six months, the patient is in good health with no evidence of residual or recurrent disease.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_452_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_452_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..81e2ff1fe93220c826b1c49cb5ebe5928ae89179
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_452_en.txt
@@ -0,0 +1 @@
+Our patient, a 37-year-old postpartum female, presented to the Tianjin Tumor Hospital in China. Her B-ultrasonography results showed a left breast mass with the largest measuring up to 8 * 7cm in size and with left axillary multiple lymph node metastasis (BI-RADS 5). The pathology of the left breast by core needle biopsy revealed invasive micropapillary adenocarcinoma with the following results: estrogen receptor (ER) (<1%), progesterone receptor (PR) (<1%), HER-2 (3+), and Ki-67 (25%); moreover, the fine needle axillary lymph node biopsy samples confirmed metastatic and poorly differentiated adenocarcinoma with the following findings: ER (<1%), PR (<1%), HER-2 (3+) and Ki-67 (25%). The patient had undergone chemotherapy with an AC regimen (liposomal doxorubicin 40 mg on day 1 + cyclophosphamide 800 mg on day 1, q3w) for two cycles. However, no obvious reduction in breast mass was observed, and she felt pain in the left breast. Then, she presented to Shanghai Renji Hospital. Physical examination showed 9.0cm mass in left breast with diffuse edema and erythema in skin and several fixed and matted enlarged lymph nodes in the left axilla. The chest CT showed internal nodular foci in the left breast and multiple enlarged lymph nodes in the left armpit. Mammography found a diffusely increased density of the left mammary gland with local distortion and fine sand-like calcification (BI-RADS.6) . Breast MRI was carried out and showed a widely abnormal signal (with the largest measuring up to 8.7cm) and skin thickening in the left breast (BI-RADS.6), left nipple depression, fat pad edema in the subcutaneous and anterior areas of the pectoralis major muscle, and enlargement of the left axillary lymph node (, ). Therefore, the clinical stage was designated IIIB (cT4N1M0). Moreover, vacuum-assisted breast biopsy and fine needle aspiration of left axillary lymph node were performed for the patient. The pathology indicated infiltrating carcinoma with ER (-), PR (-), HER2 (2+) and Ki67 (10%). The HER2 fluorescence in situ hybridization test was positive, and the HER2/CEP17 ratio was 4.5. Then the patient started to receive neoadjuvant chemotherapy (pyrotinib 400 mg once daily + weekly trastuzumab (first 4 mg/kg, then 2 mg/kg) + paclitaxel (120 mg (80 mg/m2) on days 1, 8, 15, and 22, q28d) + cisplatin (40 mg (25 mg/m2) on days 1, 8, and 15, q28d)) (PTPC). She experienced grade 3 diarrhea and grade 2 neutropenia, and the dosage of pyrotinib was reduced to 320 mg and then 240 mg once daily for diarrhea. After 2 cycles, breast MRI showed a significant reduction in the lesion size in the left breast (with the largest measuring up to 0.7cm) and a visibly reduced size of the lymph node in the left armpit, which was evaluated as clinical partial response (cPR) by efficacy assessment according to Response Evaluation Criteria in Solid Tumors version 1.1 (RECIST1.1). After 4 cycles, the breast MRI results showed close to a clinical complete response (cCR) . The most frequent tolerated adverse events were grade 2 neutropenia and grade 2 diarrhea, which were observed in the patient but were not mitigated with further dose reduction. Modified radical mastectomy of the left breast was performed. The specimen suggested hyperplasia of the breast interstitial fibrous tissue with a few infiltrating inflammatory cells and no tumor tissue residue. The tissues from the nipple, dissected surface, lymph nodes, fibrous adipose tissue, and the left axillary lymph node were negative for disease. The postoperative pathology revealed pathological complete remission (pCR). The patient held on receiving 2 cycles of the targeted therapy plus chemotherapy with TPC, but adjuvant radiation therapy and HER2-targeted therapy with trastuzumab were administered in the neoadjuvant setting, and pertuzumab was administered over the 1-year follow-up duration. There has been no clinical evidence of disease progression so far. The disease-free survival is currently 8 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_454_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_454_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4eda0d7fad85a5a173bb10072a3d43d80a998683
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_454_en.txt
@@ -0,0 +1 @@
+A 29-year-old man was hospitalized with progressive memory impairment for 10 days. He was reported to struggle remembering different locations, especially home-base. His medical history included an epileptic seizure 3 months prior to admission, without early diagnosis and treatment. The parents denied that he had promiscuous sexual behavior with any other persons. On examination, an ulcer was noted on the anterior perineum. The patient was disoriented in space, and he did not even know the result of 93 minus 7. His Mini-Mental State Examination (MMSE) score was 22 out of 30. The remainder of his neurologic examination was normal. An electroencephalogram showed diffuse generalized slow spike-wave discharges. The blood work-up indicated a positive tolulized red unheated serum test (TRUST) with a titer of 1:32 and a positive fluorescent treponemal antibody-absorbed (FTA-ABS) test. Serum biochemistry, HIV and hepatitis serology, thyroid stimulating hormone, and glycated hemoglobin levels were unremarkable. Brain MRI showed high signal intensities on FLAIR images involving of bilateral medial and anterior temporal structures, insula, right pulvinar of the thalami, precuneus, frontal and temporo-occipital lobes, with focal meningeal enhancement , while MR-TOF angiography did not reveal any evidence of intracranial arterial stenosis. Lumbar puncture with CSF analysis was performed with an opening pressure of 15.5 cmH2O, which revealed pleocytosis (58 cells/µL), low glucose (2.18 mmol/L), and raised protein (1.39 g/L), his CSF TRUST also showed positive titres of 1:2. Furthermore, CSF sample was collected for mNGS to rule out co-infection. Interestingly, after 48 h, the results revealed 2288 sequence reads uniquely corresponding to the Treponema pallidum genome with 11.6483% coverage , confirming the diagnosis of neurosyphilis. Meanwhile, no other causative pathogen was identified. Following treatment with intravenous penicillin, 24 million units/day for two weeks, his memory and computation abilities improved greatly, and the MMSE score increased to 27 points. Repeat MRI of the brain performed on 16th day of admission showed shrinkage of FLAIR signal abnormalities within the right precuneus, frontal, temporo-occipital, and bilateral mesial temporal regions, without leptomeningeal enhancement . On the recent follow-up occasion, he was nearly a normal person and refused repeat testing, including lumbar puncture.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_470_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_470_en.txt
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index 0000000000000000000000000000000000000000..706fee0586f6364ba9182e53b90b7e6cc5f6b3ce
--- /dev/null
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@@ -0,0 +1,2 @@
+A Caucasian 15-year old male complained of severe acne and low back pain with inability to walk. His previous medical history was unremarkable except for the onset of acne vulgaris during his puberty. Three months before admission, he had showed a dramatic worsening of acne characterized by several cystic skin lesions with extensive ulcerating and inflammatory components, assuming a form of acne fulminans. Therefore, a course of systemic isotretinoin therapy was administered at the dose of 0.5 mg/kg/daily without any benefit. In addition, the boy developed depressive symptoms associated with insomnia and irritability. Thus, sertraline therapy was started.
+Ten weeks after starting isotretinoin, the patient experienced increasing low-back pain with progressive inability to walk and restriction of daily activities. At admission to the emergency department, he was suffering and unable to walk. Physical examination revealed a decreased axial range of movement, sacroiliac pain and severe nodulocystic acne with abscesses on face, neck and thorax. Laboratory investigations revealed systemic inflammation (CPR 7.15 mg/dl [normal range < 0.5 mg/dl], ESR 84 mm/h [normal range < 30 mm/h], WBC 14,950/mmc, 70% neutrophils). All rheumatologic parameters including complement and autoantibodies were within normal range. The patient tested negative for HLA-B27 typing. Culture of the pustular lesions was positive for Staphylococcus aureus. Antibiotic therapy with clindamycin was introduced and isotretinoin was interrupted. Pelvis and hip X-ray was unremarkable. Magnetic resonance imaging (MRI) showed moderate bone marrow oedema and osteitis of transverse process of fifth lumbar vertebra and symmetrical sacroiliitis . The association of acne fulminans and osteitis suggested the diagnosis of SAPHO syndrome. Whole body MRI confirmed this hypothesis revealing anterior chest wall, in particular coronal views showed sternoclavicular and costoclavicular osteitis, and axial involvement, including sacroiliac joint and spine. Consequently, intravenous antibiotics were interrupted and, NSAIDs and oral rifampicin were started, in order to control the inflammatory status and the cutaneous lesions, respectively. Despite the specific treatment, the depressive disorder was persisting along with the other complaints. Nevertheless, during the following weeks osteoarticular involvement and cutaneous manifestations worsened and gluteal bilateral HS appeared. Therefore, ADA was subcutaneously administered at the dosage of 40 mg/dose every 2 weeks. After 4 weeks of treatment a progressive improvement both of cutaneous lesions and osteoarticular symptoms was reported and ADA administration interval (at the same dose of 40 mg) was extended to 4 weeks. After six months of favourable ADA treatment, the boy experimented a relapse of osteoarticular symptoms. Therefore, ADA was administered again every 2 weeks obtaining a long-lasting remission. An MRI performed 12 months later, has shown no evidence of abnormal vertebral bone marrow signal , sterno-clavear or sacroiliac effusions . After 24-months treatment with ADA, the disease maintains complete remission. In Fig. we show cutaneous lesions on the face, on the back and on the sternal region before and after ADA treatment. On the contrary, the depressive mood disorder persists and negatively affects the quality of patient’s life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_48_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_48_en.txt
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index 0000000000000000000000000000000000000000..24bc1c4d7338505f6cf7d7e2975dce52ac94445b
--- /dev/null
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+A 63-year-old Caucasian female patient with no past medical history was diagnosed in 2014 with cutaneous melanoma on her right heel, Breslow thickness 8.5 mm, Clark level V, mitotic figures 10/mm2. Following primary diagnosis, she underwent wide local excision with sentinel lymph node dissection that was negative for residual disease. She subsequently received adjuvant high dose interferon (5 days/week for 4 weeks), according to approved guidelines at the time. Three years later, whole body computerized tomography (CT) scanning revealed a lesion of 45 mm in the lower lobe of the left lung. Patient underwent lobectomy and histology confirmed metastatic melanoma, BRAF wild type on molecular analysis. At that point, no adjuvant treatment was provided. A year later, CT restaging revealed several pulmonary nodules scattered on both lungs, enlarged lymph nodes in the left hilum and gastroesophageal area. Given melanoma relapse, the patient received pembrolizumab intravenously (iv), 200 mg flat dose every 3 weeks, without any immune-related complications except of a mild elevation of transaminases. Three months post pembrolizumab initiation, lesions and lymphadenopathy were increased in size and therefore anti-PD1 was discontinued. The patient was scheduled to receive 4 cycles of iv ipilimumab, 3 mg/kg every 3 weeks, as second-line treatment. Approximately 2 weeks after the second administration of ipilimumab, she complained of nausea, persistent diarrhea and shivering fever and was admitted to our clinic for further evaluation and management. On physical examination, fever reached 38 °C and her abdomen was distended with hyperactive bowel sounds. The white blood cell count was 6.48 × 109/L with 71.3% neutrophils; C-reactive protein (135 mg/L, normal value < 5 mg/L) and lactate dehydrogenase (379U/L, normal range: 135–215 U/L) were increased while serum albumin was low (27.5 g/L, normal range: 35–50); transaminases and cholestatic enzymes were elevated (AST: 56 U/L, ALT: 45 U/L, GGT: 307 U/L, ALP: 170 U/L) with normal bilirubin (0.74 mg/dl, normal range: 0.3–1.2 mg/dl). Thyroid-stimulating hormone was increased (17.83 mU/L, normal range: 0.27–4.5 mU/L)] giving the suspicion for immune-mediated thyroiditis with the rest of serum endocrine parameters being normal [adrenocorticotropic hormone = 35 pg/ml (normal range: 10–65 pg/ml) and cortisol = 221.9 mmol/L (normal range: 173.6–505 mmol/L)]. Approaching her as an immunocompromised case, wide-range antibiotics were empirically delivered without resolution of her symptoms. Stool cultures for bacteria, ova and parasites, Clostridium difficile toxins (A and B), as well as polymerase chain reaction (PCR) for cytomegalovirus (CMV) were all negative. Abdominal CT scan was negative for visceral metastasis showing thickening of the large bowel wall, a finding supportive of colonic inflammation. The patient underwent sigmoidoscopy that revealed mucosal edema, hyperemia and erosions of the rectum and sigmoid colon. Representative biopsies were obtained for histological evaluation.
+Histological examination revealed multiple small, non-necrotizing epithelioid granulomas within the crypts with partial or complete destruction of the crypt epithelium and derangement but not total disruption of the basement membrane, depicted in Periodic Acid-Schiff (PAS) histochemical stain. Some intracryptal granulomas were accompanied by rupture of the crypt wall and pericryptal expansion . Active inflammation was also present characterized by moderate lamina propria lymphoplasmacytic infiltrations, focal cryptitis and rare crypt abscesses. Basal plasmacytosis, intraepithelial lymphocytes or crypt architectural distortions were not apparent while neutrophils and eosinophils were scarce. Few apoptotic bodies were occasionally seen at the crypt base. Histochemical PAS and Ziehl–Neelsen stains were negative for fungi and acid-fast bacteria respectively.
+Immunohistochemistry was performed on 4 μm-thick sections using Dako Envision Flex system (Dako, Glostrup, Denmark). The following antibodies were applied: CD20 (Dako, clone L26, mouse monoclonal, 1:700 dilution, Glostrup, Denmark), CD3 (Dako, rabbit polyclonal, 1:50 dilution), CD4 (Dako, clone 4B12, mouse monoclonal, 1:50), CD8 (Dako, clone C8/144B, mouse monoclonal, 1:200 dilution) and SMA (Dako, clone 1A4, mouse monoclonal, 1:800 dilution). Based on the above immunostains, the vast majority of lymphocytes were T cells (CD3 +) predominately CD4+. SMA highlighted the attenuation of the pericryptal myofibroblasts .
+In view of the patient’s clinical history, the lesion was reported as granulomatous colitis probably induced by ipilimumab.
+Anti-CTLA4 was discontinued and iv prednisone at a dose of 75 mg/d was initiated with immediate clinical improvement of the diarrheic syndrome. The patient was subsequently treated with chemotherapy with no reported serious adverse events till September 2019, when radiology showed new disease progression. A re-challenge with another anti-PD1 agent, namely nivolumab, was decided, and currently the patient is under immunotherapy with stable disease regarding melanoma status and without any sign of colitis recurrence.
+Running through the literature on PubMed and using the following terms (CTLA4, PD1/PD-L1, ipilimumab, pembrolizumab, nivolumab, immune-related adverse events, granulomatous reactions, granulomatous colitis and colon granulomas), we ended up to 5 studies that described in total 14 cases with immunotherapy related colon granulomas. A flow diagram of the performed systematic review is illustrated in Fig. . In these cases, melanoma was commonly the underlying cancer treated with ICPIs, while the median time to colitis onset exceeded 30 days with one exception of ir-colitis presentation 27 days after the initiation of a combination immunotherapy.
+Of the 14 reported cases of colitis with granuloma formation, 1 was associated with PD1 inhibitor , 2 with nivolumab/ipilimumab combination , 3 with an anti-PD1 regimen without being clearly mentioned if the patients were receiving also ipilimumab , and 5 with anti-CTLA4 treatment [, ]. For the remaining 3 cases it is not clear whether patients received ipilimumab alone or in combination with melanoma peptide vaccines to enhance host’s immunization , therefore granuloma formation could be related to ipilimumab, to vaccination or both. Table summarizes the data of the studies reporting colon granulomas in patients under ICPIs.
+Apart from colon, granulomatous/sarcoid-like reactions (G/SLR) have also been described in different organs of cancer patients treated with ICPIs. Table presents a synopsis of published series with 3 or more patients under immunotherapy reporting at least one case of ICPIs-associated G/SLR in organs other than GI tract [–]. Lungs, lymph nodes and skin were the main tissues with granuloma formation, while melanoma was the main underlying malignancy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_500_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_500_en.txt
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index 0000000000000000000000000000000000000000..65410b13a56788a1bca71a812eba672f72794312
--- /dev/null
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+A 67-year-old woman was admitted to our department for the treatment of right empyema. She had been complaining of fever and fatigue about 7 weeks ago and had been treated with antibiotics by her primary care physician. However, as her symptoms did not improve, computed tomography (CT) was performed. A chest drainage tube was inserted because the chest CT showed pleural effusion with pleural thickening in the right thoracic cavity. She was diagnosed with empyema because bacteria were detected in cloudy fluid from the thoracic drainage tube. Blood and biochemical findings at admission showed an elevated inflammatory response (white blood cell 11520/μL and C-reactive protein 11.19 mg/dL). Chest X-ray showed remaining pleural effusion and insufficient expansion of the lung, although a drainage tube had been inserted in the right thoracic cavity . Chest CT showed fluid collection in three independent spaces within the right thoracic cavity. The first empyema cavity was from the ventral side of the superior vena cava in the anterior mediastinum to the inferior pulmonary vein along the pericardium (cavity I: Fig. a–c). The second empyema cavity was present from outside of the right upper lobe to the interlobar space between upper and lower lobes, in which a chest drainage tube has been inserted (cavity II: Fig. a–c). The third empyema cavity was located from the outside of the right lower lobe to the diaphragm (cavity III: Fig. a–c). It was assumed that a firm adhesion between the lung and chest wall was developed because a long time had passed since the onset. Therefore, we decided to use CBCT to completely debride three empyema cavities separately by VATS.
+Under general anesthesia, the patient is placed in the lateral decubitus position. A careful check is made if the C-arm of the CBCT can be adequately rotated around the operation table. We can obtain scanning images of 18.5 cm in longer axis (craniocaudal direction) by a single rotation of the C-arm, and the single rotation needs 6 s (6 s acquisition protocol (6s DynaCT Body)). The field of view of the scanned image (24 × 24 cm, DynaCT mode) provided by CBCT is smaller than that of the multidetector computed tomography (MDCT). Thus, two rotations of the C-arm are needed to obtain images of the hemithorax. Scanning was performed under inflation of the lungs with 20 cm H2O airway pressure. The amount of irradiation dose in one rotation was 60 to 70 mGy. We took the images before and after the surgical procedure in order to determine the site of skin incision and to confirm the presence or absence of an overlooked empyema cavity. Cavity I was only in a narrow range with the chest wall, and it was located on the back of cost rib cartilage. By clicking any intended anatomical structures on CBCT images, the position was readily depicted by lase projection on the body surface, which helped to place the best skin incision . In cavity II, CBCT after initial debridement showed insufficiently dissected cavity . Additional debridement resulted in successful shrinkage of the empyema cavity . For cavity III, the usual debridement by VATS was possible without using CBCT. This patient had three isolated empyema cavities requiring chest drainage tube insertion into the individual cavities followed by VATS debridement using cupped forceps. The operation time was 315 min and the amount of bleeding was 225 g. A total of only three small incisions was made in this patient for adequate debridement of the three cavities . The patient recovered uneventfully without additional interventional therapy. Chest X-ray before discharge showed a slight shadow due to atelectasis, but well expansion of the other part of the lung .
+CBCT in the hybrid operating room is currently used in various fields, such as cardiology, neurosurgery, and vascular surgery. With regard to respiratory surgery, although some reports describe the usefulness in identifying the intrapulmonary small lesions , it remains controversial if CBCT is useful in surgical treatment of empyema. Decortication via open thoracotomy requires wide adehesiolysis in order to peel the fibrous capsule of each cavity via single thoracotomy incision, which can often result in lung injury, thereby development of bronchopleural fistulae. Therefore, for some patients who have multiple isolated empyema cavities by developing firm intrathoracic adhesion, it is better performing debridement and drainage, individually. For these cases, VATS is advantageous because it does not necessarily require adhesiolysis and wide skin incision. However, concern remains whether the debridement without intrathoracic adhesiolysis is adequate or not because of the possibility of residual or overlooked contaminated cavities. Although transthoracic echo may also be useful to identify the location of the empyema cavity, this modality is not helpful to know whether the debridement is adequately accomplished or not. If the debridement was incomplete as a result of worrying about an accidental injury of the surrounding organ, additional interventions may be required due to the persistent empyema cavity or insufficient expansion of the ipsilateral lung [, ]. In the present case, accurate and effective VATS debridement and drainage with small skin incision was accomplished by using CBCT.
+With respect to the radiation exposure, Chao et al. reported based on their experience with preoperative or intraoperative localization of small intrapulmonary nodules. They reported that the amount of radiation exposure by intraoperative localization with CBCT was comparable to that by preoperative localization with MDCT . Because the amount of exposure by CBCT may depend on the times of C-arm rotation, we must attempt to restrict the times and extent of radiation exposure by CBCT.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_554_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_554_en.txt
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index 0000000000000000000000000000000000000000..841e638f2f0586324c12f714d940422db19e3aec
--- /dev/null
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@@ -0,0 +1,4 @@
+We present the case of a 19-year-old Hispanic female previously healthy, whose relevant medical history only included smoking 4 cigarettes a day for one year. The patient was admitted to our hospital for left periorbital pain, ipsilateral ocular motor nerve palsies and diplopia. Four days prior to admission, the patient started with first episode in her life of severe left periorbital pain; 48 hours later, she also presented limited left eye movements, ipsilateral palpebral ptosis and horizontal diplopia. Pain did not cede after the administration of NSAID, which was the reason why the patient decided to resort to the ER for examination.
+At the hospital, she was submitted to a thorough physical examination by a multidisciplinary team integrated by three ophthalmologists, a neurologist and three specialists in internal medicine. The results of the physical and neuro-ophthalmologic examination were weight 89 kg, height: 1.57 mt, BMI 36 kg/m2, 20/20 vision, normal eye fondues bilaterally, left palpebral ptosis, exotropia of the primary look of the left eye, paresis of the third, fourth and sixth left cranial nerves, and hypoesthesia over the first and second division of the left trigeminal nerve. The right eye and the rest of the physical examination did not show further abnormalities .
+Since the beginning, we considered Tolosa-Hunt syndrome as a possibility, but started the clinical approach as a painful ophthalmoplegia. Her initial laboratory tests showed white blood cell count, 8.500/ml; red blood cell count, 4.86×106/μl; haemoglobin, 15.1 g/dl; platelets, 293×103; glucose, 98 mg/dl, blood urea nitrogen, 8 mg/dl; creatinine, 0.6 mg/dl; ELISA for HIV, negative; D-Dimer, 271 ng/ml (<500 ng/ml). Thyroid function tests showed TSH, 1.00 μUI/ml (0.34-5.60); Total T3, 0.96 ng/ml (0.87-1.78); free T 3, 2.64 pg/ml (2.50 y 3.90); free T4, 0.76 ng7 dl (0,54-1.64); Total T4, 10.72 μg/dl (6.09-12.23). The cerebral spinal fluid reported 2 mononuclear cell/uL; glucose, 51 mg/dl; proteins, 15 mg/dl; ADA and PCR in CFS for tuberculosis and cultures were negative. ANA´s, were positive in a homogenous pattern 1:40; anti-dsDNA, 15.1 U/ml (0-9.6); c-ANCA, positive 1:40 and x-ANCA, 1:20. CT scan of brain and paranasal sinus, MRI and MRA of the brain were normal.
+Since the studies showed no abnormalities and we excluded neoplasic, infectious, vascular, thyroid and metabolic causes of painful ophthalmoplegia, we decided to start treatment for Tolosa-Hunt Syndrome with metilprednisolne 1 gr IV daily for 3 days, and noticed significant response of the left periorbital pain, palpebral ptosis and the ipsilateral ocular motor nerve palsies in the next 72 hours. At day 4, we changed treatment to prednisone at 1 mg/kg daily. One week later, we initiated steroid tapering every week, and at week 6 the patient was asymptomatic and her neuro-ophthalmologic examination was completely normal. Today the patient is still on prednisone 10 mg/day .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_580_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_580_en.txt
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index 0000000000000000000000000000000000000000..b954c92276fef49597c9a98bef32bf0eb0661556
--- /dev/null
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@@ -0,0 +1,6 @@
+This study included a 44-year-old obese male (BMI 32.0) who showed no symptoms. Twenty years ago, he was diagnosed with a hepatic mass but the mass was not treated. In July 2020, during an abdominal ultrasound examination at a medical checkup, a 50 mm × 57 mm hyperechoic lesion was observed in segment 8 (S8) of the liver. He came to our hospital with suspected hepatocellular carcinoma.
+The patient developed systemic lupus erythematosus and lupus nephritis aged 24 years, and type 2 diabetes and hypertension aged 32 years.
+Physical examination was normal.
+His blood tests showed mild inflammatory reaction and renal dysfunction but no liver dysfunction. The patient did not have hepatitis virus or tumor marker elevation. Urinalysis showed mildly elevated urine protein but no other abnormalities.
+Ultrasonography (US) revealed a hyperechoic mass with a 79 mm oval halo in S8 of the liver . An abdominal plain computed tomography (CT) scan indicated a heterogeneous low-density mass with internal fat . The patient suffered from renal dysfunction and could not undergo contrast-enhanced CT. We performed abdominal magnetic resonance imaging (MRI) of the T1-weighted image using the Dixon method. The T1-weighted opposed phase image showed an apparent signal drop in the peripheral area of the lesion. The center of the lesion showed a predominant fat component, and the surrounding area showed a mixed fat component. The T2-weighted image showed hyperintensity, the diffusion-weighted image (DWI) showed a hyperintensity area in the peripheral region of the lesion, and the apparent diffusion coefficient (ADC) map showed hypointensity corresponding to the hyperintensity area on DWI, which indicated restricted diffusion. The central fat-predominant area showed hypointensity on the DWI and mixed hypo- and hyper-intensity on the ADC map .
+The lesion contained erythroblastosis cells on glycophorin C staining, granulocytic cells on myeloperoxidase staining, and megakaryocytes on CD61 immunostaining. Hematoxylin and eosin staining showed fat droplet deposition in the background liver tissue, which suggested chronic liver inflammation .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_618_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_618_en.txt
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index 0000000000000000000000000000000000000000..543e604c3c5c5b568e59333f56edcdba7a1ff39e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_618_en.txt
@@ -0,0 +1,3 @@
+A 57-year-old gentleman with a history of active smoking, insulin dependent diabetes mellito (IDDM), hypertension, dyslipidaemia, and chronic coronary artery disease (CAD), presented complaining of severe ED. He underwent percutaneous coronary intervention (PCI) in 2010 with implantation of three DES on left anterior descending artery, OM1, and right coronary artery. He was asymptomatic for chest pain, and echocardiography demonstrated normal cardiac function. He had normal external genitalia and secondary sexual characteristics. Sexual hormones analyses were in the reference range (total testosterone 7.34 ng/dL; free testosterone 17 pg/mL; sex hormone binding globulin 54 nmol/L; DHEA-S 394 g/dL). Ultrasound evaluation revealed normal prostate. Patient was taking 1 tablet of Bisoprolol 1.25 mg in the morning. He showed no response to increasing doses of different oral PDE5i drugs as well as no response to intra-cavernosal injections to prostaglandin E1 (IC-PDE1) over a 1-year period. Libido was normal. Dynamic Doppler Ultrasound with IC injection of PDE1 (Caverject® 10 mcg and after 10 min additional 10 mcg) showed a peak systolic velocity (PSV) of 12 cm/s on the left cavernosal artery and a PSV of 6 cm/s on the right cavernosal artery suggestive of a bilateral severe vasculogenic ED (normal response after Caverject > 25 cm/s). International Index of Erectile Dysfunction-5 questionnaire (IIEF) score was 3 points (normal 26–30; severe ED 6–10; moderate ED 11–16; mild ED 17–25). Selective angiography showed significant and diffuse atherosclerotic disease of the right mid and distal internal pudendal artery (IPA) associated with absence opacification of distal vascularization of the cavernous bodies and critical stenosis of the left internal iliac artery (IIA) ( and ). By utilization of a 6 Fr. left internal mammary guiding catheter (Cordis, Milan, Italy), the left IIA was engaged, and a 0.014' BMW wire (Abbott, Milan, Italy) was utilized to cross the stenosis. After non-compliant 5 mm × 40 mm balloon pre-dilatation at 10 atm (Sequent Neo NC, B.Braun), a self-expandable 6 mm × 18 mm bare-metal stent (Vascuflex® – B.Braun,) was precisely placed at the ostium of the vessel with no residual stenosis . Then, the IPA was engaged, and stenosis crossed by a Sion Blu 0.014' wire (Asahi Intecc Co. Japan) followed by semi-compliant balloon 2.0 mm × 20 mm (Sequent Neo, B. Braun) inflation at 10 atm in the proximal, mid, and distal segments and subsequently by sirolimus-eluting balloon 2.5 mm × 30 mm inflation (Magic Touch ED, Concept Medical) at proximal and middle segments followed by 2.0 mm × 20 mm sirolimus balloon inflation at the distal segment for 2 min at 8 atm, respectively. After waiting for 10 min to rule out elastic recoil, a 2 × 18 drug-eluting stent (DES; Supraflex Cruz, SMT) was implanted in the mid-segment of the IPA due to >30% residual stenosis with an optimal final acute result at control angiography . Femoral access was closed by a 6 Fr Angioseal VIP closure device (Terumo Europe).
+One hundred and twenty millilitre volume of peripheral blood was utilized to concentrate 12 mL of autologous mononuclear cells by point-of-care device (Hematrate® Blood Filtration System, Cook Regentec), designed to obtain an autologous concentration of mononuclear cells (MNCs) utilizing whole-blood selective filtration . Mononuclear cells were immediately injected into the cavernous bodies under echo-guidance . This procedure was repeated at 35 and 70 days after the index procedure, following the same protocol used for critical limb ischaemia non-option patients.
+The patient's hospital course was without complications. He was discharged with aspirin 100 mg lifelong, clopidogrel 75 mg for 1 year (choice related to the presence of multiple risk factors, previous coronary revascularization and multiple stents placement in the pudendal arteries usually considered a low flow district), rosuvastatin 20 mg, and fenofibrate 200 mg, Tadalafil 5 mg/daily, and vitamin E supplementation. After 3-months from the procedure, the patient reported an excellent response to PDE5i. At 6-month, the patient underwent Dynamic Doppler ultrasound with 10 mcg of IC-PDE1, which showed peak systolic velocity of 27 cm/s on the left and 32 cm/s on the right cavernosal arteries. IEF-5 score was 16 (delta IEF 13), suggestive of an excellent mid-term result. No complication was observed at the site of MNCs injection at the time of out-patient visit. At 1-year follow-up, the patient reported stable improvement in sexual function with an IEF-5 score of 18. He underwent control angiography demonstrating complete stent patency of the left IIA and excellent result on the right IPA with a marked increase in vascularization of the distal IPA and common penile artery ( and —arrows).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_62_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_62_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0daa4c7404430ae55ea76feb44841c6c8acfe5f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_62_en.txt
@@ -0,0 +1,7 @@
+A 60-year-old male patient with metastatic colon cancer of the liver was referred to interventional radiology for right PVE prior to major hepatic resection.
+He was diagnosed with sigmoid colon cancer and underwent anterior resection surgery 6 mo back. He developed liver metastasis for which right liver lobe resection was planned by a hepatobiliary surgeon. Due to a small left liver lobe, preoperative right PVE is requested to enhance the volume of the residual left liver lobe.
+He is a known case of diabetes mellitus Type 2 Stage 3 on insulin and metformin for 9 years.
+His personal and family history is unremarkable.
+General examinations did not reveal any abnormality. Abdominal examinations revealed surgical scars from previous laparoscopic surgery and a stoma. No others abnormality could be detected.
+The laboratory results of routine hematological testing, blood sedimentation rate, and tumor-associated markers were within normal limits. Alpha-fetoprotein is 14 ng/mL. Carcinoembryonic antigen is 2.4 ng/mL. Carbohydrate antigen 19-9 is 19 U/mL.
+He underwent contrast-enhanced CT, which showed multiple right hepatic metastasis, small left hepatic lobe, and a normal patent portal venous system with a standard anatomy .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_683_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_683_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..018b2ebe448c75debb2a9de0711859265e419baf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_683_en.txt
@@ -0,0 +1,6 @@
+A 34-year-old female was admitted for traumatic brain injury. She slipped on the bathroom floor and fell, resulting in loss of consciousness. She regained consciousness after a few minutes but did not seek consult. She was initially well but started to complain of intermittent right-sided headache 3 days postinjury, prompting consult at a general clinic. Cranial CT scan showed a large acute epidural hematoma on the right temporal area, measuring 41 cc in volume and resulting in a midline shift of 0.4 cm. The lateral and third ventricles were enlarged but did not exhibit transependymal effusion, and the cerebral sulci were effaced. There was also a linear and nondisplaced right temporal bone fracture [-]. She was advised to seek neurosurgical consult at the emergency room but did not comply until the 5th day postinjury.
+Her medical history was significant for a diagnosis of congenital hydrocephalus from aqueductal stenosis, but she did not undergo surgery. She was also an epileptic maintained on phenobarbital, with the last seizure episode occurring about 15 years ago. She had a recent history of mild COVID-19 infection 5 months prior. Despite having hydrocephalus, she did not exhibit developmental delays as a child and underwent schooling at the proper age. She finished high school at the top of her class, earned a bachelor’s degree at age 20, and is currently pursuing a master’s degree while employed full time.
+On examination, the patient had a Glasgow Coma Scale (GCS) of 15 with equal and briskly reactive pupils. She was slightly macrocephalic, and her head circumference of 59 cm was in the upper 97th percentile when plotted against her height. Her visual acuity was 20/25 bilaterally, and fundoscopic examination did not show papilledema. She did not have any craniopathies or sensory or motor deficits. A repeat cranial CT scan performed on the 5th day postinjury showed stable size of the hematoma. She still had mild headache, but it was markedly decreased in severity compared to 2 days prior.
+Because the patient was asymptomatic except for mild headache and was already on the 5th postinjury day, it was decided to treat the patient conservatively with analgesics and close clinical monitoring at the neurosurgical ward. The patient’s headache resolved and she did not develop any deficits; thus, she was sent home on the 8th day postinjury.
+A repeat cranial CT scan was performed 3-week postinjury, which showed a decrease in the size and attenuation of the epidural hematoma. A transcranial Doppler study revealed that the pulsatility indices of all the intracranial arteries were within normal limits and did not show signs of increased intracranial pressure.
+The patient’s latest follow-up was at 10-month postinjury. She continued to be well and asymptomatic and did not have any new complaints.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_700_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_700_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c5c492abf4808c590fbfc3eb02c8bcc97d140dea
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_700_en.txt
@@ -0,0 +1,11 @@
+The patient experienced rapid decreases in hemoglobin and platelet levels for 3 months.
+Past treatment for blood diseases: Twelve years earlier, a 51-year-old Chinese man was diagnosed with acquired aplastic anemia (AA) in several blood disease centers due to gradually aggravated fatigue. He was prescribed cyclosporine and stanozolol, achieving significant hematological improvement.
+Three years ago, the patient developed evident hemoglobinuria and was diagnosed with PNH based on increased marrow cellularity and a significant decrease in cluster of differentiation (CD)55 and CD59 expression on erythrocytes and granulocytes. Cyclosporine and stanozolol were tapered off, and antiplatelet drugs became his main treatment. During the three years of PNH history, his complete blood count (CBC) results fluctuated within the following range: White blood cell (WBC) count, 5.50–7.50 × 109/L; red blood cell (RBC) count, 2.90-3.30 × 1012/L; hemoglobin (Hb) level, 80-100 g/L; and platelet (Plt) count, 170-230 × 109/L.
+Three months earlier, the patient’s hemoglobinuria worsened, and he initiated oral administration of methylprednisolone at a dose of 8 mg/d and sodium bicarbonate at a dose of 1.0 g three times per day at another hospital to alleviate complement-mediated hemolysis.
+Rapid decreases in hemoglobin and platelet levels following GC treatment: Before methylprednisolone treatment, the patient’s CBC showed the following results: WBC count, 6.73 × 109/L; RBC count, 3.15 × 1012/L; Hb level, 85 g/L; Plt count, 195 × 109/L; and absolute reticulocyte (Ret) count, 290.2 × 109/L. Following GC treatment, the patient’s fatigue worsened, and headache, palpitation and dyspnea symptoms emerged and worsened. Seven days after initiating methylprednisolone treatment, his CBC showed the following results: WBC count, 5.28 × 109/L; RBC count, 2.73 × 1012/L; Hb level, 70 g/L; Plt count, 106 ×109/L; and Ret count, 283.3 × 109/L. From that time, intermittent transfusion of packed RBCs was initiated, and the dose of methylprednisolone was increased to 20 mg/d. Along with the increase in methylprednisolone dose, his Hb level and Plt count further decreased, and the frequency of blood transfusion increased. Four days before presenting at our center, the patient’s fatigue was severe with intolerable palpitations and dyspnea.
+The patient had no history of diseases in hematological, immunological or other systems before the diagnosis of AA.
+The patient had no family history of inherited, hematological, autoimmune or malignant diseases.
+The physical examination results of the patient were as follows: height of 171 cm; body weight of 70 kg; body temperature of 36.1 °C; breathing rate of 19 breaths per minute; heart rate of 90 beats per minute; and blood pressure of 130/90 mmHg. Physical examination revealed the presence of a pale face and conjunctiva in the absence of conspicuous mucocutaneous hemorrhage, jaundice and exanthemata. No significant signs of nervous system, respiratory system, cardiovascular system, gastrointestinal system, urogenital system or skeletal musculature system abnormalities were found.
+Routine laboratory examinations: On admission, the patient’s CBC showed the following results: WBC count, 4.75 × 109/L; RBC count, 1.72 × 1012/L; Hb level, 65 g/L; Plt count, 98 × 109/L; and Ret count, 274.90 × 109/L. The coagulation profile was within the normal limits with a D-dimer level of 0.77 mg/L. Urine examination revealed occult blood of 3+ and protein of 1+. Biochemical analysis revealed elevated serum levels of conjugated bilirubin (10.4 μmol/L), unconjugated bilirubin (24.4 μmol/L), lactate dehydrogenase (LDH, 3349 U/L) and hydroxybutyric dehydrogenase (HBDH, 2695 U/L) in the absence of abnormalities in hepatic and renal functions. The results for hepatitis A, B, and C viruses as well as human immunodeficiency virus were negative. Various antinuclear antibodies and biomarkers of neoplasms were also negative.
+Specific laboratory examinations for blood diseases: Morphological examination of the marrow smears revealed increased cellularity with a significantly increased percentage of erythroid precursors in the absence of evident dysplastic features . Bone marrow biopsy confirmed the increased cellularity and increased erythropoiesis. Coomb’s test was negative. Significantly decreased CD55 and CD59 expression on erythrocytes (11.24% and 7.80%) and granulocytes (40.26% and 37.35%) was identified by flow cytometric analysis. Decreased serum levels of complement C3 but not C4 were detected. Serum levels of ferritin were slightly decreased, and serum levels of folic acid and vitamin B12 were within the normal limits. Anti-erythrocyte and anti-platelet antibodies were undetectable. Myeloid neoplasm-associated gene mutations were also undetectable.
+No evident abnormalities were found in the patient’s chest and abdominal computed tomography scans.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_727_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_727_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..92da550aba29a954264224c1fa81c5fcc9613202
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_727_en.txt
@@ -0,0 +1,2 @@
+On March 11, 2016, a 64-year-old mestizo man with a history of benign prostatic hyperplasia and use of an indwelling catheter presented to our emergency department with urinary retention. Cystoscopy revealed intravesical clots and obstructive bilobar prostate. Following the procedure, the patient exhibited signs of systemic inflammatory response syndrome and pathologic urinalysis. Therefore, antibiotic therapy with ampicillin/sulbactam was initiated without improvement in the clinical features. The urine culture report showed the presence of carbapenem-sensitive Pseudomonas aeruginosa and Enterobacter cloacae. Therefore, the therapy was subsequently escalated to meropenem (1 g every 8 h). The patient presented with clinical deterioration and ventilatory failure and was referred to the ICU for orotracheal intubation. He also developed cardiopulmonary arrest, which required basic and advanced resuscitation techniques for 11 min with subsequent sinus rhythm. On physical examination, the patient was under sedation, tachycardic, and hypothermic with evidence of purulent urethral discharge, and he required vasopressor support and sedoanalgesia. He had multiple organ dysfunctions due to urinary and pulmonary sepsis with the identification of carbapenem-resistant Klebsiella pneumoniae in the blood and lower respiratory tract secretions. The antibiotic therapy was adjusted to colistimethate (90,000 IU/kg) divided into three daily doses, doripenem (1 g every 8 h), and fosfomycin (4 g every 6 h). The patient initially progressed toward improvement, but 72 h later, he presented with new signs of inflammatory response. Therefore, a new blood culture was performed, revealing a carbapenem-resistant A. baumannii isolate (minimum inhibitory concentrations [MICs] ≥ 16, ≥ 16, and ≥ 8 μg/ml for imipenem, meropenem, and doripenem, respectively) that was also resistant to gentamicin (MIC ≥ 16 μg/ml), ciprofloxacin (MIC ≥ 4 μg/ml), and colistin (MIC 16 μg/ml) and sensitive only to tigecycline (MIC 1 μg/ml). Following this test, tigecycline administration was initiated (100 mg every 12 h), and colistimethate was suspended, with fosfomycin and doripenem continued until the completion of 14 days of treatment. Nevertheless, due to the persistent systemic inflammatory response on day 10, rifampicin (600 mg/day) and ertapenem (1 g every 12 h) were initiated for pharmacological synergism until day 14. With the prescribed antibiotic therapy, the patient improved in terms of infection, with an absence of fever and decreased leukocyte count. New blood and urine cultures were done, with negative results.
+Molecular typing confirmed the genus and species of the isolate as A. baumannii (excluding other species of the Acinetobacter genus), as well as the presence of the blaOXA-23 gene (associated with carbapenem resistance). The isolate belonged to the sequence type (ST) 944, which has also been described in isolates identified in Russia, Italy, and the United States. Studies have identified intrahospital outbreaks of colistin-resistant bacteria with predominant genotype according to multilocus sequence typing was ST-258, ST11, ST273, and ST15 for K. pneumoniae; ISAba1 in P. aeruginosa, and pmrA1 and pmrB genotype ST94 for A. baumannii . There are few reports on the resistance mechanisms associated with resistance to colistin in A. baumannii, the most important one being that related to loss in the production of lipid A of lipopolysaccharide. This loss has been associated with mutations in the pmrAB and lpxACD operons, lpxK, or the ISAba11 insertion [, ]. The sequencing of these two operons in the A. baumannii isolate identified two nonsynonymous mutations (H31P and I215M) in the lpxC gene from the ATCC 19606 strain and another nonsynonymous mutation (A178G) in the pmrC gene from the ATCC 17978 strain [–]. None of these mutations has previously been reported in colistin-resistant strains. Although they have been found in the A. baumannii isolate, their possible association with resistance should be confirmed experimentally.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_72_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_72_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..271f7be7c5bd0c5ef3efb2a278a3cfacdcb5e174
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_72_en.txt
@@ -0,0 +1,7 @@
+A 75-year-old man presented to our hospital with dyspnea.
+He was diagnosed with interstitial pneumonia 11 years ago. He had been treated with prednisolone (5 mg/d) and home oxygen therapy (3 L/min) for 1 year. However, between November of the same year to January of the following year, his lung function deteriorated, leading to hospitalization for 10 times over the next 13 mo for acute type 1 respiratory failure. The maximum length of stay at home between hospitalization was 30 d. Before his final admission to our hospital (his eleventh admission), the patient was at home for 6 d. At that time, hospitalization until the very end of life was proposed to the patient.
+The patient had type 2 diabetes.
+At home he lived with his wife, and while he could consume food independently, he required assistance in changing clothes. Furthermore, excretion was done on the floor, and bathing was not possible due to restricted movements caused by exertion dyspnea. His modified Medical Research Council grade was 4. He smoked 80 cigarettes a day between the ages of 20 and 50.
+The patient’s was thin during the final admission. He was fully conscious, with a body temperature of 38.4 ºC and a respiratory rate of 57 breaths/min. His SpO2 was 60% at 15 L oxygen/min with a mask with reservoir and 94% with non-invasive positive pressure ventilation [inspiratory positive airway pressure, 8 cmH2O; expiratory positive airway pressure, 4 cmH2O, and fraction of inspired oxygen (FiO2) 100%]. Fine crackles were heard bilaterally on the chest.
+Blood tests showed increases in his white blood cell count [32100 cells/µL, (neutrophils: 48.2%)] and C-reactive protein level (9.12 mg/L); no abnormalities were detected in the patient’s urinalysis.
+Chest X-rays showed reticular shadows on both sides of the lungs, and the computed tomography scan displayed a mixture of frosted glass shadows, reticular shadows, and tractive bronchodilation on both lungs .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_741_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_741_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ca6e6453116680faa6b41ee8c978645fa6561804
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_741_en.txt
@@ -0,0 +1,2 @@
+A 23-year-old woman, referred to our clinic with symptoms of sore throat, halitosis and gradually increasing shortness of breath during a period of 2 months. She had a vague history of choking 2 months ago. She didn’t have any history of fever, hemoptysis, dysphagia, or cough. She also complained of mild alteration of her voice quality recently. During this period she was visited by several practitioners but her lateral neck radiograph interpreted as normal.
+On physical examination she did not have any respiratory distress. Indirect laryngoscopy showed a whitish exudate just below the true vocal cords. Retrograde careful evaluation of lateral neck radiography showed a foreign body in the subglottic area which was very similar to a calcified thyroid cartilage . Poster anterior chest radiography also showed the foreign body . The patient was admitted to our ward and underwent a direct laryngoscopy under general anesthesia with jet ventilation. Just below glottic area, there was a big chicken bone which was embedded in the surrounding tissue with white exudates around it. After removal of it with a forceps, there was exuberant granulation tissue in the posterior wall of subglottic area. In order to decrease granulation tissue, Mitomycin soaked cotton (1 mg/mL concentration) was remained in place for about 6 minutes and intraoperatively, an 8 mg dose of intravenous dexamethasone was used. The patient revisited 1 week and 1 month, postoperatively and the patient was not noticed any other problems.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_799_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_799_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cadb84b3420249eb42bc717a33246a597287298e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_799_en.txt
@@ -0,0 +1,3 @@
+A 58-year-old woman with metastatic HR+, HER2- breast cancer presented to the ED with a 3-day history of nausea and vomiting, dyspnea, rash, and blood glucose of 319 mg/dL. Her medical history included type 2 diabetes for which she took empagliflozin, metformin/sitagliptin, and gliclazide. A few weeks prior, molecular profiling revealed the presence of a PIK3CA gene mutation, and she started fulvestrant and alpelisib. Her metastatic breast cancer had already progressed on endocrine and chemotherapy treatment. At that time, self-recorded fasting blood glucose readings were 180–216 mg/dL, and HbA1c was 7.7% (61 mmol/mol). The patient was instructed to monitor blood glucose levels frequently. If glucose levels persistently increased, we would refer her to endocrinology for further management. A follow-up assessment occurred one week after alpelisib initiation, in which the patient reported weight loss of 2–3 kg, decreased appetite, and blood glucose readings ranging from 190 to 306 mg/dL. Before she could return for another follow-up, she began to vomit and presented to the ED three days later.
+On presentation to the ED, the patient demonstrated dyspnea, nausea and vomiting, and a generalized maculopapular rash on her torso. Labs reported anion gap: 36 mEq/L, pH: 6.99, total CO2: 6 mEq/L, glucose: 402 mg/dL, ketonemia and ketonuria. The patient was admitted to the hospital and started on an insulin sliding scale. Empagliflozin was thought to be a possible cause of the DKA by the ED team and was discontinued. Because alpelisib was recently started and implicated for the rash, it was also held during admission. The patient’s condition worsened overnight, and she was transferred to the ICU. She received bicarbonate infusion and intravenous insulin as per the institutional DKA protocol. Upon resolution of the DKA, she was discharged six days after presentation to the ER. At that time, her gliclazide dose was increased to compensate for the discontinuation of empagliflozin.
+Two weeks later, the patient returned to the oncology clinic to restart alpelisib. At the time of restarting alpelisib, her blood glucose levels had returned to baseline (180–216 mg/dL). To circumvent the rash development, she was instructed to take desloratadine 10 mg once daily starting two days before the first dose of alpelisib. Four hours after her first alpelisib dose, she returned to the ED. She described feeling unwell one hour after taking alpelisib and experienced emesis, dysphagia, and a pruritic rash on her abdomen, back, and thighs. Her self-monitored blood glucose readings indicated a rapid rise from 198 mg/dL to 306 mg/dL shortly after alpelisib administration. The patient was also febrile. Labs in the ED revealed anion gap: 20 mEq/L, CO2: 21 mEq/L, glucose: 397 mg/dL with ketonemia and ketonuria. She was diagnosed with diabetic ketoacidosis, rash secondary to alpelisib, and possible pneumonia. She was started on DKA insulin protocol and antibiotics empirically. The next morning, the patient was transitioned to subcutaneous insulin and maintained on her diabetic medications as per admission. She defervesced quickly, and blood and urine cultures remained negative for infection. Her rash improved within days of alpelisib discontinuation. Endocrinology was consulted, and they started basal insulin with supplemental mealtime insulin. Alpelisib and gliclazide were discontinued. She was discharged six days after admission. Following her discharge, she did not have any further hyperglycemic complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_802_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_802_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ce75f272b9979f8b5b8b2699acdae183591ccdc2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_802_en.txt
@@ -0,0 +1,5 @@
+A 60-year-old female experienced an acute onset headache that was temporarily relieved with ibuprofen but presented to the emergency department 3 days later due to headache persistence. It was noted that she had a medical history of triple-negative breast cancer (TNBC) and ST-segment elevation myocardial infarction, as well as a family history of lung cancer and thyroid cancer. Head computed tomography (CT) revealed a small volume subarachnoid hemorrhage within the sulci overlying the posterior left cerebral convexity . Digital subtraction angiography (DSA) revealed a 3.9 × 3.5 × 4.2 mm aneurysm or pseudoaneurysm involving a bifurcation point of a distal M4 segment of the left MCA [ and ]. Mild stenosis of the distal parent vessel and branch vessel origins was also noted.
+Embolization through distal navigation was attempted with a Headway® DUO microcatheter over a Synchro2® Soft microwire. However, due to the distal location, navigation was ultimately unsuccessful. Surgical clipping with intraoperative DSA guidance was then performed. The aneurysm was successfully clipped and resected, and the sample was sent for histopathology [ and ]. A postoperative CT scan of the head demonstrated expected postoperative changes involving the parietal lobe . Histopathological examination of the aneurysm sample confirmed triple-negative invasive ductal breast carcinoma . After surgery, the patient remained neurologically intact. Six weeks after surgery, she underwent CyberKnife stereotactic radiosurgery to the region of the resected aneurysm and began treatment with chemotherapy.
+Four months later, the patient presented once again with acute severe headache. Magnetic resonance imaging revealed multiple small lesions within the brain parenchyma, compatible with new metastatic deposits. Catheter angiography showed bilateral cerebral aneurysms, including a new mixed fusiform and saccular pseudoaneurysm arising from a distal M3 posterior division branch of the right MCA. In addition, there was a mixed fusiform and saccular pseudoaneurysm arising from a distal branch of the left callosomarginal artery with a saccular component measuring up to 2 mm in maximum dimension [ and ], as well as a 1 mm saccular outpouching arising from a distal M2 anterior division branch of the right MCA, suspicious for an additional small pseudoaneurysm .
+Given the patient’s medical condition, these aneurysms were not felt to be amenable to open surgical repair, and endovascular therapy would have required parent artery sacrifice with associated risk of stroke. The patient was seen by an oncologist and radiation oncologist, and it was suggested by the team that there was a chance the aneurysms would be responsive to radiation therapy. The patient was subsequently treated with whole-brain radiation therapy and chemotherapy with capecitabine (Xeloda®). Radiation was well-tolerated other than headaches and fatigue, although the patient was capable of limited self-care and confined to a bed or chair >50% of waking hours. A short-term follow-up DSA was recommended to be sure that there was no unexpected, dramatic enlargement or change in configuration of the lesions. Although a nonsurgical course had been chosen, given the paucity of data regarding these unusual aneurysms, we felt that it was important to be able to modify our recommendations to the family if a significant change had occurred, potentially indicating a very high risk of imminent bleeding. Follow-up cerebral angiography 6 days after initiation of radiation therapy demonstrated interval decreased size of the right MCA posterior division distal M3 segment aneurysm.
+Over the ensuing 4 months, CT revealed progression of malignancy in the chest, abdomen, and pelvis. Termination of chemotherapy and radiation therapy was decided, and the patient was offered palliative care. She was placed on a tapering schedule of dexamethasone (Decadron®) to control inflammation and the anticonvulsant medication levetiracetam (Keppra®). The patient died 6 months later while receiving palliative treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_811_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_811_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4f6877fb7bee8cf2dd9346e93dd0f322473f7526
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_811_en.txt
@@ -0,0 +1,8 @@
+A 51 year-old male veteran presented with progressive lethargy, fevers and constant frontotemporal headache for past 3 weeks as well as 20 pound weight loss in past 6 months. Born in Guam, the patient had been stationed as part of the military in Texas, Arizona and Kansas. His medical history was notable for polycythemia vera (PCV) treated with ruxolitinib for 18 months. Three months before admission, he had recurrent mouth ulcers, followed by a dental root canal procedure complicated by ulcerative gingivitis, pulpitis and tooth erosions requiring antibiotics and multiple oral surgeries. All antimicrobials had been discontinued over a month prior to presentation.
+On admission the patient was febrile to 103.5 °F, tachycardic, and saturating 95% on 2 l of oxygen by nasal cannula. Physical exam revealed somnolence, diminished breath sounds at the left lung base and diffuse abdominal tenderness. Neurologic exam identified no focal deficits. Initial laboratory studies (normal range) revealed hyponatremia to 125 (136–145) mmol/L and a creatinine elevation to 1.8 (0.67–1.17) mg/dL. He also had an elevated alkaline phosphatase of 208 (35–140) U/L and total bilirubin of 1.6 (< 1.2) mg/dL. White cell count was 8002 (4000-10,000) cells/mm3 with 74% polymorphonuclear cells and 13% lymphocytes. The C-reactive protein level was 3.89 (< 0.5) mg/dL and the erythrocyte sedimentation rate was 36 (< 30) mm/hr. Rapid HIV antibody testing, as well as HIV viral load, were negative.
+The brain MRI revealed innumerable rim enhancing lesions at the gray-white junction consistent with pyogenic abscesses secondary to hematogenous infection . A lumbar puncture revealed 10 mononuclear cells and 9 polymorphonuclear cells/ml CSF. Glucose was 27 (40–70) mg/dL and protein was 72 (15–45) mg/dL. Vancomycin, ceftriaxone and metronidazole were initiated empirically.
+The patient subsequently underwent chest and abdominal CT examinations to evaluate diminished breath sounds and abdominal tenderness. A retrocardiac mass was seen measuring 2.7 cm as well as bilaterally enlarged adrenal glands consistent with infiltrative infection or neoplasm.
+CSF cultures grew no bacteria; however, cryptococcal antigen was detected with titer of 1:> 256 in CSF and 1:128 in the serum. Fungal CSF cultures grew Cryptococcus neoformans. An adrenal biopsy performed by interventional radiology revealed numerous fungal organisms on histopathology. Gomorri methenamine silver (GMS) and periodic acid-Schiff (PAS) stains highlighted budding yeast forms within macrophages, most consistent with histoplasmosis. Histoplasma capsulatum subsequently grew in fungal blood cultures. Histoplasma antigen was 11.9 (< 0.5) ng/mL in urine, 8.46 (< 0.4) ng/mL in the serum and 1.86 (< 0.4) ng/mL in CSF. Cryptococcal susceptibilities ultimately returned with an MIC of < 0.03 μg/ml to isavuconazole and 0.25 μg/ml to posaconazole; Histoplasma susceptibilities were < 0.03 μg/ml to both isavuconazole and posaconazole. The patient was diagnosed with concurrent cryptococcal meningitis as well as disseminated histoplasmosis.
+Amphotericin infusion as Ambisome at 5 mg/kg every 48 h with flucytosine 1 g q6hrs were initiated for treatment of both identified fungal organisms with improvement of symptoms. Given limited evidence of the successful use of the newer azoles, posaconazole [–] and isavuconazole [–] for CNS disease, the patient was continued on amphotericin infusions for three months and transitioned to 372 mg isavuconazole daily when renal toxicity was noted with Ambisome. A follow up MRI at that time demonstrated diminishing rim-enhancing lesions. The retrocardiac mass was smaller in size on repeat imaging; however, the appearance of the adrenal glands remained unchanged. Cryptococcal antigen titers were 1:16 in serum and 1:8 in CSF. Histoplasmosis antigen in the urine was 0.83 (< 0.5) ng/mL and was no longer detected in the serum. A biopsy of the brain lesions was not performed; however, we hypothesized that the brain lesions were caused by hematogenous spread of histoplasmosis to the gray-white junction with resulting granuloma formation. At the time this case report was written, the patient was still being treated with isavuconazole.
+Of note, once the patient was diagnosed with the two fungal infections, ruxolitinib was discontinued. Given the severity of his presentation, his primary oncologist believed that a re-challenge with ruxolitinib was contraindicated.
+After further discussion with the patient, he had recollected a 2 cm ulcerative, painful tongue mass that first appeared three months after initiating ruxolitinib. This had been biopsied in the past and was not malignant, but had not been evaluated with fungal culture. Retrospective review of the pathology slides was suggestive of histoplasmosis, with small budding yeast forms noted within granulomas on GMS stain .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_817_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_817_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd20aa506571c57adb51b201cf8be0cd83b84c08
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_817_en.txt
@@ -0,0 +1,5 @@
+The patient was a 72-year-old man with no pertinent medical history. An upper gastrointestinal imaging (UGI) performed for GC screening revealed an abnormality wherein there was a horizontal inversion of the upper gastrointestinal tract and deformation of the stomach body. Upper endoscopy showed an elevated lesion with an ill-defined border in the anterior wall of the lower-third of the stomach body , and histopathological examination revealed a moderately differentiated tubular adenocarcinoma. Contrast-enhanced multidetector computed tomography (MDCT) showed inverted thoracic and abdominal organs and illustrated the wall thickness of the stomach body, which had no obvious metastasis . Furthermore, the aortic arch to the thoracic aorta was in the normal anatomical position ; hence, the case was diagnosed as SIP. The 3D angiography revealed a complete right–left reversal of the abdominal arteries . SI is known to be frequently associated with chronic sinusitis and bronchiectasis, and this clinical triad is called the Kartagener syndrome . However, chronic sinusitis and bronchiectasis were not seen in this patient.
+Preoperative staging of GC was clinical Stage IIB (cT3N0M0) according to the tumor/node/metastasis (TNM) classification of malignant tumors 8th edition.
+LDG with D2 lymph node dissection (LND) and modified delta-shaped Billroth-I reconstruction was performed. Although this case was SIP, the abdominal organs were completely inverted ; hence, this operation could be performed with the usual LDG symmetrically . Five trocars were placed in the left–right reversal of the usual LDG in our hospital. The surgeon and the assistant performed this operation by reversing the standing position and the roles of the left and right hands from the usual LDG. The surgeon had to operate the energy device with the non-dominant hand. However, the surgeon used the energy device with the dominant hand for supra-pancreatic LND. The problem encountered with this method was that the forceps of the left hand crossed the energy device; however, the supra-pancreatic LND could be safely performed without the energy device interfering with the pancreas.
+In this operation, there were two problems that could not be solved by performing the operation symmetrically. One of the problems was the method of retracting the lateral segment of the liver. We usually use the Nathanson liver retractor in laparoscopic gastrectomy (LG), which was also used in this case. However, the tip of the liver retractor was oriented toward the hepatic hilar side due to its asymmetrical hook shape. Therefore, the retraction of the lateral segment of the liver was somewhat insufficient, and special care was required not to damage the liver . The second problem was intracorporeal suturing. We usually perform intracorporeal suturing with the surgeon in the paraxial position; however, in this operation, the surgeon performed the suturing in the co-axial position between the patient’s legs. By shifting to this standing position, the surgeon was able to suture with the dominant hand and the normal needle direction.
+Operation time, including intraoperative frozen section histological analysis for the proximal resection margin, was 323 min, and blood loss was 10 ml. After an uneventful postoperative course, the patient was discharged on postoperative day 10. Postoperative staging of GC was pathological Stage IIIB (pT4aN3aM0) according to the TNM classification of malignant tumors 8th edition. The patient received S − 1 + docetaxel adjuvant chemotherapy for 1 year after surgery without any signs of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_823_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_823_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aad9326a6e7f7b9033682e650f0af25915916cf0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_823_en.txt
@@ -0,0 +1,6 @@
+A 72-year-old male patient, smoker (47 pack-years), with no known medical history was presented with symptoms of fatigue, shortness of breath for the past 2 months (New York Heart Association functional Class III) and bilateral lower limb oedema since 2 weeks. His electrocardiogram displayed sinus rhythm at 90 b.p.m. with left axis deviation, intraventricular conduction delay (QRS duration 118 ms) and QS morphology in leads III, aVF and V1–V5. His blood pressure and oxygen saturation were within normal range (135/85 mmHg and 96%, respectively). Lung and cardiac auscultation revealed absence of breath sounds in the right lower lobe and a harsh pansystolic murmur at the left lower sternal edge, respectively. The patient also had jugular vein distention. Chest X-ray displayed significant right-sided pleural effusion. Laboratory tests showed high proBNP (8904 pg/mL), slightly elevated troponin I (cTnI 0.083 ng/mL), mild anaemia (Hgb 12.2 g/dL, Hct 37.4%), and a normal renal function.
+Transthoracic echocardiography demonstrated an aneurysm of the basal inferior and inferoseptal segments of the left ventricle as well as dilation and systolic impairment of the right ventricle with hypokinesia of it’s free wall. Colour Doppler revealed a shunt between the left and right ventricle through the aneurysmatic segment and moderate insufficiency of the atrioventricular valves. The left ventricular ejection fraction was 48% (via Simpson) and pulmonary artery systolic pressure was elevated (50 mmHg). Qp/Qs ratio was 2.4.
+The patient was admitted to the coronary care unit and heart failure treatment with bisoprolol (2.5 mg q.d.), zofenopril (10 mg q.d.), and furosemide (40 mg b.i.d.) was initiated and titrated. Delayed treatment of the septal rupture was decided due to his stable haemodynamic status. Right heart catheterization revealed elevated pulmonary artery and wedge pressures, whereas cardiac output was normal and Qp/Qs ratio was estimated 2.8. Coronary angiography uncovered proximal occlusion of the right coronary artery , while the left coronary circulation did not present severe stenosis. Right coronary artery intervention was not attempted due to the non-viability of the underlying infarcted myocardium. Acetylsalicylic acid (ASA) (100 mg q.d.) and atorvastatin (40 mg q.d.) were added.
+Over the course of hospitalization, the patient’s symptoms improved significantly. A transoesophageal echocardiogram was performed , which showed a 14 mm serpiginous defect with irregular borders and no favourable rupture anatomy for device closure at the site aforementioned in TTE, so he was referred for surgical repair.
+During surgery, scarred myocardium was found at the right ventricular wall and basal segments of the posterior and inferior walls of the left ventricle. Ventriculotomy was achieved through the posterior LV wall. The septal defect was measured 15 mm and was repaired with two Teflon patches, without any residual shunt.
+The patient didn’t present any complications and has been symptom-free ever since. He is followed up by his cardiologist at the local health centre.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_832_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_832_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7e2275529cd8fa72c51316a71b8f35e619ba51e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_832_en.txt
@@ -0,0 +1,7 @@
+A previously healthy, 4 week old, Caucasian boy was brought to the emergency department by his mother because he had accidentally been given the mothers’ dose of citalopram. Instead of the vitamin D drops she intended to give him, she accidentally switched bottles of the citalopram and vitamin D. These bottles are similar, as shown in Fig. . The mother noticed the incorrect medication bottle around 30 min later and immediately presented the infant to the emergency department. She administered 10 drops of citalopram, corresponding to 20 mg. With a weight of 3355 g corresponding to a dose of around 6.0 mg/kg.
+Upon first physical examination we saw an extremely jittery, agitated infant with an evident opisthotonos, as shown in Fig. . Vital signs were stable, the patient had a respiratory rate of 50/min and an oxygen saturation of 100% in room air. At presentation the patient showed an isolated systolic hypertension. Blood pressure was 110/38 mmHg (reference value p95 for systolic pressure 105 mmHg), with a regular heart rate of 190 beats per minute . An electrocardiogram showed sinus tachycardia with normal intervals. A nasogastric tube was inserted to empty the stomach; activated charcoal and sodium sulfate were administered over a 2 h period to prevent any possible further absorption of the citalopram. Furthermore, an intravenous cannula was placed with maintenance fluid and secure intravenous access.
+The patient was transferred to a neonatal intensive care unit (NICU) for intensive monitoring, concerning the possible risk of cardiac rhythm disturbances and convulsions. Laboratory testing was performed including a complete blood count, infection parameters and electrolyte concentration, all results were within normal limits. Because of the risk of convulsions and intracerebral hemorrhage, amplitude-integrated electroencephalography (aEEG) and cerebral ultrasound were performed, which showed no abnormalities.
+After 16 h the patient was transferred back to the medium care neonatal ward. In the following days he continued showing signs of extreme jitteriness and increased muscle tone. After 4 days these symptoms were found to be acceptable enough to discharge the patient. Before, during and after admission the patient was only fed formula feeding, breast milk was not used.
+During several weeks, at ambulant follow-up, the patient showed persistent signs of increased muscle tone for at least 1 month after discharge. Furthermore, he showed signs of agitation and gastro-oesophageal reflux. Treatment was started with esomeprazole to counteract the effect of the gastro-oesophageal reflux. After 7 months patients symptoms disappeared completely and the patient was discharged from further ambulant follow-up.
+To assess pharmacokinetic parameters as well as to predict time to improvement of symptoms, citalopram and the active metabolite desmethylcitalopram concentrations were measured in the serum of the patient. Citalopram and desmethylcitalopram concentrations were analyzed using a validated UPLC-MS-MS method at the Onze Lieve Vrouwe Gasthuis hospital in Amsterdam, the Netherlands. Two hours after ingestion, the citalopram plasma concentration was 77 μg/l with no detectable desmethylcitalopram concentration. Fifty-four hours after ingestion, citalopram serum level decreased to 33 μg/l and desmethylcitalopram increased to a concentration of 43 μg/l.
+To objectify the severity and clinical course, Finnegan scores were randomly measured during the course of admission (Additional file ) . Fig. shows the course of the known Finnegan scores, citalopram and desmethylcitalopram serum levels. Finnegan scores were as follows: 2 h after ingestion 11, 24 h after ingestion 8, 46 h after ingestion 6, 66 h after ingestion 3, more elaborate data is shown in Additional file . Unfortunately during the time of admittance at the NICU, Finnegan scores were not measured.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_857_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_857_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..69e7b7613d660f1549c27310132b765fe53cce33
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_857_en.txt
@@ -0,0 +1,5 @@
+A 60-year-old Caucasian male patient was admitted to the Neurology Department at the Academic Medical Centre because of speech impairment and right limb weakness. Onset was sudden and symptoms had already been present for approximately 4 hours. The patient’s medical history revealed long-standing arterial hypertension, ischaemic heart disease and nicotinism.
+An examination performed after hospital admission revealed right progressive CNVII paresis, mixed aphasia and paresis of right limbs [2/5 in Medical Research Council Muscle strength scale]. Computed tomography (CT) of the head revealed an acute ischaemic focus in the left hemisphere and white matter lesions, a surrogate for cerebral small-vessel disease. The electrocardiogram recorded atrial fibrillation with a ventricular rate of 70 beats/min. Ultrasound examination and angio-CT scan (arterial and venous phase) of the head revealed a left-sided occlusion of the common carotid artery (CCA), external carotid artery, and the internal carotid artery (ICA) at the cavernous section (with an extended thrombus in the ICA above the embolism) . At this time, preserved blood flow was confirmed in the middle cerebral artery (MCA) and anterior cerebral artery (ACA) on the left side . In the ultrasound duplex Doppler examination, the material occluding the CCA was hyperechogenic, with thrombus extension into the ICA, suggesting the presence of fibrous embolic material migration into the CCA, occlusion of the ICA and propagation of the thrombosis into the distal part of the carotid artery. The movement of the embolism in the CCA was visible during the ultrasound examination with distal CCA bulb occlusion and no signs of dissection or aneurysm.
+Because of the duration of the symptoms, the unstable neurological condition of the patient, the extent and nature of lesions occluding the arteries, and the newly created cerebral ischaemia focus, a decision was made to undertake combined interventional treatment involving surgical and endovascular therapy. Because of the size and nature of the embolic material (mostly hyperechogenic, probably fibrous and non-compressible lesion), surgical embolectomy was undertaken in the first step of the procedure with the endovascular methods reserved for adjunct treatment if required.
+The procedure was performed in a hybrid operating room under fluoroscopic control (started in the 6th hour from the start of symptoms). From the incision on the front edge of the left sternocleidomastoid muscle, the ICA and its division were dissected. A transverse cut on the CCA was made, just below the ostium of the ICA. Through arteriotomy, an extensive embolism of the CCA bulb was removed: 10 × 7 mm in size, hard, with fibrous structure. After removing the embolism, a good inflow and lack of back flow were recorded. Using a 3 F Fogarty catheter, a 10-cm thrombus was removed from the ICA; after removing the embolus, arteriography showed restored flow in the ICA, but lack of contrast in the cerebral circulation corresponding to the ACA and MCA . Based on the arteriographic image, a decision was made to implement thrombolytic treatment: 0.3 mg/kg of recombinant tissue plasminogen activator (rt-PA; Actylise, Boehringer Ingelheim, Germany) was administered through a catheter placed in the ICA. Follow-up angiography revealed blood flow in the ICA and the ACA . The arteriotomy was sutured using a vascular suture (Prolene 5–0). Because of parenchymatous bleeding from the wound caused by administering rt-PA and heparin (2500 U; as a routine surgical measure), haemostatic dressing and suturing were used, while closure was delayed until the next day to allow normalisation and prevent clotting abnormalities.
+Systematic improvement of the neurological condition continued in the post-surgery period without complications. During anticoagulant therapy, unfractionated heparin was used at an initial daily dose of 15000 U/24 h, which was later changed to 25000 U/24 h based on the activated partial thromboplastin time. Through continuous heart rate monitoring, atrial fibrillation was observed. Follow-up ultrasound and angio-CT of the head (1st day following the intervention) revealed proper blood flow in the affected arteries, but a CT scan of the head revealed a marked ischaemic focus . On the 10th day from the onset of the symptoms, the patient left the ward in a neurologically good condition, with discrete aphasia, yet able to move independently. Based on the clinical course and results of additional tests (imaging and electrophysiological testing), it was determined that the stroke occurred in the patient as a result of cardiogenic embolism from atrial fibrillation (diagnosed de novo during hospitalisation). As a further prophylaxis against stroke, dabigatran in daily dose of 300 mg was introduced from the 10th day. The written informed consent of the patient was obtained for participation in this study and for publication of the results.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_887_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_887_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7920084d7332ed80973b60688b791c86f8deab04
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_887_en.txt
@@ -0,0 +1,6 @@
+A 63-year-old man admitted to the stroke service at our center presented with the sudden onset of headache, vomiting, and right-sided hemiparesis followed by loss of consciousness (World Federation of Neurological Surgery grade IV). A computed tomography (CT) scan revealed diffuse thick SAH combined with a large right temporal intracerebral hematoma , and a ruptured right middle cerebral artery aneurysm was successfully clipped following extensive hematoma evacuation by emergent surgery performed at 6 hours after SAH onset. The early postoperative course was uneventful, and the neurological deficits disappeared with the exception of mild left hemispatial neglect. He received standard post-SAH fluid and drug management at our institution. On the ninth day after SAH onset, however, he became restless and then developed aphasia and right-sided hemiparesis. Transcranial Doppler (TCD) measurements were compatible with mild left middle cerebral artery (MCA) vasospasm (left MCA peak velocity, 149 cm/s; mean velocity 120 cm/s). Diffusion-weighted magnetic resonance (MR) imaging performed immediately after the onset of symptoms revealed no apparent ischemic findings , but subsequent technetium 99 m hexamethylpropyleneamine oxime single photon emission CT (Tc-99 m HMPAO SPECT) revealed a mild reduction in rCBF in the left anterior cerebral artery (ACA) and MCA territories ] indicative of clinical deterioration attributable to vasospasm. Hyperdynamic therapy with dobutamine (initial dose: 3 μg/kg/min; increased in 3 μg/kg/min increments every 4 hours to a level at which the deterioration resolved) combined with mild hypervolemia with supplemental low-molecular-weight dextran (500 mL/day) was initiated.
+Cerebral digital subtraction angiography (DSA) was performed under local anesthesia via a transfemoral approach since there was no clinical improvement after 2 hours of maximal hemodynamic augmentation with dobutamine (12 μg/kg/min) to raise cardiac output to supranormal plateau level (cardiac index >5.0 L/min/m 2 ), assisted by radial artery waveform-based pulse contour cardiac output monitoring (FloTrac system version 3.02, Edwards Lifesciences, Irvine, CA, USA). Prior to DSA, transcranial rSO2 was measured by a NIRS cerebral oximetry device (INVOS 5100C, Somanetics, Troy, MI, USA), which was composed of a light-emitting diode and two detectors located 30 and 40 mm from the diode, allowing compensation for NIR absorption from the scalp and the skull to determine rSO2 in the underlying area of the brain. Each of the four-channel sensors (SAFB-SM, Somanetics, Troy, MI, USA) was placed symmetrically on the scalp of the patients at the approximate location overlying the spasm-affected vascular territory and on the mirror--image location in the opposite hemisphere.
+DSA revealed severe vasospasm of the distal portion of the A1 segment of the left ACA and of the proximal left A2 and M2 segments and diffuse spasm in their branches . After systemic heparinization, a 5-Fr. guiding catheter was advanced to the cervical portion of the internal carotid artery and a microcatheter was placed at the top of the internal carotid artery, Arrow] and fasudil hydrochloride (25 mg) was infused at a rate of 1.0 mg/mL (consisting of 60 mg of fasudil hydrochloride mixed in 60 mL of normal saline) for distribution into both the ACA and MCA territories, resulting in significant reversal of vasospasm in distal A1 and M1 segments and improvement of cerebral circulation time (as measured by the interval between the first image in which contrast is visible above the supraclinoid internal carotid artery and the peak filling of the cortical parietal veins) from 6.6 to 5.3 seconds. Since focal severe vasospasm still existed in the distal potion of M3 (superior division), superselective infusion of fasudil (25 mg) into the MCA distribution was performed by directing the microcatheter into the distal portion of M1 [, arrow]. Although further dilation could not be obtained in the M3 segment, good angiographic results were obtained in the remaining spastic vessels . Within an hour of completion of the procedure, his symptoms improved.
+The intra-arterial fasudil likewise produced improvement of low and fluctuating rSO2 in the left ACA--MCA territory immediately after onset of each infusion[, Ch-1], and the left MCA territory flow then gradually increased following superselective infusion in the distal M1 segment[, Ch-3]. TCD velocities normalized after the procedure (left MCA peak velocity, 132 cm/s; mean velocity 98 cm/s), compatible with angiographic improvement of the M1 vasospasm.
+The postprocedural course was uneventful, and the symptoms were managed with hyperdynamic therapy under stable but slightly reduced (< 10%) rSO2 on the left side. However, he developed aphasia and weakness of the right hand with decreased voluntary movements over the course of the next 24-36 hours. TCD velocities consistently remained within normal range, but decreased and unstable rSO2 in the left ACA--MCA territory were detected. Diffusion-weighted MR imaging revealed small hyperintense signals in the left insular cortex and medial frontal cortex . Tc-99 m HMPAO SPECT detected decreased rCBF in the left ACA and MCA territories, in contrast to hyperperfusion observed in the superior trunk of the left MCA territory [b. Recurrent vasospasm in the distal vascular territories, particularly in the left ACA and MCA territories, was strongly suspected and DSA was performed immediately as an additional.
+Repeated DSA demonstrated moderate vasospasm of the distal A1 and diffuse vasospasm in the distal ACA and MCA branches as well as persistent focal spasm in the distal potion of the M3 segment . Then intra-arterial fasudil infusions (25 mg/each) were performed again, resulting in improvement of the distal vasospasm and cerebral circulation time[Figure , inset] from 5.8 to 4.9 seconds. In response to intra-arterial fasudil infusions, rSO2 in the left ACA--MCA territory rapidly increased to a level close to that on the contralateral side . The patient's symptoms gradually resolved over the next 72 hours accompanied by maintenance of stable rSO2 values. Cardiac output (> 5.0 L/min/m 2 ), systolic blood pressure (< 180 mmHg), and heart rate (< 130 bpm) were also maintained within each target for hyperdynamic therapy by titration of dobutamine dose and intravenous calcium antagonists. No apparent periprocedural clinical/vital signs or radiological findings of increased intracranial pressure or hemorrhage associated with the intra-arterial fasudil therapy were observed. Follow-up MR angiography on day 14 (corresponding to 3 days after the second endovascular therapy) confirmed improvement of vasospasm . Diffusion-weighted MR imaging revealed no additional ischemic findings after repeated endovascular therapy . Abnormal rCBF distributions in the left hemisphere were also normalized . The patient underwent ventriculoperitoneal shunt placement on day 30 for the treatment of post-SAH normal pressure hydrocephalus , resulting in favorable functional outcome with a modified Rankin Scale score of 1 at 2 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_893_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_893_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9d7dc81414ededb4d41077ac98d21c45cd9cf892
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_893_en.txt
@@ -0,0 +1,9 @@
+An 81-year-old Caucasian man presented with a large painless swelling of the cranial vault, covering almost the whole left side and also major parts of the right side of the skull.
+He had first noticed a small swelling over the left frontal region about 40 years ago. During the following four decades the swelling slowly expanded. For more than 15 years his family physician had recommended an MRI for further examination. The patient refused it over a long time period because he felt no pain or other discomfort. He experienced no significant problems during his customary life activities.
+He finally agreed to further diagnostic procedures after a short period of dizziness following an ambulatory treatment of a focal retinal detachment. After this episode no further clinical symptoms appeared. Neurological examination was entirely normal. No cognitive deficits were found.
+Examination of the lesion revealed a subcutaneous mass covering most of the left cranial vault and major parts of the right side. Palpation revealed a soft elastic mass, adherent to the surface, without fluctuation.
+In contrast to the giant size of the cyst, on first sight no severe deformation of the head had developed. The overlying skin did not show pathologic changes, such as defects or inflammatory signs.
+A spiral computed tomography (CT) (Philips Brilliance 64 CT-scanner) with surface volume rendering technique revealed a large swelling of the scalp, especially over the left hemisphere . Computed tomography (CT) with surface reconstructing and insets of axial, coronal, and sagittal scans demonstrated a giant cystoid lesion of the skull, with large calvarial defects on both sides, left more than right. The outer and the inner table of the skull bone were widely destroyed; in some areas the inner table was thinned out . A distinct compression of both brain hemispheres was caused by the tumor, with a slight midline shift to the right side .
+The MRI scan T2 weighted images (Philips Achieva 1.5 T) revealed an inhomogeneous, mainly hyperintense mass without penetration of the dura. Significant compression of brain hemispheres and ventricles without cerebral edema suggested a slow growing tumor. In diffusion weighted images there was a restriction of diffusion with low signal in the ADC maps . The contrast enhanced T1 weighted images (0.1 mmol/kg Gadovist (gadobutrolum), Bayer Health Care) showed a mild thickening of the intact dura. No enhancement in the epidermoid tumor was found .
+In summary, radiological features were suggestive of the presence of an extradural intradiploic epidermoid cyst.
+After thorough discussion of the diagnostic findings with the patient, he favored a biopsy to assure the histological classification of the tumor but refused the option of a complete removal of the tumor and subsequent cranioplasty. A biopsy was taken in the left frontal region. Histological examination revealed laminated keratin material, cholesterol crystals, and cellular debris. Pathological findings were consistent with the diagnosis of an epidermoid cyst. Due to a superficial wound infection surgical revision was necessary. His postoperative course was uneventful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_915_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_915_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..680189d9681887dc2fe3d717a481e3ab524f2afc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_915_en.txt
@@ -0,0 +1,8 @@
+A 21-year-old woman was admitted to our department for a giant hepatic tumor that was found one month prior during a physical examination.
+One month ago, an ultrasound examination at a local hospital revealed a giant hepatic tumor. However, the patient did not experience any obvious abdominal pain, distention, nausea, vomiting, chills, or fever.
+She denied a medical history of oral contraceptive use, hepatitis, metabolic disorders, and immunodeficiency diseases.
+The patient was unmarried, and her last menstrual period ended 11 d before admission. No additional family history was presented.
+The patient’s sclera was not stained yellow and superficial lymph nodes were not enlarged. Her abdominal examination showed that her abdomen was flat and soft, and there was no obvious tenderness throughout her abdomen. The lower margin of the liver was palpable 15 cm below the xiphoid, but the spleen was not palpable.
+Routine blood, kidney function, and coagulation function tests as well as the levels of tumor markers such as alpha-fetoprotein (AFP; 2.7 ng/mL, reference range 0-20 ng/mL), carcinoembryonic antigen (CEA; 0.71 ng/mL, reference range 0-5 ng/mL), and CA19-9 (2.39 ng/mL, reference range 0-37 ng/mL) were all within normal ranges. The C-reactive protein level was mildly elevated (8.25 mg/L, reference range 0-8 mg/mL). The liver function test revealed mildly elevated gamma-glutamyl transpeptidase and alkaline phosphatase (gamma-glutamyl transpeptidase, 309 IU/L, reference range 10-60 IU/L; alkaline phosphatase, 182 IU/L, reference range 42-125 IU/L). The hepatitis A-E markers were all negative.
+A CT scan performed at our hospital revealed a giant hepatic tumor measuring 22 cm × 20 cm × 10 cm, which completely replaced the left hepatic lobe. On non-contrast enhanced CT, the tumor showed a heterogeneous hypodensity, with a clear boundary . On the contrast-enhanced CT, the tumor presented with patchy or nodular enhancement and the subcapsular feeding arteries were visible in the arterial phase , which became intensified and hyper-attenuated in the portal phase . However, some regions of the tumor were not enhanced in the arterial and portal phases.
+To further diagnose the patient’s condition, MRI was also performed. On T1-weighted MR images, the tumor appeared heterogeneous hypointense with a complete capsule . On T2-weighted MR images, diffusion-weighted imaging, and multiplanar reconstruction images, the tumor appeared heterogeneous hyperintense . Following an injection of Gd-DTPA, the tumor presented with heterogeneous enhancement and the subcapsular feeding arteries were also visible in the arterial phase . In the delayed phase, the tumor had more intense enhancement over a larger range than in the arterial phase, and the capsule was significantly enhanced .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_923_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_923_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..448765e3111b8482567b8bb694787c000b76b1e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_923_en.txt
@@ -0,0 +1,4 @@
+A 46-year-old woman presented to our clinic with a right palpable breast mass in January 2022. Ultrasonography (US) revealed a 2.3 × 1.7 × 1.3 cm hypoechoic mass in the right breast at 11 o’clock position, with a BI-RADS category of 4a. Multiple enlarged lymph nodes (LNs) were detected in bilateral axillae. Her past medical history was notable for a low-grade FL under watchful waiting . A retroperitoneal mass was found during a regular health examination in December 2020 and biopsy suggested Grade 1–2 FL. Immunohistochemistry (IHC) revealed positive expression of CD21 (FDC), CD20, CD23, CD10, BCL-2 and BCL-6, as well as negative expression of cyclin D1. Ki-67 index was 20%. A positron emission tomography (PET)-computerized tomography (CT) scan demonstrated significant uptake (SUVmax 7.6) in the retroperitoneal LN, measuring 4.1 × 2.9 cm. Bilateral axillary, left parasternal, paravertebral, intraabdominal, intrapelvic, and bilateral inguinal LNs were also 18F-fluorodeoxyglucose (FDG)-avid. She remained in good performance status and asymptomatic under close surveillance by her hematologist for over a year.
+The patient was immediately suggested an open biopsy or core biopsy to determine the nature of the right breast mass. However, she refused due to personal reasons. In October 2022, the patient presented with a large mass in her right breast with skin involvement. She also suffered from recurrent fevers with headache, chills, and joint pain since August 2022, followed by short of breath and rapid progression of the right breast mass. US showed an 8.3 × 3.6 × 4.1 cm mass in the right breast, with lymphadenopathy at all three levels of bilateral axillae. Whole-body PET-CT demonstrated a hypermetabolic mass in the right breast and hypermetabolic LNs on both sides of the diaphragm. Increased 18F-FDG activity was also detected in enlarged spleen and bone marrow . Biopsy of the right breast mass was then performed and the pathological examination revealed no special type, histological grade 3 TNBC with a Ki-67 index of 70% . Blood test revealed significantly high white blood cell (WBC 114.28×109/L) and lymphocyte counts (LY 106.73×109/L), low hemoglobin (HGB 97g/L), and an elevated lactate dehydrogenase (LDH) of 443 U/L. Abnormal serum tumor markers including CA19-9 of 189.2 U/mL, CA125 of 938.0 U/mL, and CA15-3 of 183.5 U/mL were also detected. Bone marrow aspiration and biopsy confirmed bone marrow infiltration by FL ( and ). Therefore, stage IV FL with a FLIPI score of 4 and locally advanced TNBC were confirmed and both were indicated for systemic therapy.
+The patient subsequently underwent neoadjuvant therapy with R-CHOP (rituximab, cyclophosphamide, vincristine, doxorubicin, and prednisone). After two cycles of R-CHOP, the right breast mass decreased from 8.5 × 6.7 cm to 4.9 × 5.6 cm based on CT examination ( and ), showing a partial response (PR) according to Response Evaluation Criteria in Solid Tumors (RECIST) version 1.1. WBC, LY, and LDH decreased to normal limits. CA15-3 descended to 99.3 U/mL. However, the mass in the right breast increased rapidly after the completion of the third cycle of R-CHOP ( and ). Next-generation sequencing (NGS) performed on the breast tumor sample revealed a HRD score of 72 and pathogenic mutations in ARID1A, FBXW7, SLX4, and TP53 genes. According to the NGS results, the neoadjuvant regimen was changed to R-TP (rituximab, nab-paclitaxel, and cisplatin). The patient responded well to the R-TP regimen with a rapid reduction in tumor size, from 7.4 × 8.7 cm to 3.9 × 3.7 cm ( and ). After three cycles of R-TP, CA15-3 descended to 51.8 U/mL. PET-CT was performed again and showed that hypermetabolic LNs on both sides of the diaphragm decreased in size as well as 18F-FDG uptake. A significant decrease in size and 18F-FDG uptake was also detected in spleen .
+The patient then underwent right modified radical mastectomy and right axillary LN dissection. The pathological examination of right axillary LNs demonstrated both LN metastases from TNBC (1/50) and FL infiltration (49/50) . The pathological staging of TNBC was T3N1M0, IIIA. After surgery, the patient continued to receive R-TP for 3 cycles and adjuvant radiotherapy for breast cancer.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_92_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_92_en.txt
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index 0000000000000000000000000000000000000000..ad18fae28b236f5caaff4ff6fae950d9e1815d43
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+A 33-year-old female, with a medical history of schizophrenia and bipolar disorder, presented to our trauma center after being an unrestrained driver in a motor vehicle crash going approximately 50 miles/h. Her accident was a high impact mechanism.
+In the trauma bay, the patient complained of the right hip and leg pain and was found to have associated shortening and deformity of the extremity. There was a 2 cm × 1 cm open laceration over the distal tibia with exposed bone fracture fragments. The patient was intubated for airway protection and radiographs were obtained of the right hip, femur, and lower leg demonstrating a right hip fracture dislocation with associated right femoral and tibial shaft fractures (-).
+Computed tomography (CT) scan of the pelvis further delineated the posterosuperior hip dislocation with associated fractures of the posterior wall of the acetabulum and femoral head .
+Attempts in the emergency department to obtain a closed reduction of the hip dislocation were unsuccessful due to difficulty posed by her femur and tibia fractures. To reduce the hip and minimize the risk of developing AVN, she was taken urgently to the operating room for surgical management. In the operating room, the patient was placed supine on a radiolucent table with a small bump underneath the right buttock. Given the nature of her hip injury, priority was given to the reduction of the hip dislocation. A 5 mm Schanz pin was placed percutaneously along the axis of the femoral neck .
+Traction and gentle rotation were applied to reduce the femoral head back into the acetabulum and an inferior infrafoveal femoral head impaction fracture was confirmed.
+Next, the open tibia fracture was debrided, closed primarily and both the tibia and femoral shaft fractures were treated with intramedullary nails (-).
+Finally, a fluoroscopic dynamic examination under anesthesia, as described by Moed et al., was performed to assess the stability of the posterior wall acetabulum fracture .
+The posterior wall of the acetabulum and hip joint was found to be stable in 90° of flexion with internal rotation, adduction and axial loading. The post-operative pelvic CT scan demonstrated a concentric hip reduction with a known femoral head fragment in the inferior portion of the hip joint .
+The patient was made toe-touch weight-bearing on the right lower extremity and discharged from the inpatient rehabilitation unit on post-operative day 16. The patient returned to the emergency department approximately 6 weeks later for suture removal, and it was discovered that she was placing full weight on her right lower extremity. Radiographs obtained during this encounter demonstrated maintenance of hip joint congruency and healing femoral and tibial fractures (-).
+Despite being given an appointment for follow-up in our orthopedic outpatient center, she was not seen in our clinic again.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_949_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_949_en.txt
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index 0000000000000000000000000000000000000000..4957c73af4b9eec3798b23dcf9168b8ef2503c83
--- /dev/null
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+A 63-year-old woman was admitted to our hospital in December 2017 with a mass in the urethral orifice. She had noticed the mass 2 yr prior without any diagnosis and treatment, and it had slowly increased in size in the past few months. She had no other symptoms. Physical examination found a fleshy, hemorrhaged, uneven polypoidal mass 3 cm × 4 cm in diameter located at the bottom right of the urethral orifice. Radiographic examination of the chest, abdomen, and pelvis was unremarkable. Urine analysis showed that urinary occult blood test was positive and 65.34 red blood cells were observed per high-power field. There was no significant past medical history except for hypertension, and other laboratory tests were normal. Cystourethroscopy demonstrated a villous mass with exophytic growth in the distal urethra and smooth mucosa of the bladder. Biopsy of the urethral lesion showed villous adenoma with well-differentiated adenocarcinoma. Complete gastrointestinal evaluation failed to find any similar lesions. The whole urethra and part of the bladder were excised and the specimen was sent to the Department of Pathology for pathological and immunohistochemical examination. No further treatment was offered. After follow-up at 11 mo, the patient had no recurrence. Publication of this case report was approved by the Ethics Committee of Affiliated Hospital of Qingdao University.
+The excised lesion was a soft grayish mass measuring 1.5 cm in diameter and appeared papillary and fleshy with hemorrhage and negative surgical margins. The appearance was identical to villous adenoma of the colon. Several blunt finger-like processes lined by pseudostratified columnar cells with frequent goblet cells were observed under a light microscope . The nuclei were stratified atypical and hyperchromatic. Abundant mucin was seen both intracellularly and extracellularly . Carcinomatous areas consisted of dysplastic glands and some of the glands presented with high-grade intraepithelial neoplasia . In focal areas, the glandular component was characterized by increased disorganization of structure. More importantly, the carcinoma invaded the muscularis layer. The gross and microscopic examination was suggestive of urethral villous adenoma with focal well-differentiated adenocarcinoma.
+Formalin-fixed, paraffin-embedded tissue was cut into 5-µm sections for im-munohistochemical evaluation. Immunohistochemical examination was positive for carcinoembryonic antigen (CEA), cytokeratin (CK) 7, CK20, epithelial membrane antigen (EMA), and p53 protein, and the positive ratio of Ki-67 was 60% in the adenocarcinoma . All immunohistochemical staining was carried out by the avidin–biotin–complex method, as previously described[,].
+We carried out a review of the literature on urethral villous adenoma. PubMed and Embase were searched using the following keywords: urethra OR urethral AND villous adenoma. We only included articles in English. A total of 11 cases with urethral villous adenoma were reported from 1981 to 2003 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_962_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_962_en.txt
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index 0000000000000000000000000000000000000000..25106ca7c62ac2df21edf1b98c66a457acf5ee96
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+A 62-year-old male with several risk factors (hypertension, hypercholesterolaemia, and smoking) complained of occasional chest discomfort for a few months. Finally, he was referred to the emergency department for evaluation of severe retrosternal pain accompanied with shortness of breath. His physical examination was unremarkable (blood pressure 149/99 Hg, heart rate 69/min, saturation of arterial blood without added oxygen was 97%), but electrocardiogram revealed pronounced ST-segment elevations in anterior leads .
+He was immediately taken to catheterization laboratory. Angiography suggested a diffuse CAD; surprisingly, the left anterior descending artery (LAD)—a presumed culprit—showed only a moderate obstruction of the mid-vessel with well-preserved blood flow (, , ). Optical coherence tomography (OCT) was performed to address disparities between electrocardiographic and angiographic findings. The impression of diffuse CAD was confirmed since no ‘healthy’ arterial structure was seen within the examined LAD ; indeed, the intimal thickness throughout the vessel exceeded 600 µm. The massive plaque burden comprised mostly fibrous plaques. The culprit lesion with a minimal diameter 1.77 mm, minimal luminal area 2.46 mm2, per cent diameter stenosis 44%, and per cent area stenosis 66% appeared in the mid-LAD. Importantly, the hallmark of an unstable lesion such as a thin-cap fibroatheroma, plaque rupture, and thrombus was clearly seen .
+Having recognized the high-risk features of the culprit, a decision was made to proceed with percutaneous coronary intervention (PCI) and a 2.75 × 22 mm drug-eluting stent was placed across the lesion. Stent apposition was considered adequate, minor malapposition was corrected with a larger non-compliant balloon, no edge dissections were observed, and the blood flow remained normal.
+The high-sensitivity troponin T peaked the same day at 27 ng [upper limit of normal (ULN), 14 ng/L), Q-waves did not develop, and myocardial contractility seemed unaffected (ejection fraction, 57%). The hospital course was uncomplicated, and he was discharged on daily doses of aspirin 100 mg, ticagrelor 180 mg, nebivolol 2.5 mg, perindopril 2 mg, and rosuvastatin 20 mg.
+The patient resumed his previous activities, took medication regularly, and the low-density lipoprotein (LDL) cholesterol decreased to 1.4 mmol/L. However, the chest discomfort persisted while riding his bicycle. Typical symptoms were provoked at high exercise workload (13.5 metabolic equivalents) with ST-segment depressions (0.35 mV) in lateral precordial leads.
+He was readmitted to the hospital for invasive coronary evaluation. On angiography, the stented segment remained patent and there was no progression at other coronary sites. However, fractional flow reserve (FFR) after 200 µg intracoronary adenosine was impaired in LAD [0.72, lower limit of normal (LLN), 0.80] as compared with the left circumflex artery (0.96). Moreover, the resting full-cycle ratio (RFR) was decreased to 0.82 (LLN, 0.90); the pullback from the distal LAD showed a continuous gradient without a step-up at the stent level . The procedure was terminated without further intervention.
+The patient was instructed to pursue his physical activities and carry on with his previous medications along with ranolazine 325 mg b.i.d. and trimetazidine 35 mg b.i.d. Three months later, his clinical condition remained stable.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_968_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_968_en.txt
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index 0000000000000000000000000000000000000000..1e0142186047d471d76e694e2deccf8e62c7c57c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_968_en.txt
@@ -0,0 +1 @@
+A 70-year-old man presented to his primary care physician with chest discomfort, palpitation and dizziness. He denied chest pain, shortness of breath and fatigue. When electrocardiogram revealed ST-segment elevation in all the anterior leads (V1 to V6), the patient was referred to our hospital. An echocardiogram showed the presence of a large immobile mass attached to his right ventricle extending to the outflow tract . The serum level of soluble interleukin-2 receptor was markedly increased to 6,500 U/mL (reference range, 122–496 U/mL). 18F-Fluorodeoxyglucose (FDG) positron emission tomogram showed multiple foci of abnormal FDG accumulation in right cervical and mediastinal lymph nodes, cardiac wall, and stomach with elevated maximum standardized uptake values of more than 27 . A right cervical lymph node biopsy specimen was obtained and revealed histological features of DLBCL, not otherwise specified, with the non-germinal center B-cell-like (non-GCB) immunophenotype, being positive for CD20, BCL6, and MUM1 and negative for CD10. An esophagogastroduodenoscopy (EGD) showed a large circumferential ulceration on the greater curvature of the gastric body . Histopathological assessment of the biopsied gastric tumor from nine different sites (white arrows in Fig. a) revealed diffuse infiltration of abnormal large lymphoid cells. These cells were positive for CD20, BCL-6 and MUM1 and negative for CD10. On the basis of these results, the gastric lesion was also determined to be DLBCL, non-GCB subtype. There were no pathological findings suggesting mucosa associated lymphoid tissue (MALT) lymphoma such as lymphoepithelial lesions or eosinophilic degeneration of epithelial cells. Helicobacter pylori (H. pylori) was not detected in the biopsy specimens. On the other hand, biopsy specimens from three other sites (red arrows in Fig. a) were found to have microtubular glands and cribriform proliferation, suggesting the existence of a moderately differentiated tubular adenocarcinoma (tub2). These adenocarcinoma cells were surrounded by DLBCL cells . On immunohistochemical staining using anti-human CXCR4 mouse monoclonal antibody (clone 44716) and anti-human/mouse CXCL12/SDF-1 mouse monoclonal antibody (clone 79018), DLBCL cells were positive for CXCR4 and adenocarcinoma cells were positive for CXCL12/SDF-1 . The patient was started on R-CHOP chemotherapy regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisolone), resulting in a complete remission after six cycles. Follow-up EGD after chemotherapy detected a scar lesion instead of a tumor . Biopsy specimens from the scar were negative not only for lymphoma cells but also adenocarcinoma cells.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_969_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_969_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64b39c58c8e845189f313bf6775de6c2d1c37d3d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_969_en.txt
@@ -0,0 +1,5 @@
+A 35-year-old female was diagnosed with type I DM at the age of 9 years. During childhood her DM was poorly controlled and the patient gained significant weight. At the age of 25 years her weight was 105 kg with a body mass index (BMI) of 40 kg/m2 and her renal function started to deteriorate with progression to requiring hemodialysis by age 30. With development of renal failure, secondary hyperparathyroidism was noted. Due to her obesity, she was not eligible for a renal transplant or a SPK. At this point it was decided to offer her bariatric surgery, and, after extensive discussion, it was felt that a RYGBP was the best option for her in terms of weight loss. At the age of 32 years, she underwent uneventful robotic-assisted surgery; the stomach remnant was attached to the abdominal wall for potential future access.
+Over the next 2 years she lost 60 kg and underwent SPK during which the donor duodenal segment was diverted to a bowel loop distal to her Roux loop implant site into the common channel. Induction immunosuppression with alemtuzumab was followed by maintenance with tacrolimus (trough levels 5-7 ng/mL), mycophenolate-mofetil (2 g daily), and a steroid taper. She was CMV seronegative and received a graft from a CMV positive donor and received standard prophylaxis with oral ganciclovir (GCV) for 100 days. Within 100 days posttransplant, she was readmitted to the hospital with acute CMV disease, which was successfully treated with intravenous ganciclovir.
+Shortly after this episode the patient was found to have skin lesions on her right leg, which were diagnosed as calciphylaxis. Her serum calcium at that time was 14 mg/dl and the diagnosis of tertiary hyperparathyroidism was made. A three-and-a-half-gland resection together with subtotal thymectomy was done without any complications; the left lower parathyroid gland was the only normal appearing and half of it was preserved taking care that blood supply remained intact. Intraoperative parathyroid hormone levels dropped from >1500 to 150. Calcium serum levels within 24 hours postoperatively were 9 mg/dl with ionized calcium of 3.5 mg/dl. She was discharged in good condition within 24 hours postoperatively with daily calcium supplementation of 4.5 g/day divided into three doses.
+During the following week her calcium levels started to drop and on day 10 postoperatively at an outside hospital serum calcium was found to be critically low at 5.5 mg/dl with an ionized fraction of 2.1 mg/dl. However, the patient had remained clinically symptom free. She was admitted for intravenous calcium replacement. Pushes of calcium were unable to appropriately raise her calcium levels and, therefore, a calcium drip (85 mg/h) was started. Her calcium levels came up to 7.1 mg/dl. Oral calcium dose was raised to 15 g/day and hydrochlorothiazide was started. The calcium drip was stopped and the patient was discharged home in good condition.
+Intense calcium supplementation was continued. Gradually the patient's gastrointestinal tract started to adapt and after two years her calcium levels started to stabilize. She has not experienced any additional complications from her transplant or gastric bypass. She is currently alive with excellent function of both grafts, normal calcium levels, stable weight, and an excellent quality of life almost five years after her last surgery.
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