diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1013_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1013_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..386c672cb2bfbecf9168b94538d53f36746312d5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1013_en.txt
@@ -0,0 +1,4 @@
+A 15 year old Caucasian female was transferred from a secondary care paediatric unit. She presented with a two-day history of progressive dyspnoea, cough and palpitations on a background of recent onset arthralgia, alopecia and oral ulceration. Clinical examination revealed hypertension (blood pressure 170/110 mmHg), pallor with a malar rash, symmetrical polyarthritis of the interphalangeal and metacarpophalangeal joints, alopecia and oral ulceration.
+Investigations revealed normocytic anaemia, haemoglobin 95 g/l (normal 120-160 g/l), lymphopaenia, lymphocytes 0.9 × 109/l (normal 1.2–5.2 × 109/l)), elevated inflammatory markers with an erythrocyte sedimentation rate (ESR) of 77 mm/hr. (normal 1-9 mm/hr) and c-reactive protein (CRP) of 38 mg/l (normal < 10 mg/l) and moderately impaired renal function with urea 14.4 mmol/l (normal 2.0–6.0 mmol/l), creatinine 154 μmol/l (normal 30-90 μmol/l). Coagulation screen showed a slightly prolonged prothrombin time (PT) of 13 s (normal 10.2–12.0 s) but was otherwise normal. Albumin was low (28 g/l, normal 36-50 g/l) and liver function tests were normal. Microscopic haematuria and proteinuria were present with an elevated urine albumin:creatinine ratio of 1217 mg/mmol (normal < 3.4 mg/mmol). Antinuclear antibody titres were strongly positive with a titre of 1:160, speckled pattern. Anti double-stranded DNA was positive with a titres of > 379 IU/ml (normal 0-10 IU/ml) and positive Crithidia assay >/= 1:160. Anti-Smith and anti-RNP antibodies were both positive with titres of > 480 U/ml (normal 0–5.0 U/ml) and > 240 U/ml (normal 0-5 U/ml) respectively. There was marked hypocomplementaemia with C3 0.44 g/l (normal 0.7–1.7 g/l), C4 0.06 g/l (normal 0.1–0.7 g/l) and absent CH100 classical and alternative pathway components. Antiphospholipid, anti-SSA and anti-SSB antibodies were all negative. Chest x-ray showed bilateral pleural effusions and cardiomegaly with a cardiothoracic ratio of 0.67. Initial echocardiography showed a large pericardial effusion with diastolic compression of the right atrium and ventricle suggestive of cardiac tamponade. The left ventricle was dilated with an ejection fraction of 25% and there was mild mitral, tricuspid and aortic valvular regurgitation. Treatment was commenced with high-dose intravenous methylprednisolone (30 mg/kg/dose, maximum dose of 1 g) and diuretics and immediate transfer to a tertiary paediatric intensive care unit was arranged.
+On admission to the intensive care unit she had developed periorbital oedema and ascites with worsening dyspnoea and reduced oxygen saturation. Echocardiography revealed a large pericardial effusion, oedematous myocardium and valvulitis with an ejection fraction of 13% with no evidence of tamponade (see Fig. ). Renal function deteriorated further with a creatinine increase to 270 μmol/l (normal range 30-90 μmol/l) and the patient became anuric. Intermittent positive pressure ventilation, inotropic support, plasma exchange and haemodialysis were required. High-dose intravenous methylprednisolone was continued for 3 days and then changed to oral prednisolone at 1 g/kg/day. Cyclophosphamide was commenced at a dose of 850 mg/m2 on day four of admission due to severe renal impairment and ongoing need for haemodialysis and multiorgan involvement.
+Follow-up echocardiography showed normalisation of function by day five of admission with a small pericardial effusion as the only persistent abnormality. Renal biopsy revealed grade 4 lupus nephritis. The patient was discharged from the intensive care unit on day seven of admission and subsequently discharged from the hospital on day fourteen. Treatment at discharge included a weaning dose of prednisolone, hydroxychloroquine, enalapril and carvedilol. Cyclophosphamide treatment was continued monthly for a total of six doses after which the patient was maintained on further immunosuppression. Remission has been maintained with mycophenolate mofetil and hydroxychloroquine over the past 2 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1024_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1024_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4943616a10671c43852f37cfc57f07a8c440ef66
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1024_en.txt
@@ -0,0 +1,2 @@
+A 51-year-old, gravida 1, para 1, Japanese female complained of abnormal genital bleeding for two months and presented to a clinic. An ovarian tumor was found during abdominal computed tomography (CT), and so the patient was referred to our hospital. The abnormal genital bleeding had stopped when she visited our hospital. An ultrasound scan of her right ovary revealed a swollen region of 7 cm in diameter, which contained multiple cysts, and the uterine endometrium was 9-mm-thick. Cervical cytology and an endometrial biopsy produced normal findings.
+On magnetic resonance imaging (MRI), an ovarian tumor, which measured 7 cm in diameter and contained multiple cysts, was detected, and a large part of the tumor exhibited high signal intensity on T1-weighted imaging and low signal intensity on T2-weighted imaging. No solid components were detected . We decided to perform a laparoscopic right salpingo-oophorectomy. The patient’s medical history included endometriosis from the age of 25 without specific therapy and subarachnoid hemorrhaging due to the rupturing of an aneurysm at the age of 43. The patient was diagnosed with hydrocephalus after she underwent surgery for the subarachnoid hemorrhaging, and an LP shunt was inserted. Her medical history also included kidney stones, schizophrenia, hypertension, and diabetes mellitus at the age of 50. We confirmed the route of the LP shunt on a CT scan, which had been conducted at another clinic. It revealed that the LP shunt had been placed from her left flank to Douglas’ pouch . Under general anesthesia, laparoscopic right adnexectomy was performed. A 12-mm trocar was inserted at the umbilicus, and three 5-mm trocars were inserted 3 cm inside the right and left upper anterior iliac crests and on the midline of the lower abdomen. The abdominal pressure was set at 8 mmHg. The ovarian tumor was located in Douglas’ pouch and had adhered to the back of the uterus. Also, the head of the shunt tube was located in Douglas’ pouch and was an obstacle to the operation. We temporarily shifted the head of the shunt tube from Douglas’ pouch to the vesicouterine pouch to prevent damage to the shunt and ensure that the operation could be conducted smoothly . The operation time was 2 h and 11 min, and the total volume of intraoperative blood loss was 50 ml. The patient’s postoperative course was uneventful, and she was discharged on postoperative day 3. The histological diagnosis was an endometriotic cyst. The patient was examined at 1 month after the surgery at our hospital’s outpatient clinic, and no adverse events were observed. She was followed-up at the outpatient clinic of a general practitioner.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1048_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1048_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..14101451d382b3a32bc1b218f9110b0e159db996
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1048_en.txt
@@ -0,0 +1,4 @@
+The patient is a 54-year-old gentleman, who presented with a few months of mid-epigastric pain, nausea and vomiting with associated weight loss in February 2012. CT and MRI scans revealed a 3.3 × 3.1 cm pancreatic head mass encasing superior mesenteric artery and vein with associated mesenteric periportal lymphadenopathy. He also had sub-centimeter lung nodules presumed to be metastatic deposits. He thus had a clinical stage 4 unresectable pancreatic cancer. Genomic analysis of tumor biopsies revealed the presence of KRAS mutation (G12D) and loss of CDKN2A/B.
+The patient was placed on a clinical trial with first-line treatment of Reolysin and gemcitabine, receiving cycle one day one on March 2012. Reolysin was administered at a dose of 1 × 1010 TCID50 IV on days 1, 2, 8, and 9 (immediately after gemcitabine on days 1 and 8) in combination with 800 mg/m2 IV gemcitabine on days 1 and 8, with 21-day cycles. The patient displayed a clinical response with improvement in cancer-related pain. The best radiographical response was documented as stable disease by Response Evaluation Criteria in Solid Tumors (RECIST) guidelines .
+With the patient on treatment, a biopsy of the pancreatic mass was performed after cycle 25 day 8 in February 2014. The biopsy features were consistent with the diagnosis of pancreatic adenocarcinoma, with confirmed KRAS mutation (G12D) and loss of CDKN2A/B. Immunohistochemistry (IHC) was performed on Reolysin-treated or untreated HCT116 colon cancer cells as a positive and negative control for reovirus staining, respectively . Viral replication was detected using antibodies against the reovirus protein, as the presence of viral RNA may not necessarily imply infectious virus particles. A polyclonal antibody, raised in goats, was derived from mature reovirus viral capsid proteins . Importantly, IHC analyses of biopsy specimens from a pancreatic cancer patient revealed strong positivity for reoviral protein and activated caspase 3 within the tumor . Biopsies from pancreatic cancer patients frequently contain benign fat, which may serve as an excellent internal negative control. Images of the stained fat cells were negative for reovirus and active caspase-3 and were from the same tissues that displayed positive staining for reovirus and active caspase-3 . Serial section analysis showed a very high concordance of reoviral protein and activated caspase-3, which is characteristic of a productive reovirus infection. In addition, co-expression analysis demonstrated that the reoviral protein and active caspase-3 were being expressed in many of the same cancer cells . Our preclinical studies with Reolysin identified induction of ER stress and NOXA to be key determinants for Reolysin-mediated apoptosis [, ]. In agreement with the induction of active caspase-3, we also noted a significant increase in the expression of GRP78/BIP, which is commonly induced following ER stress and NOXA in the biopsy sample following Reolysin and gemcitabine treatment .
+Toxicities were manageable and included grade 1 fever likely due to Reolysin and grade 3 thrombocytopenia and neutropenia due to gemcitabine. The patient also had a biliary obstruction, which required stenting in November 2013. He completed 27 cycles of treatment with the last one in April 2014. At this time, he presented with disease progression with ascites and jaundice.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1059_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1059_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e4aa1f7ecbb3db9757c70cf7a0229428038c8889
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1059_en.txt
@@ -0,0 +1,11 @@
+The subject of our study, a 56-year-old Caucasian Italian woman, presents with an occlusal open bite and a complete dental formula, with only the left superior second premolar missing, substituted by an implantoprosthetic rehabilitation . The patient, a medical doctor, has a normal blood pressure range, is not affected by any metabolic disease and is a non-cigarette smoker. For the evaluation of her occlusal muscle activity, a bilateral electromyography (EMG) of her masseter muscle was recorded using an evaluation system of mandibular movement (K6-I; Myotronics, Seattle, WA, USA) and Duo-trode surface Ag-AgCl electrodes (Duo-trode; interelectrode distance: 19.5mm, Myotronics). EMG data were recorded at a sampling rate of 240Hz and amplified at a time constant of 0.06 seconds. For the evaluation of her muscle activity, voluntary dental clenching was executed and recorded during swallowing. In accordance with the dental diagnostic protocol , a preliminary evaluation of the patient’s myoelectric activity in dental occlusion was performed through muscle EMG in order to assess their functional balance. Registered values showed a remarkable functional asymmetry of masseter muscles, 23mV for her left masseter and 103mV for her right masseter . According to the expressed electromyographic values, muscular activity was symmetrized by applying a 15 minutes transcutaneous stimulation of trigeminal motor branches at low frequency for elevator occlusal muscles and at medium frequency for submandibular antagonist muscles. This method allowed detection of the functional trajectory of occlusal elevator muscles and to record a symmetric craniomandibular relation, positioning a self-hardening material between the dental arches. The same material was used to make a cusp bite modeled on the inferior dental arch named orthotic-syntropic bite for its peculiar use of electrostimulation. When the orthotic was applied, electromyographic control was repeated to verify occlusal myoelectric balance. Registrations have documented substantially equal values: 57mV for left masseter muscle and 61mV for right masseter . Immediately after, the patient was submitted to pupillometric and hemodynamic examinations in habitual occlusion first and with the orthotic soon after.
+For pupillary diameter measurement, we used a computerized corneal topographer MODI02 software 2005 LITE (CSO, Florence, Italy), made of a survey section by Placido disk 24 loops, camera sensor charge-coupled device (CCD) 1/3 inch and a claim support. The instrument presents, during the pupillar acquisition phases, a constant lighting of the disk and a 56mm distance of work. The points measured during data acquisition are 6.144, with a model elaboration higher than 100.000 points. Registered pupillometric analysis showed a remarkable right and left baseline asymmetry, respectively 4.98mm and 4.40mm , whereas in the occlusal rebalance condition an equivalent pupil diameter was registered, 4.13mm right pupil and 4.10mm left pupil . Indeed, pupillometric data analysis registered in occlusal rebalance shows a more suitable reduction of the basal diameter, with clear right side decrease, relating to higher occlusal myoelectric values.
+For blood flow computerized examination, a GE HealthCare echograph, Voluson E8 Expert model, was used, with a 3D-4D-color-power Doppler volumetric probe. The duplex color scanner investigations were executed with an interval of 60 minutes, in habitual occlusion first, and with the orthotic after . The following evaluations were performed (see Table ).
+systolic pulsatility and average flow velocity: (P.I. Index);
+systolic and diastolic relationship-flow: (R.I. Index);
+systolic peak in cm/second: (P.S. Index);
+diastasis cordis in cm/second: (E.D. Index);
+systole-diastole relationship: (S-D Index);
+Carotid artery: C.a.;
+Vertebral artery: V.a.
+The registrations reveal that the patient’s left V.a. hemodynamic is more influenced by trigeminal proprioception. In fact, the orthotic application reduces on the left the S-D index of 70.94 and equilibrates the values of both vertebral arteries, 3.40 (left) and 3.21 (right), respectively. Whereas, in the ED index, diastolic flow increase of 12.06 cm/second of the left V.a. makes the values of both arteries equal, 12.70 (left) and 12.16 (right) respectively. Moreover, in the PI index it is possible to observe that the different average flow between the right (1.0) and left (2.88) vertebral arteries is totally cancelled in occlusal rebalance, with perfectly equal values (1.23). Also the PS Index confirms the previous results because a general reduction of hemodynamic values is registered both in carotid and vertebral arteries after orthotic application. In fact, the systolic hematic peak, expressed in cm/second, shows decreases of 2.05 on the right and of 7.69 on the left in the carotid arteries, while in vertebral arteries the decreases are of 7.42 on the right and of 4.37 on the left. The RI index does not seem to be influenced by occlusal proprioception.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1065_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1065_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bc4153ee5c2df78de04c3a7060370b48443cd39e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1065_en.txt
@@ -0,0 +1,5 @@
+We describe the case of a 25-year-old black Cameroonian woman of Bakossi origin with basic primary education, gravida 3 para 1 (G3P1010), who lost a child in 2012 following complications of neonatal infection and later had an abortion in early 2015. She presented to a district hospital in the South-West Region of Cameroon for her first antenatal visit with a 21-week pregnancy. Her blood pressure was 107/66 mmHg and she had a uterine fundal height of 26 cm.
+She was requested to do some paraclinical examinations including blood group, hemoglobin level, glycemia, human immunodeficiency virus (HIV), syphilis, toxoplasma, rubella serology, stool analysis, urine analysis, and a fetal ultrasound. Most of these tests were done and were found to be normal. However, toxoplasma and rubella immunoglobulin G (IgG) serologic tests were both reactive; analysis was done with the aid of ImmunoComb® IgG and ImmunoComb® II IgG serologic tests, respectively. She also had a proteinuria of 100 mg/dl; her blood group is AB rhesus positive. She did not benefit from a morphologic fetal ultrasound partly because there was none in the hospital and because of the financial constraints she presented, which limited her movement to the nearest regional referral hospital located approximately 100 km from the site of her antenatal clinic via a poorly accessible road. She was, however, put on daily 65 mg of elemental iron and 5 mg of folic acid supplement, and she received anti-tetanus vaccine, intermittent preventive treatment against malaria, and a long-acting insecticide-treated bed net. She was encouraged to consult a gynecologist-obstetrician at the nearest referral hospital.
+By her next antenatal visit 4 weeks later, she had not consulted the specialist physician and was still unable to attend the paraclinical examination requested earlier. Emphasis was placed on the risk of her baby sustaining life-threatening malformations and she was advised to continue with the supplements and follow-up visits. She was again encouraged to undergo a fetal ultrasound and to consult a gynecologist-obstetrician. Adding to the challenges faced by this expectant mother, the district hospital did not have an ambulance that could have helped the health care provider to overcome the road accessibility and financial challenges she faced.
+During her 34th week of pregnancy she returned to the hospital in labor pains with a blood pressure of 110/68 mmHg, uterine fundal height of 40 cm, and was at 8 cm cervical dilation with bulging membranes. After placing her on a 5% glucose infusion, the membranes were ruptured, and a turbid amniotic fluid of approximately 2000 ml oozed out. This was followed by the delivery of an anencephalic recently dead baby boy weighing 1600 g. Active management of third stage of labor was done (Additional file ).
+The devastated mother and her partner received psychosocial care for 3 days; she was discharged from hospital and scheduled for routine psychosocial follow-up. She was further counseled on the need to consult a gynecologist-obstetrician before her next pregnancy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1118_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1118_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bb4b1f29d27a7b5a61d42bc602cd57e0872614ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1118_en.txt
@@ -0,0 +1,6 @@
+The patient is a 69-year-old female who underwent a right radical nephrectomy 10 years ago, in 2011 for a pT3b N1 M0 grade 3 clear cell carcinoma of the right kidney. Adjuvant sunitinib therapy was initiated and then discontinued after 2 months due to myelosuppression and rash. In February 2013, the patient was found to have recurrence in the right lung upon follow-up CT imaging. The patient was started on sunitinib and then switched to pazopanib February 2014 due to progression. Pazopanib was held briefly during radical radiotherapy to oligometastatic disease.
+The patient developed hypertension a couple of months after starting pazopanib. This was effectively treated with amlodipine. After persistently stable disease, she made a joint decision with her oncologist to discontinue her pazopanib June 2019. She did not experience any other side effects while on pazopanib except for some moderate gastric reflux. Her past medical history is only significant for hypothyroidism and hiatal hernia. She has family history of a father who died in his 60s of a myocardial infarction and sisters with hypertension. She has a substance history of a remote 3 pack year smoking history and occasional alcohol use. Her most recent BMI was calculated to be 24.4.
+In July 2020, CT imaging showed recurrence with enlargement of a left apical pulmonary nodule. She received radical intent radiotherapy with a dose of 60 Gray in 30 fractions, then she was started back on pazopanib. Due to severe reflux symptoms and the development of atrial fibrillation, pazopanib was briefly held January 2021 and restarted February 22, 2021. She was also placed on bisoprolol and warfarin by her cardiologist during this period. CT of her chest, abdomen, and pelvis on February 10, 2021 did not reveal any signs of disease progression and demonstrated normal splenic artery anatomy .
+On March 5, 2021 at 10 pm, the patient suddenly developed excruciating, sharp left upper quadrant pain that radiated to her entire abdomen. She had associated nausea and loose bowel movements but no vomiting, fever, lightheadedness, rashes or petechiae. She activated emergency medical services and was brought to her local emergency department in Northern Ontario. Her pain improved with IV opioid analgesics, but her abdomen became continually distended and her hemoglobin dropped into the low 70s. A CT of her abdomen and pelvis was performed to reveal free fluid within the peritoneal cavity and contrast pooling noted adjacent the splenic hilum, related to the splenic artery . The splenic artery measured 1.5 cm representing either a ruptured aneurysm or pseudoaneurysm. The patient ultimately received Vitamin K, 6 units of red blood cells and was transferred to a tertiary center elsewhere in Ontario for definitive treatment of her ruptured splenic artery aneurysm.
+She had coil embolization of the splenic artery by intervention radiology . Her recovery was complicated by a post-operative hematoma and elevated troponin, no intervention was required.
+After an extended stay in hospital, the patient was discharged home and pazopanib was discontinued. In a follow-up appointment, the patient does not disclose any complaints and states her home blood pressure has been stable. The patient remains in good health at the time of writing this case report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1122_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1122_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd00e252eaa10703b30ef34b5a915a08a6380d74
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1122_en.txt
@@ -0,0 +1,8 @@
+A 40-year-old female patient visited the emergency department (ED) with a 3 d history of fever, minor headache, and abdominal pain.
+The patient had been living in a postpartum care center after giving birth by cesarean section 3 wk prior to her ED visit. Eleven days prior, the front of her neck was swollen, and a needle aspiration was performed at a private surgical hospital; however, her thyroid gland showed no specific findings.
+The patient had no relevant medical history, apart from a cesarean section performed 3 wk before presentation.
+The patient denied any family history of malignant tumors.
+During physical examination in the ED, the patient’s vital signs were measured: Body temperature (40.6 ℃), blood pressure (100/48 mmHg), heart rate (100 bpm), and respiratory rate (18 breaths/min). No specific findings were observed in the thyroid gland. Moreover, no notable clinical findings such as neck stiffness, tonsil hypertrophy, abdominal tenderness, abnormal breath sounds, or costal spine angle tenderness were observed. Additionally, the patient exhibited no signs of infection at the site of abdominal surgery (cesarean section) or thyroid fine-needle aspiration. Colposcopy was performed to preclude endometritis; however, no specific findings were observed.
+The patient’s laboratory test results revealed bicytopenia (hemoglobin: 14.0 g/dL; platelets: 133000/μL; absolute neutrophil count: 2512/μL). However, other laboratory tests including total bilirubin level measurement (0.3 mg/dL), liver enzyme level measurement [aspartate transaminase (AST): 65 U/L; alanine transaminase (ALT): 35 U/L], thyroid function test (T3: 65.1 ng/dL; free T4: 0.88 ng/dL), and urinalysis (one white blood cell/high-powered field), showed no significant abnormalities. The C-reactive protein (CRP) level was elevated at 4.46 mg/dL.
+The patient’s chest radiograph was normal. Abdominal computed tomography (CT) was performed due to elevated CRP levels and intermittent post-delivery abdominal pain. However, a prominent infectious focus was not observed.
+After administration of an antipyretic drug, the patient’s fever subsided, and vital signs remained stable during long-term follow-up in the ED. Four days later, the patient was discharged with a prescription for broad-spectrum antibiotics and a referral to the infectious disease outpatient department to evaluate her fever of unknown etiology. However, 4 d after discharge, the patient returned to the ED with a fever of 38 ℃ and decreased blood pressure of 60/30 mmHg. Laboratory test results revealed thrombocytopenia (platelets: 94000/μL), and other test results [total bilirubin level: 3.1 mg/dL; liver enzyme levels (AST: 202 U/L; ALT: 444 U/L)] and renal function indicators (blood urea nitrogen: 42.1 mg/dL; creatinine: 3.35 mg/dL) indicated multiorgan failure. The patient’s ferritin and triglyceride levels were 3429.0 μg/L (normal range: 13.0-150.0 μg/L) and 957 mg/dL (normal range: 10.0-150.0 mg/dL), respectively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1129_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1129_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b2f01a4d9ac573f3e702fddb846e09d8aa8a6a1a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1129_en.txt
@@ -0,0 +1,3 @@
+A 40-year-old woman and her husband had recently travelled from the United States to Bogota, Colombia for 7 days. They spent time outdoors in both urban and rural areas. She recollects having had mosquito bites and had three bite marks on her leg. She was asymptomatic during her stay.
+On day 3 after returning to the USA, she developed itching of her scalp. On day 4, she felt fatigued and developed low-grade fever and back pain. On day 5, she presented to the outpatient infectious diseases clinic for evaluation after her scalp became erythematous and she started developing a pruritic, maculopapular rash on her face and trunk that rapidly spread over her entire body. Her wrist and ankle joints became very painful and swollen. She also developed a pressure-like sensation behind her eyes with conjunctival redness.
+She had received yellow fever vaccine previously. She lived in an area of Florida with no local transmission of CHIKV or DENV. There had been no other recent travel. Her husband who travelled with her was asymptomatic and was not tested.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1143_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1143_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e4b0ed42d2247b221dd8ad7c8ea726e457eeb572
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1143_en.txt
@@ -0,0 +1,3 @@
+A 27-year-old Japanese man was brought to the emergency room with coma. He was diagnosed as having schizophrenia at the age of 13 and as having autism spectrum disorder at the age of 18. The medication at that time was 50 mg/day of atomoxetine, 5 mg/day of risperidone and 3 mg/day of guanfacine, although risperidone was decreased from 9 to 5 mg and guanfacine was increased from 2 to 3 mg 35 days before. He had been drinking over 4 L of water for the last few weeks. His impaired consciousness level was 3 points (E1V1M1) of the Glasgow coma scale (GCS). His vital signs were as follows: temperature, 39.1°C; blood pressure, 174/98 mmHg; heart rate, 95 beats/min; oxygen saturation, 92% (under 9 L of O2 supply). shows laboratory data in emergency room. He suffered from abnormal balance of electrolytes. As shown in , he had significant hyponatremia and hypochloremia with normal potassium concentration, and reduction of blood osmotic pressure. His inflammation markers were markedly elevated. In addition, he suffered from rhabdomyolysis. Indeed, his creatine kinase, myoglobin and urinary myoglobin levels were significantly high. As shown in , his head computed tomography (CT) revealed severe cerebral edema. In addition, significant fluid retention was observed throughout the body, namely, pleural effusion, pulmonary and intestinal edema . We evaluated the causes of hyponatremia in this patient. Since antidiuretic hormone (ADH) level was elevated to 0.8 pg/ml when sodium level was 109 mmol/L, we diagnosed him with syndrome of inappropriate secretion of ADH (SIADH). Based on these findings, we thought that he probably suffered from severe cerebral edema which was induced by hyponatremia associated with NMS and SIADH. In addition, rhabdomyolysis and NMS was diagnosed necessitating comprehensive therapy in intensive care unit (ICU).
+On admission to ICU, he required mechanical ventilation and administration of 0.9% NaCl. Moreover, we started immediately administering 10% glyceol (600 ml/once a day, 5 days + 400 ml/once a day, 2 days + 200 ml/once a day, 2 days) for cerebral edema and continuous furosemide (3 days) for diuresis. In addition, he was treated with methylprednisolone (1,000 mg/once a day, 3 days) for cerebral edema and suspection of autoimmune encephalitis, and with dantrolene (40 mg/once a day, 1 day + 100 mg/once a day, 4 days + 60 mg/once a day, 2 days) for NMS. Eye openings and spontaneous limb movements were observed several times at day 2 (his sodium level, 115 mmol/L). His impaired consciousness was improved and he was able to speak sometimes at day 3 (his sodium level, 130 mmol/L). The patient was extubated at day 3 and his head CT revealed the improvement of severe cerebral edema at day 4 . Finally, we successfully treated severe cerebral edema and hyponatremia, which was induced and complicated with NMS, water intoxication, SIADH and rhabdomyolysis. shows a time course of his cerebral edema and shows his clinical time course in ICU. His adrenal and thyroid function was normal (adrenocorticotropic hormone, 61.7 pg/ml; cortisol, 13.0 μg/dl; thyroid stimulating hormone, 3.208 μIU/ml; free triiodothyronine, 2.89 pg/ml; free thyroxine, 1.03 ng/dl; respectively) after correction of hyponatremia. He was transferred from ICU to general ward at day 9 and was discharged 29 days after admission.
+After discharge, he was followed-up by the psychosomatic center of another hospital. He continued to receive the same psychosomatic treatment and did not have recurrence of malignant syndromes or water intoxication.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1162_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1162_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd9f3c7b6b46709da5cf536fb97919d0bb0a2cfa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1162_en.txt
@@ -0,0 +1,6 @@
+A 20-year-old Greek man presented to our hospital in late May of 2010 because of high fever (up to 40°C, unresponsive to anti-inflammatory drugs), appetite loss, nausea and vomiting, persistent headache and a feeling of significant malaise for 5 days. He was diagnosed at a provincial hospital with an atypical infection and had received azithromycin for 3 days, without any improvement.
+He had not travelled recently either within the country or abroad. He denied intravenous drug use, new sexual partners or tattoos. He had no animal exposure. He did not use tobacco products or alcohol and had not taken any medication. He was previously healthy. According to his medical history, he reported allergic rhinitis and conjunctivitis for his first 5 years of life, chickenpox at the age of 5 years, a streptococcal pneumonia at the age of 6 years, several episodes of tonsillitis until the age of 12 years and a tonsillar abscess at the age of 11 years. He reported no drug allergies. No contacts with similar symptoms were identified. He had no antecedents of Asian origin. The family history was non-contributory and no family members had rheumatic diseases.
+On admission, his temperature was 38.3°C, blood pressure at 80/50mmHg, pulse was measured at 100 beats per minute and blood oxygen saturation at 92%. A physical examination revealed bilateral conjunctival chemosis, strawberry lips and tongue, dry mucus membranes, a mild skin rash of his trunk, erythema of his thenar and opisthenar regions of both palms, an oedema of palms and soles and tachycardia with S3 and S4 gallop. Results of examinations of his lungs, abdomen, neurological and musculoskeletal systems were normal.
+Laboratory findings revealed leucocytosis (13.2×103 per cubic millimetre) with neutrophilia (91%) and left shift with segmented neutrophils, anaemia (haematocrit 33%) and normal platelets upon admission, which were later elevated . Acute phase reactants were elevated: erythrocyte sedimentation rate (ESR), 127mm 1st hour; CRP, 30mg/dL and fibrinogen 761 seconds. Serum creatinine levels and serum glutamic oxaloacetic transaminase rates were normal, serum glutamic-pyruvic transaminase at 80IU/L, alkaline phosphatase at 147IU/L, gamma-glutamyl transpeptidase at 67IU/L, lactate dehydrogenase at 263IU/L, creatine kinase at 254IU/L, bilirubin was normal, albumin at 3.1g/dL and sodium at 132mmol/L. Urine analysis was normal. Results of blood and urine bacterial cultures and serological tests for bacteria and viruses were negative. Alpha 2 and gamma immunoglobulin levels were elevated. All blood tests for autoimmune diseases were negative. Immunophenotype examination revealed reduced cardinal number of CD3+CD8+ T lymphocytes. The results of a chest X-ray, an electrocardiogram and a transthoracic echocardiogram were normal.
+The patient did not respond to broad-spectrum antibiotic treatment. Desquamation of his fingers and toes began on the seventh day since the disease onset. Autoimmune diseases and juvenile idiopathic arthritis were excluded, as he did not fulfil diagnostic criteria for any of these diseases. Drug hypersensitivity reactions could explain his clinical appearance; however, he was previously healthy and there was no need for him to take medication. Immediately after the suspicion of KD (on the 10th day after the onset of symptoms), he was given IVIG at 2000mg/kg once and aspirin at 50mg/kg orally for the first 3 days, and at 100mg per day for another 3 months. His treatment was based on the diagnostic criteria developed for KD in children because there had been no validated criteria for adult cases of KD. Antibiotic treatment was discontinued at this time.
+Immunoglobulin and aspirin had a striking result, since the patient was afebrile and in better condition on the very next day after the initiation of treatment. During the following days, all clinico-laboratory findings gradually improved and only a reactive thrombocytosis remained. In total, he remained hospitalised for 10 days. A computed tomography coronary angiography performed 1 month later showed no coronary aneurysms. Today, about 5 years later, our patient remains healthy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1179_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1179_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a3fe427412191792e28de96e789305f273a90e3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1179_en.txt
@@ -0,0 +1,2 @@
+A 65-year-old Japanese man was diagnosed in April 2010 with stage IV lung adenocarcinoma, manifesting multiple metastases in the lung, adrenal gland and brain. He received 31 Gy of basicranial radiation for the brain metastases. Given that he was found to harbor an epidermal growth factor receptor (EGFR) mutation, he was also treated with the EGFR-specific tyrosine kinase inhibitor (TKI) gefitinib (250 mg/day). As a result of the development of adverse effects including fatigue, dermatitis, and liver dysfunction, however, the dose of gefitinib was initially reduced by half and treatment with the drug was subsequently discontinued after a total of 2 months. Computed tomography and magnetic resonance imaging revealed that the size of the original lesion and the number of brain metastases had increased. Treatment with the combination of cisplatin (125 mg) and pemetrexed (0.75 mg) was initiated. After 8 weeks, this regimen was switched to vinorelbine (32 mg) and docetaxel (80 mg) because of the development of adverse effects. This latter treatment was also not tolerated well, and so administration of the EGFR-TKI erlotinib (150 mg/day) was initiated. The patient again experienced general adverse effects including dermal exanthema. At this time, he developed a foreign body sensation in both eyes and visited his local ophthalmologist, who referred him to the corneal service at Yamaguchi University Hospital for the treatment of corneal epithelial disorders with corneal thinning.
+Slitlamp microscopy revealed bilateral superficial punctate keratopathy and conjunctival epithelial disorders. Corneal ulceration on his right eye was also observed, but no signs of infection or inflammation were apparent. His visual acuity was 20/25 OD and 20/25 OS. Schirmer's test detected bilateral mild hypolacrimation (5 mm), and his corneal and conjunctival epithelial disorders were thus attributed to aqueous-deficient dry eye. We treated him by insertion of punctal plugs in both lower lacrimal puncta. Three weeks after plug insertion, his corneal and conjunctival epithelial disorders had apparently improved. However, 2 months after his first visit to our clinic, he was referred to us again for the treatment of bilateral corneal ulcers, which were confirmed by slitlamp microscopy . Slight stromal edema, ulceration with an opaque epithelium, and a shallow anterior chamber were also observed in the right eye. The next day, the anterior chamber of the right eye was flat, and so we treated this eye with a bandage soft contact lens. The right anterior chamber remained flat, however, and the patient was diagnosed with noninfectious corneal perforation of unknown cause and was prepared for tectonic keratoplasty. The oral administration of erlotinib was interrupted in preparation for general anesthesia, and the patient was treated with gatifloxacin eyedrops only. Two days later, the anterior chamber of his right eye had spontaneously reformed and the epithelial defects of both eyes had healed . The keratoplasty was therefore canceled and we monitored the patient carefully, but his corneal condition remained stable. Treatment with erlotinib at half the original dose was reinitiated and both eyes were maintained by the administration of artificial tears, with the punctal plugs remaining in place. Corneal ulceration or other corneal disorders did not recur.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1219_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1219_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2bc8f5de23bb237837a35c6acecb9fb3cbc2ae01
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1219_en.txt
@@ -0,0 +1,3 @@
+A 25-year-old woman was referred to our outpatient clinic with complaints of chronic headache and irregular menses. Hormone profile showed only moderate increase in Prolactin (96 ng/ml). Sellar magnetic resonance imaging (MRI) showed a pituitary mass. The patient had total pituitary adenectomy using an endoscopic endonasal transsphenoidal approach. After tumor resection, diaphragmatic opening was seen with intra-operative evidence of CSF leak. Sellar floor reconstruction was performed by mucosal graft and Glubran®2 glue filling the surgical cavity. Early post-operative period was uneventful and clinical and histopathologic finding were consistent with a non-functional pituitary adenoma.
+After 2 months of surgery, the patient complained of headache, facial pain and greenish foul-smelling nasal discharge with solid particles. Patient was diagnosed with rhinosinusitis and treated with multiple courses of nasal decongestants and antibiotics for 4 months but without improvement. Brain MRI showed inflammation and thickening of the sphenoidal and para-sphenoidal mucosa .
+Surgery with endoscopic endonasal approach was decided. Intra-operatively, the sellar floor was seen intact with no CSF leak nor discharge. A solid glass-like patches (acrylic glue) was seen in the inferior and lateral areas of the sphenoid sinus and was surrounded with inflamed infected mucosa and abundant pussy discharge . Efforts were made to erupt and de-crust the solid mass until total resection was achieved. Early post-operative period was uneventful, and a course of antibiotics was continued until total regression of the discharge. Endoscopic follow-up was performed in the 1st, 2nd and 3rd post-operative months, and showed no signs of rhinosinusitis with well-healed nasal mucosa.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1224_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1224_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3af5c4b2d7306512cb918b3dfbcf9983016f8d5c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1224_en.txt
@@ -0,0 +1,9 @@
+A 35-day-old girl was admitted to Kunming Children’s Hospital in October 2019 due to a lesion in the right frontotemporal region.
+The lesion was found at birth, as a subcutaneous mass with granular and papillary surface. The patient was firstly diagnosed with “cavernous hemangioma”, without treatment. The skin lesion easily bled upon touch, and showed repeated ulceration, erosion, and scab formation. There was no obvious enlargement of the lesion and subcutaneous mass from birth until now.
+The patient was born at 38 wk of pregnancy, with a birth weight of 3.1 kg and no perinatal infection or suffocation.
+The patient had no specific personal and family history.
+Physical examination revealed good general condition. The vital signs were stable, and no other abnormality was found. Dermatological examination showed a red lesion in the right frontotemporal region, with thick brown scab on the surface. After cleaning the scab, the surface of the skin lesion was bright red, appearing like granulation tissue. The lesion was granular and papillary and easily bled upon touch, with about 1.5 cm × 4 cm in size. A small amount of pale yellow thin secretion was observed on the lesion surface. There was a pedicle at the base of the skin lesion. A subcutaneous mass was felt at the base of the lesion, with slightly hard texture and a clear boundary. The mass expanded beyond the red area, with a size of about 3 cm × 5 cm. The surrounding skin had no redness or swelling, and the mass showed no tenderness .
+Blood routine test showed lymphocyte count at 4.51 × 109/L (1.0-3.0 × 109/L), lymphocyte percentage at 60.60% (20%-40%), neutrophil percentage at 30.80% (50%-70%), platelet count at 528 × 109/L (100-300 × 109/L), platelet hematocrit at 0.52% (0.108%-0.282%), and platelet distribution width at 10.0 fL (15.5-18.1 fL). The remaining indicators were unremarkable. Surface secretions were cultured for 48 h, and three plasma coagulase tests were negative; meanwhile, mixed growth of Staphylococcus was detected, with no Haemophilus isolated. Stool routine, urine routine, liver function, and kidney function tests were normal. These laboratory findings did not point to any specific diagnosis.
+Skull plain computed tomography (CT) and enhanced scans showed slightly thickened subcutaneous soft tissue of the right temporal region, and the stripes showed a high-density shadow, with a CT value of about 31 HU. Enhanced CT showed enhancement, with a CT value of about 61 HU. No obvious signs of damage were seen in the adjacent skull. There were no lesions with definite abnormal density in the brain parenchyma (no obvious abnormal enhancement). There was no enlargement, stenosis, or occlusion in the ventricular system; no widening of subarachnoid space of each ventricle or displacement of the midline structure was found.
+Dermatoscopy showed that the skin lesion was lobular and crumby. The lesion center was reddish or white, while the edges were white or yellowish band-like. There were polymorphic vascular structures and white radial streaks in the lesion, with some vascular clusters scattered .
+Pathological examination showed papilloma-like hyperplasia of the epidermis, with the epidermis partly sinking into the dermis to form several cystic depressions, lined with stratified squamous epithelium. Glandular cavity-like structures were seen in the dermis, with some opened into the epidermis. A large number of lymphocytes, neutrophils, and plasma cells infiltrated in the interstitial area was observed, as well as splinter hemorrhage. The cavity wall and villous epidermis of the glandular cavity were composed of two layers of epithelial cells; the inner layer included columnar cells, with oval and eosinophilic nuclei and abundant cytoplasm; apocrine secretion was observed .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1225_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1225_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f00681993970e623cc3eee0ec1774774655819b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1225_en.txt
@@ -0,0 +1,6 @@
+On April 26th, 2020, a 68-year-old man presented to the emergency department with symptoms of acute progressive symmetric ascending flaccid tetraparesis. Patient medical history included dyslipidemia, benign prostatic hypertrophy, hypertension, and abdominal aortic aneurysm in follow-up. Ten days before admission, dry cough associated with fever, dysgeusia, and hyposmia appeared. Neurological manifestations started 5 days later with progressive acute weakness of distal lower extremities.
+On admission, oxygen saturation was 96% on room air, with a respiratory rate of 17 breaths/min, and the body temperature was 37.2 °C. Chest computed tomography highlighted a bilateral basilar ground glass opacity, with oropharyngeal swab positive for SARS-CoV-2 on reverse transcriptase-polymerase chain reaction (RT-PCR) assay. No pathological findings were auscultated on pulmonary objective examination.
+The patient was then isolated and antiviral drugs have been started. Neurological examination showed bifacial nerve palsy (House-Brackmann grade 3) and muscular weakness, with a Medical Research Council scale of 1/5 in proximal and 2/5 in distal of the lower limbs. The osteo-tendon reflexes were hypoactive with bilateral areflexia to the Achilles tendons. No sensory deficit was recorded. Upper motor neuron disorder or meningeal irritation signs have not been found.
+Baseline laboratoristic analysis showed thrombocytopenia (101 × 109/L, reference value: 125–300 × 109/L) and lymphocytopenia (0.48 × 109/L, reference value: 1.1–3.2 × 109/L). Cerebrospinal fluid assessment showed an albuminocytologic dissociation with increased protein level (98 mg/dL, reference value: 8–43 mg/dL) and normal cell count (2 × 106/L, reference value: 0–8 × 106/L). Additional serological tests (i.e., ANA, anti-DNA, c-ANCA, p-ANCA, Campylobacter jejuni, Mycoplasma pneumoniae, Salmonella enterica, Cytomegalovirus, Epstein-Barr virus, herpes simplex virus 1 and 2, Varicella-Zoster virus, influenza virus A and B, human immunodeficiency virus) were negative. Normal serum vitamin B12 level and serum protein electrophoresis were found.
+Four days after neurological symptoms and signs onset, motor nerve conduction studies showed delayed distal latencies and absent F waves in early course, supporting demyelinating pattern in accordance with GBS diagnostic criteria . Sensory nerve conduction showed nerve action potentials; the recorded values were all in range, in line with the patient clinic.
+A diagnosis of Guillain-Barré syndrome was then made. Intravenous immunoglobulin was administered at a dose of 0.4 g/kg for 5 days. Thrombocytopenia and lymphocytopenia progressively returned in the following days, with complete resolution of the admission radiological pulmonary findings. The improvement of the respiratory and laboratory clinic was followed by a progressive recovery of limb strength and a return to osteo-tendon normoreflexia. Thirty days after hospitalization, following the negative result of the oropharyngeal swab for SARS-CoV-2, the patient was discharged to continue the rehabilitation program at home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1234_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1234_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ca0201d2df8169df09b82107309c14195617ee5b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1234_en.txt
@@ -0,0 +1,7 @@
+A 63-year-old Caucasian woman presented to the outpatient cardiology office with dyspnea on exertion and weakness.
+Patient presented with recent onset dyspnea on exertion and weakness for 1-2 wk. Review of systems was positive for palpitations, fatigue and weight gain, but negative for chest pain, syncope, fever and cough.
+Past medical history included hypertension, hypothyroidism, right breast ductal cell carcinoma treated with mastectomy and breast implant, platelet granule disorder, asthma requiring chronic intermittent prednisone use.
+Physical examination revealed a regular pulse of 72/min, blood pressure 138/95 mmHg and body mass index 26.7 kg/m2. Cardiac examination revealed normal heart sounds without murmur or gallop. Her lungs were clear to auscultation. Bilateral trace pitting edema was noted at her ankles.
+Electrocardiogram (EKG) showed normal sinus rhythm with right bundle branch block (RBBB), unchanged from prior EKG. Thirty-day event monitoring showed 3 episodes of isolated supraventricular ectopics which represented < 0.1% of the total beat count. During hospitalization for community-acquired pneumonia, the patient developed symptomatic paroxysmal atrial fibrillation (AF) .
+Transthoracic echocardiogram showed a right ventricular (RV) mass, preserved RV function and a preserved ejection fraction of 60%-65%. A biopsy was not pursued given the high risk of bleeding due to platelet granule disorder. Cardiac MRI showed LHIS as well as well-defined capsular mass along the epicardial surface of RV free wall diffusely infiltrating the myocardium and mediastinal lipomatosis . No early or late enhancement of mass with gadolinium contrast was seen, suggesting a benign cardiac lesion. The characteristic features of the lesions in RV and IAS on fat suppression of the imaging provided a diagnosis of cardiac lipoma and LHIS respectively.
+Genetic testing for arrhythmogenic right ventricular dysplasia (ARVD) and 24-h urine cortisol test was negative.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1242_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1242_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2144000323d539f3d942f546a719bbcbb859a0a7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1242_en.txt
@@ -0,0 +1,4 @@
+A 61-year-old German woman presented to our orthopedic clinic after Felix IV fracture in revision total knee arthroplasty. Two years ago, the patient had undergone revision TKA with a rotating hinge prosthesis complicated by an intraoperative fracture of the tibial tubercle. Screw fixation had been performed, but 3 months later nonunion of the fragment had persisted, resulting in plate osteosynthesis with a one-third tubular plate. After another dislocation of the tibial tubercle, the patient presented to our clinic with anterior knee pain, loss of extension strength, and a feeling of rotational instability. On clinical examination, pressure pain of the proximal tibia, decreased extension strength to Janda 3/5, and inability to raise the extended knee were noticed. This maintained extensor function is the result of an intact medial and lateral retinaculum. The knee’s range of motion was 0–110° of flexion with preserved mediolateral and anterior/posterior stability. X-ray showed the rotation hinge prosthesis without loosening signs, the one-third tubular plate, and the dislocated tibial tubercle fragment indicating persistent Felix IV C fracture .
+Reconstruction of the knee joint’s extension system was planned. After preparation of the subcutaneous tissue, the dislocated tibial tubercle appeared surrounded by extensive metallosis presumably induced by the contact between the one-third tubular plate and the tibial prosthesis. Following the removal of the plate, the fragment proved to be necrotic requiring a total extirpation instead of mobilization and refixation. Subsequently, the ventral surface of the tibial prosthesis was exposed . Reconstruction of the extension system should be performed by the implantation of MUTARS attachment tube made of polyethylene terephthalate. Since the tibial prosthesis did not offer any connecting points for the synthetic graft, cement was used as an extender to simultaneously serve as fixing point and to preserve the prosthesis from loosening. Afterwards, the tube was doubled into a laminar sheet and fixed with two cancellous bone screws in the ventral tibia . ORTHOCORD sutures were used to attach the tube to the articular capsule still beyond the patella . Extensive jet lavage was performed before wound closure. Check of patellar tracking was promising; likewise, postoperative X-ray showed regular patella position .
+To support the integration of the tube in the surrounding subcutaneous tissue, knee flexion was at first limited to 30° and then escalated to 60° and 90° every 2 weeks with full weight-bearing.
+Follow-up was performed after 3 and 10 months. On clinical examination , the patient showed irritant-free skin and soft tissue conditions; no redness or overheating; extension/flexion 0–0–110°; straight-leg raise completely possible; and force level 4/5 on side comparison of the knee stretchers. Active knee stretching with a flexed knee joint was possible without any problems. There was a centered patella run and no subluxation of the patella. Peripheral circulation, motor skills, and sensitivity were intact. X-ray confirmed correct implant position and central patella tracking . The patient was highly pleased by the restored extension function and significantly reduced knee pain.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1249_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1249_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9e2bdfcbabd02c9bbb46c65b9a70bdbb27f39648
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1249_en.txt
@@ -0,0 +1 @@
+A 15-year-old male presented to the emergency department with a 4-hour history of substernal chest pain and reported an episode of syncope lasting a few minutes. He also reported homicidal ideation and audiovisual hallucinations. The patient reported using “Spice”, a synthetic cannabinoid, repeatedly over the last few hours in order to maintain his euphoric mood. He used a vaporizer for consuming “Spice”. The patient was agitated and experienced audiovisual hallucinations instructing him to harm himself and others. He had no prior psychiatric or medical history. He denied drug allergies. Surgical and family history was unremarkable. Social history revealed that the patient was an emancipated minor, smoking a pack of cigarettes per day, drinking 3-5 beers per month, and a regular user of marijuana and synthetic cannabinoids. He also reported smoking crack cocaine once at age of 13. Physical examination revealed normal cranial nerve examination, tachycardia, hyperventilation, and an erythematous lesion resembling a canker sore in the lateral tongue with surrounding erythema. Blood pressure was 137/83 mmHg, temperature was 37.3 ºC, pulse rate was 75 beats per minute, and respiratory rate was 12 breaths per minute. Laboratory testing revealed no electrolyte abnormalities. Electrocardiography (ECG) showed ST segment elevation in leads V1, V2, V3, and V4, non-specific ST, T-wave changes, and T-wave inversion. Erythrocyte sedimentation rate (ESR) was mildly elevated. Cardiac enzymes were 3.2 ng/ml. Echocardiography revealed hypokinetic systolic dysfunction of the left side of the heart. Liver function tests were within normal limits. Aspirin was immediately administered to the patient and he was admitted to the cardiac catheterization lab, where no blockages in the coronary vasculature were seen. He was given a diagnosis of Takotsubo cardiomyopathy, after that catecholamine levels were seen to be elevated and urine drug screen was negative.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1251_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1251_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5db19b9c4da76b524c4e141b8893ed08d5054a29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1251_en.txt
@@ -0,0 +1,3 @@
+A 67-year-old man with a history of intrinsic asthma, but who otherwise had very good health condition, was admitted to our intensive care unit with an acute asthma attack. Peripheral oxygenation saturation had been 80–89% without oxygen, and he then received supplemental oxygen, combined with inhalative salbutamol, as well as intravenous prednisolone, dimetindene, and ranitidine by an emergency physician at his home.
+On admission to the intensive care unit, the patient was still awake, but severely tachy- and orthopnoic. Oxygen, 4 l min−1, resulted in 95% SpO2, but blood gas analysis showed a respiratory acidosis (pH 7.29, pCO2 55 mmHg, pO2 84 mmHg, HCO3−26.4, BE −1.6). Chest X-ray was normal, but severe expiratory wheezing could be heard on both lungs. The patient was on theophylline and formoterole/budesonide. Other relevant comorbidities were diabetes type 2 treated with metformin and coronary heart disease (1-vessel disease). He repeatedly inhaled salbutamol, ipatropiumbromide, and budesonide and received intravenous prednisolone, reproterole (bolus plus continuous), and magnesium. The patient was directly put on non-invasive ventilation (NIV; EVITA-4, Draeger®), facilitated with a cumulative dose of 4 mg morphine. While at first sight, the therapeutic regimen seemed to work and an ongoing deterioration with increasing pCO2-levels and signs of respiratory exhaustion were recognized. The patient’s vigilance became more and more impaired, and respiratory acidosis was later accompanied by a slight metabolic acidosis (blood gas analysis before ECCO2R: pH 7.24, pCO2 61 mmHg, pO2 289 mmHg, HCO3−26.1, BE −3.0). Meanwhile, other possible contributing causes, like pneumonia, lung embolism, and cardiac attack, were ruled out.
+After careful consideration, and with the consent of the patient and his family, a ECCO2R system was prepared. Under non-invasive ventilation conditions and local anesthesia, a 22 French double lumen cannula (Twinport®, Novalung, Heilbronn, Germany) was placed in the right upper jugular vein under sonographic guidance. The system was started with a blood flow of 1 l min−1 and a sweep gas flow of 1 l min−1 oxygen, (ILA-activve®, Xenios, Heilbronn, Germany). Due to the respiratory effort of the patient along with hypovolemia, blood flow initially fluctuated between 0.6 and 1.5 l min−1. Fluid repletion was therefore conducted with balanced crystalloids combined with albumin to achieve a better intravascular effect. With the circuit running, a rapid improvement in almost all former deranged qualities was noticed: breath rate decreased from 40 to 16 per minute, SpO2 rose to 100%, and pCO2 was intentionally lowered very slowly (with 2 l min−1 sweep gas flow). Due to the sudden relief, the patient fell asleep for a few hours and NIV was down-graded to nasal oxygen (4 l min−1). Three hours after starting the ECCO2R circuit, blood gas analysis was normal (pH 7.39, pCO2 44 mmHg, pO2 93 mmHg, SpO2 97%, BE 1.2). On day two, the patient was put on oral prednisolone (50 mg day−1). There was no more dyspnea or wheezing and both, nasal oxygen and sweep gas flow, could be reduced. Early mobilization and physiotherapy was started the very same day. Thirty-four hours after initiating the ECCO2R system, the patient was completely weaned, and the cannula could be removed without any complication. On day 4, the patient could be discharged from the ICU without need for supplemental oxygen and 6 days later, he left the hospital without any impairment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1275_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1275_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c3299fcf8b4078dacf779af242b8919e81de2adf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1275_en.txt
@@ -0,0 +1 @@
+A 47-year-old woman was transferred to our hospital complaining of abdominal pain. The pain was severe and accompanied by a loss of consciousness. She was known with chronic kidney disease and was on regular hemodialysis. On arrival at the hospital, her blood pressure was 93/67 mmHg, pulse 78 beats per minute, body temperature 36.7 °C, and Glasgow Coma Scale score of 13/15 (E3V4M6), with loss of consciousness. She had severe tenderness over the entire abdomen without rebound or guarding. An arterial blood gas analysis on room air showed a pH of 7.535, pCO2 of 28.1 mmHg, pO2 of 107 mmHg, HCO3 of 23.6 mmHg, base excess of − 5.1, and lactate of 10 mg/dl. Blood tests showed a mildly elevated white blood cell count of 10,950/μl, urea of 27.9 mg/dl, and creatinine of 5.59 g/dl, which was high for a dialysis patient, creatine kinase of 67 U/L, and C-reactive protein of 0.38 which was almost normal. Computed tomography (CT) revealed extensive portal vein gas and intestinal emphysema in the ileum and ascending colon. . The patient was diagnosed with NOMI and underwent emergency surgery. There was no intestinal fluid contamination in the abdominal cavity, but there was a moderate accumulation of serous ascites. The serosa of the ascending colon to cecum [Fig. A(a)] and terminal ileum [Fig. B(a)] were red in areas, but there was no obvious necrosis. Intraoperative ICG imaging with 5 mg intravenous ICG administration showed a granular distribution of the fluorescent dye (fine granular pattern) in the ascending colon to cecum [Fig. A(b)] and a poorly fluorescent lesion except around blood vessels (perivascular pattern) in the terminal ileum [Fig. B(b)] . Because the serosal side of the intestine was not grossly necrotic, we decided to manage the patient conservatively and only perform a second-look surgery if there were clinical, blood, and CT findings suggestive of necrosis the next day, and so bowel resection was not performed. Postoperatively, prostaglandin E1 was injected intravenously at 0.05 ug/kg/min. A contrast-enhanced CT performed the day after the surgery showed good blood flow in the ascending colon and ileum, and abdominal findings and blood tests had not worsened; therefore, a second-look surgery was not performed. Intraoperatively, the intestinal emphysema disappeared and the serous membrane color tended to improve, so postoperative open abdomen management was not performed and the abdomen was closed by conventionally. The acute postoperative course was uneventful; however, the patient required prolonged hospitalization for diabetes control. On POD 24, the patient suddenly passed a large quantity of bloody stool. An emergency colonoscopy revealed a longitudinal ulcer in the ascending colon to cecum , and a deep ulcer, with exposed blood vessels, in the terminal ileum . However, since there was no active bleeding, we decided to treat the patient conservatively with red blood cell transfusion alone, without emergency endoscopic treatment or surgery. On POD25, a large amount of blood was again found in her stool, and she went into shock. She received a massive blood transfusion and underwent an emergency laparotomy. The patient was in a state of shock and required urgent treatment. Although intravenous radiology was a treatment option, hemostasis by laparotomy was chosen, because the CT and endoscopy of the previous day showed that the bleeding site was in the terminal ileum, hemostasis by surgery was easy, and the patient was ready for surgery quickly. A large amount of blood in the colon and small intestine was seen through the serous membrane, suggesting a severe bleed. The terminal ileum wall 25 cm from the ileocecal valve was firm and thickened, but there were no obvious changes on the serous surface of the rest of the small intestine [Fig. B (a)]. The thickened terminal ileum was the most likely site of bleeding, and the mesenteric vessels in the area were first ligated to stop bleeding. Next, an incision was made in the terminal ileum, and intraoperative endoscopy was performed . This confirmed the presence of a deep longitudinal ulcer in the terminal ileum, where the origin of the bleeding was expected to be located [Fig. B(b)]. The extent of intestinal resection was determined after confirming that ulceration was present only in the terminal ileum and ascending colon to the cecum, with no ulcerative lesions on the oral side from the deep longitudinal ulcer in the terminal ileum . Right hemicolectomy including the terminal ileum of the bleeding ulcer lesion was performed and an ileo-transverse colon anastomosis was performed by hand. The resected specimen showed extensive mucosal erosion of the ascending colon to cecum and a deep longitudinal ulcer with exposed vessels in the terminal ileum . Thirty cm of the terminal ileum and 20 cm of the ascending colon to cecum was resected . Her postoperative course after the second surgery was uneventful, and she was discharged on the 28th day after the second surgery. One year after the surgery, NOMI, and intestinal bleeding had not recurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1291_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1291_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..37931dd99cd0ed445704bd884d665d9e3f57237e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1291_en.txt
@@ -0,0 +1 @@
+A 54-year-old Caucasian Greek man presented to the Accident and Emergency department of our hospital with a 20-day history of abdominal pain, vomiting and loss of appetite. He mentioned an eight kg weight loss over the last 20 days, as he had been drinking almost exclusively water due to his symptoms. He had not presented to any hospital facility earlier because he lived in a remote area in the mountains. On admission, he had the septic image of paleness, tachypnea, tachycardia (110 beats/minute) and a fever of 38.5°C, as well as a rigid abdomen. Abdominal and plain chest X-rays demonstrated free gas under both the hemidiaphragms. After initial resuscitation (placement of intravenous lines and nasogastric tube followed by adequate administration of fluids), our patient underwent an emergency exploratory laparotomy. Our patient's worsening clinical image and his deteriorating clinical signs (tachypnea and tachycardia), along with the presence of his acute abdomen led us to conclude that an emergency laparotomy constituted the treatment of choice. In the face of the emergency situation a computed tomography (CT) scan was not performed. Laparotomy revealed peritonitis due to a perforated ulcer on the anterior wall of the duodenum, which was sutured, while the suture line was reinforced with an omental patch . After a thorough lavage of the peritoneal cavity, further exploration of the intra-abdominal organs revealed a second posterior pre-pyloric ulcer on the lesser curvature of the stomach, perforated into the lesser sac . A wedge resection with staplers was carried out , while no further acid reduction procedures were undertaken due to sepsis. A Nissen fundoplication was performed as an anti-reflux measure. Our patient recovered uneventfully and was discharged home on the 13th post-operative day; at this time we administered an appropriate eradication therapy. More specifically, we followed the protocol of triple therapy: a proton pump inhibitor, amoxicillin and clarithromycin were administered. After discharge our patient was referred to gastrointestinal specialists. Our colleagues planned a surveillance endoscopy according to their protocol.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1304_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1304_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9e0bac145bcac2a8fba6b000ffd8b35647225595
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1304_en.txt
@@ -0,0 +1,2 @@
+A 20-year-old female underwent deformity correction and spinal fusion surgery for presumed adult idiopathic scoliosis with posterior spinal instrumentation comprising pedicle screws and hooks extending from T3-T12 . The pre-operative assessment including an ECG did not demonstrate any abnormalities and her past medical history was uneventful while she had a normal level of physical activities including sports. The anesthetic and scoliosis surgery was uncomplicated with the patient maintaining good O2 levels and blood pressure while the intraoperative neuromonitoring showed stable motor and sensory potentials throughout. Her initial post-operative course was without incident until post-operative day 2 when she had episodes of acute de-saturation which prompted USG Doppler for bilateral lower limbs and computed tomography pulmonary angiography (CTPA). While both the studies ruled out any evidence of pulmonary embolism, CTPA revealed right heart strain pattern and an enlarged right side of the heart. A subsequent 2D echocardiography revealed a large atrial septal defect (ASD) which had remained asymptomatic up to that point. In addition, the CTPA demonstrated a lateral breech at the left T10 pedicle screw level with the screw tip being in close proximity to the aorta. A multidisciplinary team meeting was held where it was decided to prioritize cardiac management for ASD and keep the malpositioned screw under observation with removal planned for a later date. An ASD repair procedure was performed and this was uneventful with the patient making a good recovery.
+After recovery from the cardiac procedure, a repeat computed tomography (CT) scan was performed to plan removal of the screw; the CT scan showed the position of the left T10 screw in close vicinity of the aorta . To determine the exact position of the screw tip in relation to the aorta, an angiogram and an intravascular ultrasound was done which showed no evidence of intra-luminal extension of the screw tip. In addition, a transesophageal ultrasound was performed and this ruled out any extra-luminal contact with the aorta. Two years following the primary scoliosis correction, it was decided to proceed with removal of the spinal instrumentation with the vascular surgeon and intervention radiologists being on standby. The midline longitudinal scar was reopened and the spine was exposed across the previously operated segments from T3-T12. A solid posterior spinal fusion was noted across the previously operated levels which allowed the spinal instrumentation to be removed without compromising the surgical outcome of scoliosis correction. Intraoperative neuro-monitoring was used and the procedure was uncomplicated. The fusion mass was re-grafted using allograft bone. The patient was followed in our clinic for an additional period of two years during which there was no clinical or radiographic evidence of scoliosis recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1322_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1322_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..49f2f3b8fadaae4ebb8f7bc1b2317927ce484cee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1322_en.txt
@@ -0,0 +1,5 @@
+A 48-year-old Asian woman presented to an ear, nose and throat (ENT) surgeon at our facility with complaints of headache and bleeding from the right nasal cavity for 15 days. She was known to be hypertensive and was taking amlodipine and enalapril.
+Anterior rhinoscopy revealed a mildly deviated nasal septum and a right nasal polyp. A physical examination did not reveal any other abnormalities. There was no hepatosplenomegaly or lymphadenopathy.
+The results of a computed tomography (CT) scan showed a low-density lesion with a few areas of soft tissue density completely filling the right maxillary sinus extending to the middle meatus and posterior nasal cavity, with a widened antrum. There was no bony lesion. The radiological diagnosis was antrochoanal polyp.
+The results of all laboratory tests were normal. Subsequently, endoscopic polypectomy and middle meatal antrostomy were performed. Multiple irregular grey to dark brown soft tissue fragments measuring up to 3 × 2 × 1.5cm were sent to our histopathology laboratory. The culture from the surgical specimen was negative for fungus. A histological examination revealed mature adipose tissue mixed with hemopoietic cells . Hemopoietic cells are made up of trilineage elements: myeloid, erythroid and megakaryocytic cells .
+Based on this histomorphology, a hematological investigation including bone marrow aspiration and trephine biopsy were performed to rule out any underlying hematological disorders. Bone marrow aspirate and trephine biopsy were normocellular without fibrosis. Based on these findings, extra-adrenal myelolipoma was diagnosed. Our patient had an uneventful post-operative course and has remained disease-free at 36-month follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1332_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1332_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a7f243b03bdb4c95d402e81bcacb8f164542709
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1332_en.txt
@@ -0,0 +1,4 @@
+Following a right radical orchidectomy and four cycles of chemotherapy for a metastatic non-seminomatous germ cell tumor of the testis, our patient, a 21-year-old man of Caucasian origin, underwent RPLND for a residual mass. The procedure was prolonged and in order to achieve complete surgical excision, a right radical nephrectomy and excision of the inferior vena cava from the iliac veins to the level of the left renal vein was necessary due to tumor infiltration and encasement.
+Three days postoperatively, the patient developed bilateral leg pain, lower limb oedema and abdominal distension secondary to abdominal ascites . This continued to worsen and on day nine postoperatively, he developed a paralytic ileus, pleural effusions and respiratory failure, and was transferred to the intensive care unit for elective intubation, ventilatory support and chest tube drainage of the pleural effusions .
+With fears that our patient would develop intra-abdominal compartment syndrome and that the respiratory compromise would be worsened, a 12 Fr pigtail drainage catheter was inserted under ultrasound guidance on postoperative day 22 into the abdominal cavity, immediately producing 11 litres of chylous fluid. Shortly after a drain was inserted, the respiratory compromise improved and the patient was extubated. The drain continued to maintain an output of six liters per day for a further four days before settling to an average output of between two and three liters per 24 hours. Conservative management consisted of a parenteral diet of medium chain triglycerides, diuretic therapy and 20% albumin three times a day. Daily intraperitoneal infusion of 200 mls of the water-soluble contrast medium Conray 280 mg I/ml (Iothalamate meglumine) in order to promote peritoneal lymphatic fibrosis was attempted but produced no real improvement. Blockage of the intra-abdominal drain necessitated its replacement on two separate occasions.
+On day 41, the patient was discharged to the ward where he maintained this improvement. Total parenteral nutrition was commenced to supplement poor oral intake. The patient had also developed bilateral foot drop on day 22 postoperatively. This was felt to be due to pedal oedema compressing each peroneal nerve at the head of fibula. It improved gradually with resolving peripheral oedema and physiotherapy. He was discharged to a peripheral hospital for further care on day 53, with an average output of 1.5 liters. Histologically, all the resected retroperitoneal tissue was free from residual tumor and contained only lymphoid tissue with large areas of necrosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1347_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1347_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5561bbe753307037f4def591ce5b682cd2171c26
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1347_en.txt
@@ -0,0 +1,5 @@
+A 53-year-old Japanese man visited our hospital for a scheduled follow-up examination for uveitis due to BD. His best corrected visual acuity (BCVA) was 20/16 in both eyes. Intraocular pressure was 15 and 11 mmHg in his right eye and left eye, respectively. Slit lamp biomicroscopy with Goldmann three-mirror examination did not reveal active uveitis in either eye. Vitreous haze was graded as trace . Anterior chamber flare was evaluated based on the aqueous flare value measured with the Kowa FM-600® laser flare meter (Kowa Medicals, Nagoya, Japan) in photon counts per millisecond. Aqueous flare values measured with laser flare meter (LFs) were 12.6 and 7.6 photon counts per millisecond in his right eye and left eye, respectively; both were expected to be within normal range. An ultra-widefield (UWF™) high-resolution digital image (optomap®) was obtained with a Daytona imager (Optos, Scotland); no active uveitis lesions or vitreous opacity were detected . Spectral domain optical coherence tomography (SDOCT; RS-3000, Nidek Co., Ltd, Aichi, Japan) was used to analyze the macular lesion; no macular edema was observed.
+He had been diagnosed as having incomplete-type BD 11 years before. He was adequately treated with systemic corticosteroid and colchicine accompanied by occasional topical corticosteroids and mydriatics. Because his right visual function was disturbed by a preretinal membrane combined with vitreous opacity and secondary cataract in his right eye as a consequence of repeated bouts of severe uveitis, he underwent vitrectomy with inner limiting membrane peeling and phacoemulsification with intraocular implantation 2 years and 4 years after the diagnosis, respectively. Three years after the diagnosis he was given a systemic infusion of 5 mg/kg infliximab (Remicade®; Mitsubishi Tanabe Pharma Corporation, Osaka, Japan) every 8 weeks with no recurrence of uveitis attacks. He received no other treatments for BD besides the infliximab. He stated that his left eye had once shown mild intermediate to posterior uveitis, but that he had been completely stable since the commencement of systemic infliximab treatment.
+Four days after the scheduled follow-up examination, he returned to our hospital to receive his regularly scheduled systemic infusion of infliximab. At the visit, he complained of blurred vision in his right eye. BCVA was 20/25 and 20/16 in his right eye and left eye, respectively. Intraocular pressure was 17 and 11 mmHg in his right eye and left eye, respectively. LF was 72.0 and 6.2 in his right eye and left eye, respectively. Slit lamp biomicroscopy with Goldmann three-mirror examination revealed severe AAU and deteriorated aqueous flare in the anterior chamber, with anterior vitreous opacity that was shown by the silhouette against the retina in his right eye . Vitreous haze was graded as 2+. We did not observe any abnormal changes in his left eye (data not shown). SDOCT resulted in a cloudy image due to marked vitreous opacity, but we did not detect macular edema .
+He stated that 2 days prior he had received botulinum toxin (BOTOX®, botulinum toxin type A; GlaxoSmithKline K.K., Tokyo, Japan) 50 unit intracutaneous injections on both sides to treat axillary hyperhidrosis. Three hours after the injections, he noted severely increasing floaters and pain in his right eye. After he received the scheduled infliximab injection, however, he stated that the floaters and ocular pain in his right eye improved within a day. The severe vitreous opacity had attenuated considerably 1 month after the infliximab injection . BCVA was 20/16 in both eyes. Intraocular pressure was 10 and 9 mmHg in his right eye and left eye, respectively. LF was 31.1 and 26.3 in his right eye and left eye, respectively. Vitreous haze was graded as trace. Finally, LF was 15.2 and 14.6 in his right eye and left eye 3 months after the infliximab injection, respectively.
+After this event, he explained he had once received botulinum toxin injections in the same way last year. He received the scheduled infliximab injection 2 weeks prior. He felt no abnormality in both eyes, and a scheduled follow-up examination did not reveal active uveitis on that occasion.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1378_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1378_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b0f4bef1c6c605d2878e82bd10d0eb051e57bb62
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1378_en.txt
@@ -0,0 +1 @@
+A 73-year-old woman with past medical history of hypertension and rheumatoid arthritis stage 4 under regular anti-hypertension medication and long-term corticosteroid therapy, presented to us in August 2010 with the chief complaint of decline of visual acuity of her right eye and right periorbital pain for 2 months. At the beginning of the clinical course, she had brain computed tomography (CT) scan and orbit magnetic resonance imaging (MRI) done in June 2010, which disclosed a small enhancing lesion, about 1.2 cm × 1.1 cm × 1 cm in size, near the right side orbital apex and adjacent right side superior orbital fissure with mild encasement of the right optic nerve, and this lesion showed mild extension to the adjacent right side posterior ethmoid sinus [Figure , ]. She had pulse steroid therapy in ophthalmology service, but it was ineffective. On admission, her neurological examination showed that she had right eye blindness, right ptosis, right ophthmaloplegia, and tingle in the territory of ophthalmic branch of right trigeminal nerve. Repeated MRI of orbit after admission in August 2010 showed the progression of the lesion which enlarged up to 1.5 cm × 1.3 cm × 1.2 cm [Figure , ]. She underwent endoscopic endonasal transethmoid approach with the removal of the lesion on 19 August 2010 under general anesthesia. After the surgery, she recovered well and her right periorbital pain was much released. However, 5 days after surgery, she experienced a severe headache followed by loss of consciousness. After endotracheal tube intubation and resuscitation, brain CT was checked which showed diffuse high-density acute SAH in the basal cistern, pre-pontine cistern, ambient cistern, quadrigeminal cistern, cerebellomedullary cistern, and right sylvian fissure, with acute hydrocephalus . Emergent external ventricular drainage was done followed by performing CT angiography which showed several bleb-like wide base aneurysms over right supraclinoid internal carotid artery (ICA), and one aneurysm, about 4 mm in size and located at the medial side of the right supraclinoid internal carotid artery, showed extravasation of contrast medium. The dome of the ruptured aneurysm projected medially and superiorly . On the same day, the histology examination reported that the lesion was composed of many fungal septate hyphae demonstrated on both HE stain and periodic acid-Schiff (PAS) stain [Figure , ]. Fungal infection was diagnosed and the culture turned out to be Aspergillus fumigatus. Her intracranial aneurysms were probably fungal aneurysms, which are one of the sequels of central nervous system (CNS) fungal infection. Unfortunately, after the event, she remained in deep coma and finally she expired due to central failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1384_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1384_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..686123f002b06a96267f9ea1a89d7b228c6c5231
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1384_en.txt
@@ -0,0 +1,9 @@
+This is a two-year-four-month old female, born by a primigravida. The girl was delivered at 39 week of gestation by the Cesarean section due to placenta failure. The girl was delivered with a general good condition, her Apgar score at 1 min after birth was 9 and she displayed features of intrauterine growth restriction (IUGR). Her birth weight was 1850 g (<3 percentile), height 44.5 cm (<3 percentile), head circumference 31 cm (<3 percentile). From day 7 on, the baby was exclusively breastfed which resulted in gradual weight gain. At 16 day, the baby girl weighed 2018 g and was discharged from hospital with a general good condition.
+At the age of three months, the infant was treated at the Paediatric ENT Department for suspected hypoacusis. The Auditory Brainstem Response (ABR) test performed in sleep revealed bilateral severe hearing loss. At follow-up ABR test, sensorineural hearing loss was confirmed. At the age of 4 months, she had a hearing aid placed.
+In her infancy, physical developmental delay was diagnosed – her weight and height were substantially below 3 percentile. Her psychomotor development was normal. The girl was able to sit at the age of 8 months and simultaneously she started to stand up and crawl. When she was 14 months old, she began to walk. She started talking when she was a thirteen-month-old. No abnormality was found in the MRI of her central nervous system.
+Low weight and height gains, some dysmorphic features (triangular-shaped face, prominent forehead, ocular depression, lipodystrophy at the lumbar region and around elbows led to suspicion of SHORT syndrome.
+Our patient presents most common signs and symptoms of SHORT syndrome except Rieger anomaly,insulin intolerance, hyperextensibility of joints and clinodactyly.
+The comparison of features typical of SHORT syndrome, with our patient’s features presents Table .
+While preforming molecular genetic testing, we have found a novel mutation in PIK3R1 -variant c.1956dupT (p.Lys653*) in exon 15 of PIK3R1 which is responsible for the symptoms in the patient.
+The variant has been confirmed to be de novo mutation (not present in biological parents) that has never been reported in the literature.
+At present, the patient is 2 years 4 months old and requires multi-speciality care. Her height and weight remain considerably below 3 percentile, though her psychomotor development is correct.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1397_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1397_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f2797561244021b42f3595eb692837a5665d18ec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1397_en.txt
@@ -0,0 +1,3 @@
+A 61-year-old man was injured when his penis slipped out of his wife's vagina during penovaginal intercourse with penetration from behind (“doggy style”). His physician treated the penile swelling with hemostatic agents, but his symptoms worsened. When he presented to our institution, 13 hours had passed. Physical examination showed a swollen penis with an “eggplant” deformity caused by a hematoma on the distal ventral surface of the penis; he also had gross hematuria visible at the external urethral orifice . His past medical history was significant for benign prostatic hyperplasia, for which he was taking tadalafil.
+We ordered an immediate MRI; T2-weighted imaging revealed an isolated tear of the ventral tunica albuginea of the CS . We diagnosed a rupture of the CS with urethral injury and proceeded to the operating room. A 5-cm transverse incision of the epidermis just above the subcutaneous hematoma allowed us to remove as much blood and clot as possible. A 2-cm longitudinal injury of the tunica albuginea of the CS was visible, and the anterior urethra was ruptured; a 14-Fr urethral catheter was visible through the defect in the urethra . We repaired the tunica albuginea of the CS and the urethral mucosa using interrupted 3–0 and 4–0 absorbable sutures, respectively.
+The patient's postoperative course was unremarkable. We removed the urinary catheter on postoperative day 8, and the patient was discharged home. On postoperative day 17, he returned for follow-up. There was no discoloration or swelling of the penile shaft, and his erectile function had returned to his pre-injury status. Cystoscopy showed no obvious urethral stenosis or injury except for residual edema .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1422_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1422_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..944596fb1daa05837b6f2a3709eb0a0e1e9026c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1422_en.txt
@@ -0,0 +1,2 @@
+A 50-year-old man was referred to our institution with several years of right heart failure symptoms, AF, and liver disease of unknown aetiology. He was a fisherman and had contact with contaminated water in the past. He had lower limb oedema, significant ascites, jugular vein distention, and 3/6 pansystolic murmur heard loudest at the left lower sternal edge suggestive of tricuspid regurgitation. The patient came from the northeastern region of Brazil, where there is high prevalence of schistosomiasis. Considering the local epidemiology and the presence of hepatosplenomegaly, schistosomiasis was suspected. Due to the symptoms of right heart failure mentioned, cardiac investigations were performed as a primary cause of the liver disease.
+The electrocardiogram showed AF rhythm and there was cardiomegaly noted on chest radiograph, with gross enlargement of the right atrial shadow. Blood tests showed thrombocytopenia of 75 000/mm3 [normal values (NV): 150 000–400 000], normal renal function and liver enzymes, and brain natriuretic peptide of 198 pg/mL (NV ≤ 35). The TTE showed a left ventricle of normal dimensions with a preserved left ventricular ejection fraction (LVEF) (, ). However, the RV cavity was small secondary to a large homogeneous hypoechoic mass with evidence of severe tricuspid insufficiency, secondary to dilatation of the annulus, and severe tethering of the valve leaflets. Besides, the TTE exhibited an intracavitary thrombus adhered to the roof of the right atrium (RA; ; , ). The cardiac magnetic resonance (CMR) imaging showed severe RA dilation. This examination confirmed that RV had small cavity with reduced indexed end-diastolic and end-systolic volumes (38 and 13 mL/m2, respectively), normal systolic function (EF 65%), and moderate pericardial effusion . The late gadolinium enhancement sequence showed diffuse and heterogeneous subendocardial fibrosis in the RV apex . The patient was diagnosed with EMF and schistosomiasis by positive IgG ELISA and treated with praziquantel, but declined endocardiectomy. His heart failure symptoms improved on diuretics (furosemide 120 mg/day, spironolactone 50 mg/day, and hydrochlorothiazide 50 mg/day). In addition, the patient was commenced on warfarin with adequate international normalized ratio control for the presence of AF and thrombus.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1426_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1426_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2ce4e3c9cee84d9fd9f83836be21d1f5f9d7089a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1426_en.txt
@@ -0,0 +1,6 @@
+This case report describes to a Brazilian woman, 42 years-old, who presented with a renal failure and was submitted to haemodialysis for five years, before a kidney transplant, which occurred in 2007. After transplantation, the therapeutic regimen of immunosuppression included prednisone (5 mg daily), tacrolimus (5 mg daily) and azathioprine (50 mg daily). Dosage of serum tacrolimus was 5.8 ng/mL.
+The donor’s B19 status for this recipient was unknown. In December 2010, the patient developed significant anemia, which was resistant to erythropoietin (1,119.0 mUI/mL) and, eventually, required blood transfusion. After transfusion, the patient’s hemoglobin was 6.8 g/dL and her hematocrit was 20.2%.
+In April 2011, she presented cutaneous mucosa paleness, fatigue after minimal effort, arthropathy and malaise. She presented at the Hospital Felício Rocho, Belo Horizonte, MG, Brazil. Levels of hemoglobin and hematocrit were 3.6 g/dL and 10.3%, respectively. She received a transfusion of 600 mL of erythrocytes. Reticulocyte count was 7,200/mm3, leukocytes 4,100/mm3 and platelet 220,000/mm3. Dosage of serum creatinine was 2.3 mg/dL, iron (152 mcg/dL), transferrin saturation (89.9%), folate level (20.0 ng/mL), ferritin (938.6 ng/mL) and vitamin B12 (238.0 pg/mL), which did not suggest a nutritional or iron deficient anemia. Other laboratory investigations revealed she was seropositive for anti-Epstein-Barr (high IgG levels – 477.0 U/mL) and Cytomegalovirus (IgG positive) and negative for anti-hepatitis B, anti-hepatitis C and anti-HIV antibodies.
+At this time point, a bone marrow aspirate revealed hypocellular for red and white cells and platelets. Besides, there were dysplasia and megaloblastosis in the erythrocytic series, which were attributed to azathioprine associated with tacrolimus toxicity.
+A bone marrow biopsy was also obtained and showed severe hypoplasia of elements of the erythroid lineage, presence of larger cells with clear nuclei chromatin and eosinophilic nuclear inclusions, suggesting inclusions caused by B19. Nonetheless this evidence has indicated B19 infection, IgM and IgG assays were negative. However, as the symptoms and bone marrow biopsy were suggestive of B19 infection, a qualitative PCR testing for parvovirus B19 was performed, revealing the presence of this virus.
+The woman received 5 doses of intravenous gammaglobulin, 400 mg/Kg body weight daily, which improved the symptoms. A new evaluation revealed an important increase in hemoglobin, from 3.6 to 12.6 g/dL.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1429_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1429_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bc8c7eb18600f915f341ad969c9c1a4acffc72e5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1429_en.txt
@@ -0,0 +1,2 @@
+In November 2006, a 36 years old male presented with severe plaque type psoriasis, to our hospital clinic. He has had psoriasis for the last 13 years; first it was localized to the scalp and periodically spread to other small areas of his body so he could control his disease with topical therapy. However, for the last six years the disease spread and covered the majority of his integument. He denied prior history of psoriatic arthritis. He had a positive family history of psoriasis, which affected his father, sister and paternal grandmother, but they all had a milder disease. His past treatments included various topical agents and several years ago he had a course of UVB with significant improvement, however he could not resume phototherapy because he lost his health insurance. Otherwise his past medical history was unremarkable. He had no known drug allergies and did not smoke. His current medications included over the counter iron pills. He denied any other systemic medications.
+Examination revealed severely erythematous scaly, excoriated thick plaques involving approximately 80% of his body surface area, and pitting of his nails. The rest of his physical examination was unremarkable. After completion of the screening tests which were within normal limits except from mild normocytic anemia (HGB = 12.0 gr/d) and elevated platelets count (470 × 103/mc, normal range 180-400 × 103/mc) and receiving informed consent he was treated with efalizumab (Raptiva) 0.7 mg/kg SC once weekly and subsequently 1 mg/kg as per label. Under treatment his skin condition has gradually improved. However, after 3 months of treatment he had started to complain of arthralgia first involving his right ankle and latter on extending to 2 fingers in both hands and eventually to his left ankle. Treatment with Ibouprofen 600 mg twice daily did not relieve his pain. X-ray analysis confirmed the diagnosis of psoriatic arthritis therefore treatment with Efalizumab was interrupted after 9 months. In addition during the 9 months of efalizumab therapy his platelets count rose substantially . Then, etanercept (Enbrel) 50 mg twice weekly was started. After an initial flare of his skin condition, which was expected after cessation of efalizumab, a significant improvement of both his skin and joints ensued. Interestingly during the sixteen months of etanercept treatment his platelets count returned to normal. But unfortunately due to health insurance coverage problems he had to stop etanercept and consequently his skin conditioned dramatically deteriorated and resembled his baseline condition when he first reported to our clinic. Therefore cyclosporine (Neoral) 200 mg twice daily was introduced for approximately 2 months till he received his insurance approval for adalimumab (Humira) and again his skin and arthritis gradually improved. His platelets count rose while being off etanercept and even when he was treated with cyclosporine and his skin condition started to improve his platelets counts remained persistently high and only after adalimumab was started they returned to normal values.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1441_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1441_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f53046e98677fcd71b753281524a0a4b27deebca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1441_en.txt
@@ -0,0 +1,7 @@
+A 65-year-old male Caucasian patient was admitted with respiratory distress and suspected non-Hodgkin's lymphoma. His medical history revealed arterial hypertension, diabetes mellitus type 2 and cholecystolithiasis.
+On clinical examination our obese patient (body mass index 41.5) suffered from dyspnea at rest. He presented with enlarged cervical and axillary lymph nodes, hepatosplenomegaly and diminished breath sounds over his right lung. A blood count revealed a leukocytosis of 35,000 leukocytes/μL of blood, with 80% partially atypical small lymphocytes and Gumprecht's shadow cells. Hemoglobin concentration and thrombocytes were within normal range. Immunophenotyping revealed that 67% of leukocytes were CD19+ B-lymphocytes, with co-expression of CD5, CD20, CD23 and a clonal restriction for the lambda light chain. This established the diagnosis of CLL. Bone marrow puncture demonstrated a medium degree of infiltration, with monoclonal B-cells beginning to replace the normal hematopoiesis.
+A chest X-ray was performed and showed a right-sided complete opacity suggesting a pleural effusion . Thoracentesis produced a milky pleural fluid . The cellular content consisted of 80% lymphocytes, two thirds of which expressed the B-CLL phenotype. Further analysis of the pleural fluid revealed triglyceride levels over 700 mg/dL and cholesterol levels below 70 mg/dL, establishing the diagnosis of chylothorax. Our patient received a pleural drainage, which initially produced nearly 3 liters of chyle per 24 hours. A computed tomography (CT) scan depicted enlarged lymph nodes in the cervical, axillary and mediastinal region, and suspected splenic involvement with several hypodense lesions. Taking the findings into account, our patient was diagnosed with a right-sided chylothorax caused by a concomitantly diagnosed CLL, stage Binet B or Rai II.
+The chylothorax represented a major complication of the CLL, and so immunochemotherapy consisting of fludarabine (25 mg/m2 on days one to three), cyclophosphamide (250 mg/m2 on days one to three) and rituximab (375 mg/m2 on day one) was initiated. Our patient received four courses, repeated every four weeks. Since the therapeutic effect of reduced dietary intake on chylothorax had been described previously, our patient received total parenteral nutrition for two weeks, starting with the first cycle of the immunochemotherapy. The chylous effusion disappeared nearly completely, and the chest drain could be removed after 10 days. After two weeks an enteral low-fat diet enriched with medium-chain triglycerides was started, to continue therapy on an out-patient basis. Unfortunately the chylothorax relapsed and thoracentesis of a volume of 1 L to 1.5 L once to twice a week became necessary. Due to the low-fat intake the appearance of the pleural effusion had changed from milky-white to clear amber-colored .
+Our patient received four cycles of immunochemotherapy and regular thoracentesis on an out-patient basis. Since patients with protracted chylothorax are at risk of malnutrition and immunosuppression, our patient received antifungal and antiviral prophylaxis in addition to vitamin supplementation. However, the chylothorax persisted, despite a good clinical response of the CLL, with normalized blood counts and complete regression of the lymphadenopathy .
+In light of this, percutaneous radiotherapy of his mediastinum and thoracic duct, with an overall dose of 24 Gy, was initiated. Radiation induces an inflammatory response which can result in an obliteration of the disrupted thoracic duct . However, up to eight weeks after completion of the radiotherapy the chylothorax still persisted with continued requirement for regular pleural tapping.
+Finally our patient agreed to a surgical intervention. A supradiaphragmal ligation of the thoracic duct via a right muscle sparing thoracotomy was carried out. In addition, a decortication of his right lung was necessary because, during his surgery, a pleural fibrosis was diagnosed. The pleural fibrosis was most likely caused by the long-term chylothorax with repetitive thoracenteses. Our patient quickly recovered and the pleural effusions ceased completely. The time from the first diagnosis of chylothorax until the final surgical intervention was six months. Our patient is still in complete remission after 24 months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1455_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1455_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..267904798fa98de79fd556bb714e36ad169ac457
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1455_en.txt
@@ -0,0 +1,6 @@
+A 62-year-old woman came to our center with extremely severe hydronephrosis and multiple right renal calculi found by annual physical check. She reported no renal colic, nausea or fever and had no current use of any medications. Her temperature was 36.7 °C, pulse 89 bpm, respiratory rate 18 bpm, and non-invasive blood pressure 130/57 mmHg. Unenhanced CT scan demonstrated extremely severe hydronephrosis and multiple right renal calculi with the largest diameter of 2 cm . Urine routine was positive for nitrites and leukocyte esterase, and microscopical examination showed + + + for leucocyte.
+After thorough examination, we performed prone-position mini-percutaneous nephrolithotomy under spinal anaesthesia. A single tract was created under the guidance of ultrasound to directly reach the median calyceal group. After the insertion of a guidewire, the channel was dilated to 16Fr with a fascia dilator. During the operation, swollen mucosa could hardly be seen through turbid purulent urine. Multiple golden stones embedded in the renal pelvis were fragmented with holmium laser and flushed out, and a considerable number of the stones were removed. After 2 h’ lithotripsy, the operation finished after successful indwelling of a 6Fr double-J stent and a 16 F nephrostomy tube.
+Two hours postoperatively, the patient complained of chilly and shiver. Her blood pressure dropped to 85/60 mmHg, and blood tests showed C-reactive protein 31.4 mg/L, White blood cell 9.55 × 109/L, D-dimer 570.0 ng/ml. Symptoms were relieved after empirically intravenous infusion of 300 mg biapenem bid and micro-pump injection with dopamine.
+Three days later during the CT scan, the patient abruptly developed respiratory distress and loss of consciousness. Her blood pressure dropped to 76/45 mmHg, and oxygen saturation decreased to 85% under nasal catheter inhalation of oxygen. Clinical findings indicated the possibility of PE with shock. Supported by multi-channel intravenous rehydration, micro-pump injection with norepinephrine and mask oxygen inhalation, her blood pressure fluctuated between 108–124 and 65–78 mmHg. However, the patient still complained of dyspnea and chest pain, and her blood oxygen saturation remained unstable at an average of 92% under mask oxygen inhalation. Emergency laboratory tests showed a D-dimer of more than 3300 ng/ml. Considering the rising level of D-dimer and the patient’s clinical manifestation, we decided that PE might be the most likely diagnosis. Thus, we administrated anticoagulant therapy with 4000 U low molecular weight heparin (LMWH) at once and offered emergency CTPA, which revealed multiple embolisms in her left pulmonary artery and its branches . Meanwhile, doppler echocardiography showed that the patient’s left ventricular ejection fraction (LVEF) was 52% with severe tricuspid regurgitation, and experienced sonographers estimated that pulmonary arterial systolic pressure was about 40 mmHg (mild pulmonary hypertension). Doppler ultrasonography of lower limbs revealed intermuscular venous thrombosis in her left leg.
+It was a contradictory situation with both the urgent need for thrombolysis therapy and the high vulnerability of surgery field bleeding. In order to solve the life-threatening problem first, our multi-disciplinary team administrated 50 mg of Alteplase ivgtt which was completed within 2 h for thrombolysis, and then transferred the patient to intensive care unit (ICU) for further life-supporting therapy. In order to prevent venous thromboembolism (VTE), 0.4 ml LMWH was subcutaneously injected every 12 h in ICU. Routine re-examination of the lower limbs venous ultrasonography and echocardiography was ordered to monitor the patient’s condition. Sonographers reported the remission trend of tricuspid regurgitation and pulmonary hypertension. Intermuscular venous thrombosis in her left leg could no longer be detected 6 days after the thrombolysis treatment.
+On the 6th postoperative day, the patient suddenly developed unconsciousness and anhelation in ICU, and her blood oxygen saturation progressively dropped to 85%. Urgent intubation, mechanical ventilation and blood transfusion were applied to correct the patient’s anemia. Gradually, her oxygen saturation rose to 98%, but crimson and opaque drainage fluid kept flowing through her nephrostomy tube without any sign to stop even after clamping the catheter for 30 min. Her hemoglobin (Hb) level was still decreasing progressively . All the above clues were indicative of post thrombolysis bleeding. Diffused contrast medium in the middle and lower part of the right kidney was seen during DSA . SRAE was then performed under general anesthesia. The patient reported no obvious discomfort and generally recovered after conventional symptomatic treatment and blood transfusion. Anticoagulant treatment method was gradually changed to oral application of Warfarin 3 mg qn, and the patient was approved to be discharged 26 days postoperatively. She returned to her daily activity and reported no obvious discomfort, and during re-examination, the echocardiography showed LVEF of 70% with no obvious abnormality.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1464_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1464_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..daa4352588a4c97b3bf72f76976231481143a6d4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1464_en.txt
@@ -0,0 +1,6 @@
+A 74-year-old lady presented to our emergency department following 3 days’ history of watery diarrhoea and feeling generally unwell. She had been ‘off legs’ for 3 days and was not improving hence called the GP for a home visit. She was referred to the hospital as a case of severe sepsis for medical admission and pre-alerted into Resus by paramedics. She denied any cough, cold, or urinary symptoms. She had a past medical history of hypertension and CKD and was on Ramipril and Atorvastatin. She was at reasonably normal baseline health and 3 days back started with watery diarrhoea. There was no history of recent travel and no vomiting or per rectal bleed. On examination, she looked unwell, still responding to verbal commands, hypotensive at 80/50 mmHg, and tachycardic at 110 beats per minute with a temperature of 38.5 °C. She was hypoxic on air, with saturations of 90% on high flow oxygen. She had evidence of peripheral cyanosis and delayed capillary refill time. Her chest was clear and abdomen was soft, with no guarding or rigidity. Her Glasgow coma scale was 14 (E3V5M6). Her venous blood gas revealed metabolic acidosis with a lactate of 14.
+With a working diagnosis of severe sepsis of unknown source, she was started on broad-spectrum intravenous antibiotics and fluids. As there was no improvement in her haemodynamic status, a referral to the intensive care team was made for inotropic support.
+While all of these were being done, she was noticed to have a tender bruise on her leg; however, she denied any trauma or fall. On examination, she had a large area of blackish discolouration and vesicle formation on the posteromedial aspect of the left thigh , which was tender on palpation. The area looked suspicious of necrotising fasciitis. Her antibiotics were changed as per the microbiology advice to Tazocin and Clindamycin. A urinary catheter was inserted to monitor her fluid balance. An urgent referral to the surgical and orthopaedic team was made for definitive management of surgical debridement. Her initial blood results showed a white cell count of 13.1 and neutrophilia at 11.7. She had a CRP of 439, CPK of 4187 and an AKI stage 3 with urea at 15.2, creatinine of 291 and e-GFR of 13. Serum electrolytes showed a sodium of 137, potassium of 3.4 and chloride of 101.
+She underwent debridement of necrosed tissue within few hours of arrival into the emergency department. She subsequently stayed in the intensive care unit and had a further debridement and above-knee amputation of the affected limb . On the second surgery, she was found to have necrotic tissue extending up to the pelvis. A subsequent pus culture report confirmed group A Beta haemolytic streptococci as the causative organism. The blood culture showed no growth, and faeces culture was negative and showed no evidence of Salmonella, Shigella, Camplylobacter or Escherichia coli. MRSA was not isolated and there was no evidence of C-difficile in the stool.
+She eventually died after about 48 h of hospital stay despite an early diagnosis and prompt surgical debridement.
+Although necrotising fasciitis is a rare condition, each one of us may still come across a case in our clinical practice. As a learning point from this case, we would like to highlight the importance of a thorough clinical examination of patients with sepsis with no obvious source. As in this patient, the presenting complaint was diarrhoea, which was actually a manifestation rather than a cause for sepsis and clearly had a hidden diagnosis, which could have been missed if the patient was not adequately exposed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1499_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1499_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..31e7de0375bb51afe33df2fa1b7cc414ae91d62f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1499_en.txt
@@ -0,0 +1,4 @@
+We evaluated a 28-year-old African-American woman with a history of myoclonus and epilepsy. She was born at term from an uncomplicated vaginal delivery, with initial normal development. A teacher noticed “hand tremors” at the age of 4 years. She had normal socialization and a mild learning disability but was able to finish high school and start college. At the age of 13, she developed her first generalized myoclonic seizure, followed by multiple episodes of early morning focal onset seizure with secondary generalization and additional episodes of generalized myoclonic seizures. She was treated with zonisamide and then topiramate with good control of the seizures. A previous EEG showed diffuse excessive fast activity. Brain MRI showed mild cerebellar atrophy .
+The “hand tremor” was later identified as myoclonus and worsened during her high school years, with prominent involvement of her upper limbs. She was treated with clonazepam with moderate benefit. At her last evaluation, she displayed multifocal myoclonus at rest, mostly involving her face and distal upper limbs, mild action myoclonus at target, and no clear stimulus sensitivity. There were only very mild cerebellar signs (including mild saccadic pursuits, dysdiadochokinesia, and appendicular dysmetria) with no significant gait impairment . Patient’s cognitive profile was not formally assessed but she presented a decline over the years affecting her school career. Her parents were both from Antigua. There was no consanguinity in the family and no family history of seizures or other neurological conditions. Written authorization for the acquisition of the video for publication for scientific purposes was signed by the patient.
+Previous genetic testing, including 21 genes of progressive myoclonic epilepsy and Dentatorubro-Pallidoluysian Atrophy (DRPLA) expansion, were negative. Targeted gene testing of NUS1 revealed a novel missense mutation of the NUS1 gene, c.868C>T (p.Arg290Cys), initially classified as a variant of unknown significance (VUS). The variant was not found in large population datasets and was absent in her parents (de novo). Therefore, the p.Arg290Cys was re-classified as likely pathogenic (ACMG criteria: PM1, PM2, PM5, PM6, PP3). This variant affects the same residues reported in previous cases of CDG with recessive mode of inheritance (p.R290H). We hypothesize that the different aminoacidic change in our case (p.R290C) may have a more profound impact on an important domain of the NUS1 protein due to the biochemical differences between Arginine and Cysteine, compared to Arginine and Histidine.
+To the best of authors’ knowledge and as per Genetic Testing Registry (GTR, ) there are no gene panels for the myoclonic epilepsy in the US that include NUS1.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1520_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1520_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b8aa41defa96527d70a1af835c68571307fb2312
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1520_en.txt
@@ -0,0 +1,3 @@
+A 48-year-old woman with a non-tender firm mass in the right breast was admitted to an affiliated hospital of Shahid Beheshti University of Medical Sciences in September 2008. A palpable and immobile mass in the lower outer quarter of the right breast, approximately 3.0 cm in diameter, was revealed on examination. The mass was not attached to the skin and there was no lymph node enlargement, nipple inversion, or mass in the opposite breast. A 3.5 × 1.5 cm tumor in the lower outer part of the right breast was reported by ultrasound . So we suspected it was a breast tumor and it was surgically removed (Lumpectomy). She underwent Sentinel lymph node biopsy and stage II A invasive ductal carcinoma of the right breast with no lymph node metastasis was reported by pathological examination. Immunohistochemistry showed that the tumor was estrogen receptor positive, progesterone receptor positive, and human epidermal growth factor receptor negative.
+The patient received adjuvant treatment with 8 cycles of chemotherapy (4 cycles of adriamycin and cyclophosphamide, and 4 cycles of docetaxel), followed by 25 fractions of radiotherapy and because the patient’s mass was pathologically estrogen positive, the patient was eligible for adjuvant hormonal therapy. The patient was regularly monitored for breast cancer and had no problems. In March 2023, the patient’s routine laboratory test results were as follows: WBC = 22,000 (lymphocyte = 55%), hemoglobin = 13, platelet = 180,000, BUN = 15, creatinine = 1.0, ALT = 20, AST = 25, ALK = 160, and LDH = 420. The patient did not mention B symptoms (fever, weight loss, or night sweats) and the clinical examination was normal. Due to leukocytosis with a lymphocyte predominance, peripheral blood flow cytometry was performed on the patient, and the results were as follows: HLA-DR: 84.5%, CD3: 10%, CD4: 5%, CD5: 96%, CD19: 89.5%, CD20: 89.6%, CD23: 34.8%, CD45: 85%, Cd5/CD19: 89.
+The patient was diagnosed with chronic lymphocytic leukemia (B-CLL). Abdominal and pelvic ultrasound showed no pathological findings and based on the absence of B symptoms and disease symptoms as well as other routine laboratory tests, the patient was followed up. In July 2023, the patient had vague abdominal pain, so a comprehensive examination, tests and an abdominal and pelvic ultrasound were performed. The abdominal ultrasound detected a 3.5 cm lesion in the right kidney. To examine the lesion in more detail, we recommended computed tomography (CT) with and without contrast, and a 4 cm mass with enhancement and necrosis was reported . Based on the history of CLL, we recommended an ultrasound-guided core biopsy of the renal mass. The patient's pathology confirmed RCC . After consulting with the urology department, the patient underwent a partial nephrectomy. Postoperative pathology also confirmed clear cell RCC. The patient is being monitored periodically for renal tumors and CLL, and her general health condition is good.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1537_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1537_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da2ece165985373255bae1542fc6de3b854b8caa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1537_en.txt
@@ -0,0 +1,2 @@
+A 67-year-old male farmer presented to the Ophthalmology Unit of Obafemi Awolowo University Teaching Hospitals Complex in Ile-Ife, Nigeria, with a two-week history of pain, mucopurulent discharge and redness in the right eye. There was no history of foreign body entry into the right eye, nor was there ocular trauma or instillation of traditional eye medication. The patient had earlier used chloramphenicol eye drops which he obtained over the counter. His fasting blood sugar, complete blood count and electrolyte urea and creatinine were essentially normal for his age. The patient’s HIV status was negative on serology testing.
+Further, ocular examination revealed a visual acuity of hand movement in the right eye, unaided and aided. Slit lamp biomicroscopic examination of the right eye showed a diffuse conjunctival hyperemia and a 5.5 x 4 mm corneal ulcer with raised and irregular margins which stained with fluorescein . Whitish stromal infiltrates were present in the ulcer bed and around the ulcer margins with associated stromal oedema and folds in the Descemet’s membrane. Anterior chamber examination revealed hypopyon of about one-eighth of the anterior chamber height. Pupil was round but sluggishly reactive to light and there was early lens opacity and no glow on fundoscopy in the right eye. Ocular findings in the left eye were essentially normal. A presumptive diagnosis of infective keratitis was made. During the slit lamp biomicroscopy, corneal scrapings were taken from the margins and the base of the ulcer and were sent to the microbiology and parasitology laboratory for bacterial and fungal tests. Direct lactophenol cotton blue mounts revealed septate fungal hyphae, while direct Gram stain showed cellular debris but no microorganisms. Culture on chocolate agar yielded scanty growth of cottony white colonies after 48 hours of incubation at 37°C. However, culture on Sabouraud dextrose agar at room temperature supported growth of woolly mould with reddish brown pigmentation on the agar after 48 hours . Lactophenol cotton blue staining of the mould under light microscope (x400 magnification) revealed conidiophores consisting of phialides, arranged in brush-like structures. Moreover, the phialides were cylindrical with small collarettes producing hyaline, smooth-walled conidia, which were arranged in masses. The macroconidia were septate, cylindrical with rounded apex and flat base . No bacteria were seen. The morphology of the mould identified was consistent with C. lichenicola.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1540_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1540_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..518200848af4b699288e3394470af1f6dcadae20
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1540_en.txt
@@ -0,0 +1,3 @@
+A 23-year-old Sri Lankan man, who had been working as a motor mechanic for approximately 5 years, presented to our hospital with a 2-month history of progressive, yellowish discoloration of the eyes; bilateral ankle swelling; and abdominal distention not associated with right hypochondrial pain, pruritus, or fever. His past medical history was unremarkable except for being prescribed furosemide by a general practitioner for edema. He denied intake of any other drugs, health supplements, or herbs. He had no history of smoking and only occasionally consumed alcohol in safe amounts (within Asian standard <14 U/week). His last alcohol consumption had been several months prior to the onset of symptoms. He had no family history of chronic liver disease. He had worked in a garage as a motor mechanic and used to remove gasoline from carburetors by sucking using his mouth when suction pumps were not available. He did not practice proper mouth washing and used to swallow petroleum compounds in substantial amounts during most of his working days. He had continued this malpractice for nearly 5 years until he developed symptoms.
+His clinical examination revealed icterus and ankle edema with nontender hepatomegaly and moderate ascites. The results of the rest of his clinical examination were normal. His laboratory data were as follows: hemoglobin 12.2 g/dl, white blood cell count 8920/mm3, platelet count 204,000/mm3, erythrocyte sedimentation rate 16 mm at the end of the first hour, aspartate aminotransferase 190 U/L, alanine aminotransferase 45 U/L, alkaline phosphatase 465 U/L, γ-glutamyl transpeptidase 72 U/L, total bilirubin 26.4 mg/dl (direct bilirubin 12.8 mg/dl), total protein 58.4 g/L (albumin 23.2 g/L, globulin 35.2 g/L), prothrombin time 19.8 seconds (international normalized ratio 1.67), and serum creatinine 0.9 mg/dl. His laboratory results were negative for anti-hepatitis A virus (HAV) immunoglobulin M antibody, anti-HAV immunoglobulin G antibody, hepatitis B surface antigen, anti-hepatitis C virus antibody, human immunodeficiency virus (HIV) antibody and antigen, antinuclear antibody, anti-smooth muscle antibody, and antimitochondrial antibodies. His levels of serum ferritin, serum copper, and serum ceruloplasmin were within normal ranges. The result of slit-lamp biomicroscopy was normal. Abdominal ultrasonography revealed hepatomegaly with a coarse hepatic echotexture suggestive of cirrhosis, portal hypertension, and moderate ascites without focal liver lesions. Esophagogastroduodenoscopy revealed small esophageal varices with portal hypertensive gastropathy. His liver biopsy revealed evidence of cirrhosis with regenerating hepatocytes, but with no clue to the underlying etiology of his liver disease .
+The patient was managed conservatively with symptomatic treatment. His regular medications included ursodeoxycholic acid, spironolactone, furosemide, lactulose, and carvedilol. His symptoms and laboratory parameters gradually improved during his hospital stay and stabilized over several weeks . He was able continue his regular occupation with cautious handling of petroleum compounds. Given his advanced Child-Turcotte-Pugh (CTP) class C (CTP score 10/15) and high Model for End-Stage Liver Disease score (25), he is currently being worked up for a live-donor liver transplant.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1556_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1556_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d221e23055bd74fe95439eca4e45e0f4a11237a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1556_en.txt
@@ -0,0 +1,4 @@
+A 59-year-old woman born in Southern Italy was admitted to our ward in March 2020 after experiencing malaise, nausea, vomiting and fever lasting about a week. Chest x-ray showed bilateral basal interstitial pneumonia and SARS-CoV-2 RT-PCR in a oropharyngeal/nasal swab resulted positive. Since arterial pO2 was 57 mmHg, she was started on high-flow supplemental oxygen support. The patient reported chronic treatment with low dose prednisone for adult Still’s disease since 2010 and atenolol for hypertension.
+Treatment with hydroxychloroquine, lopinavir/ritonavir, and dexamethasone was started together with enoxaparin prophylaxis. On the 5th day of hospitalization due to severe hypoxia and worsening of respiratory performance, she underwent non-invasive mechanical ventilation with continuous positive airway pressure (CPAP), which was continued for a total of 11 days. On day 7th she was treated with two doses of tocilizumab 8 mg/kg 12 h apart. Dexamethasone treatment was given at the dose of 20 mg/day for 5 days, followed by 10 mg/day for other 6 days. During the hospitalization, she presented an episode of atrial fibrillation, which was successfully reverted by amiodarone, and hyperglycemia, for which she started insulin-based treatment, later switched to oral hypoglycemic agents. Overall her clinical condition gradually improved, and she completed oxygen weaning on day 27th of hospitalization.
+On day 25th her eosinophil absolute count (EAC) increased up to 5540 cell/µL and the patient reported abdominal pain and itching. Stool examination revealed the presence of rhabditiform larvae of S. stercoralis, while IFAT serology tested positive at a titre of 1:640. A 4-day oral treatment with ivermectin (200 mcg/kg) was administered, with a rapid decrease of eosinophil cell count and symptom improvement. She was discharged and a follow-up visit 1 month later was scheduled to check EAC, serology for S. stercoralis and stool examination.
+The patient did not develop fever or worsening clinical condition concomitant to EAC rising. She denied travelling to tropical or subtropical areas and revealed recent moving to Lombardia region from Calabria region (Southern Italy). She reported repeated episodes of diffuse itching in the last 10 years, treated with topical steroids with partial improvement.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1591_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1591_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b722617b8e3f89092d311b8bd037cbe0b101d388
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1591_en.txt
@@ -0,0 +1,20 @@
+Our patient was a 20-year-old Arabic Middle Eastern woman. She was not known to have any medical illness. She had had two previous uneventful pregnancies with uncomplicated vaginal deliveries. Her only antenatal visit to our hospital was at 38 weeks of gestation, when she presented in early labor. Her general physical examination was unremarkable. An ultrasound (US) scan showed a cephalic, normally grown fetus with decreased amniotic fluid. The patient’s whole blood platelet count was 182 × 109/L, white blood cell count (WBC) was 11 × 109/L, and whole blood hemoglobin (Hb) was 116 g/L. Her blood group was AB positive.
+On vaginal examination, she was found to have a 3-cm dilated, 80% effaced cervix and intact membranes. She was augmented with artificial rupture of her membranes and syntocinon intravenous infusion. Six hours later, she had an uneventful vaginal delivery of a healthy male newborn weighing 3.06 kg. The baby’s Apgar scores at 1 and 5 minutes were 8 and 9, respectively.
+On the morning of her first postpartum day, the patient complained of a nonpruritic maculopapular skin rash over her upper limbs , abdomen , and back. It appeared suddenly as patchy lesions. It was not associated with pustules or vesicles. Her neck, face, and the palmar aspects of her hands and lower limbs were spared. There were no noticeable striae over her abdomen. She was not known to have any allergic reactions, and she did not receive any medications that could explain the findings. Twelve hours later, she was feeling very unwell and tired. She then developed generalized abdominal pain that increased in severity and was associated with nausea and occasional vomiting. Her vital signs were normal (blood pressure [BP] 120/70 mmHg, pulse rate 83 beats/minute, and oral temperature 37.1 °C). Her urine was yellow and turbid with 3+ proteinuria, and she had numerous WBC/high-power field (HPF) but no glycosuria. The same result was confirmed by testing a second urine sample that was obtained via a Foley catheter. A dermatologist’s review indicated nonspecific maculopapular skin rash, and the dermatologist advised only observation with no specific therapy but to investigate further. This advice alerted the medical staff to do further testing, which showed that her liver function, kidney function, whole blood count, serum glucose, serum lactate dehydrogenase (LDH), and coagulation profile were within normal limits.
+Day 2 postpartum was marked by persistence of nausea and vomiting and a decrease in the intensity of skin rash. On day 3 postpartum, she had nausea, vomiting, and abdominal pain. Her skin rash showed a further decrease in intensity. She was very sick, pale, and jaundiced with epigastric and right upper quadrant abdominal tenderness. Her vital signs were stable. Investigations were repeated and showed thrombocytopenia (platelet count 54 × 109/L), hypoglycemia (serum glucose 2.11 mmol/L), renal impairment (serum creatinine 228.75 μmol/L), impaired liver function (serum alanine aminotransferase [ALT] 0.735 μkat/L, serum aspartate aminotransferase [AST] 1.15 μkat/L, serum LDH 19.8 μkat/L, serum total bilirubin 68.4 μmol/L, serum direct bilirubin 58.15 μmol/L), and coagulopathy (plasma prothrombin time [PT] 22 seconds, control 14 seconds, blood partial thromboplastin time [PTT] 36 seconds, control 26 seconds, international normalized ratio [INR] 1.85) with normal urinalysis and normal plasma d-dimer and fibrin degradation products.
+Acute fatty liver was suspected, and the patient was admitted to the ICU in the evening. In the ICU, her blood Hb was 88 g/L (dropped from 105 g/L), and her blood platelet count was 51 × 109/L. Internist, hematologist, and anesthetist consultants were involved in her care. Septic workup was done, including urine and blood cultures, as well as high vaginal and endocervical swabs for culture and sensitivity. Because she was critically ill in the ICU with too many intravenous catheters and an indwelling urinary catheter, and because patients with AFLP are at risk of infection, a decision was taken by the multidisciplinary team to start her on a renal dose of imipenem/cilastatin. She was kept on intravenous fluid, normal saline (N/S) 100 ml/hour, and dextrose infusion. Five units of fresh frozen plasma (FFP), 5 U of cryoprecipitate, and 2 U of packed red blood cells (PRBCs) were given.
+On the fourth day postpartum, the patient had persistent nausea, vomiting, and epigastric and right upper quadrant abdominal pain. Her vital signs were stable. She was jaundiced. Her skin rash had significantly decreased in distribution and intensity. She had a strict fluid input-output observation. Her urine output remained around 45–60 ml/hour. Her investigations showed anemia and thrombocytopenia (blood Hb 79 g/L and blood platelet count 44 × 109/L), acute renal impairment (serum creatinine 316.4 μmol/L), very high serum LDH (19.7 μkat/L), elevated serum ALT (0.77 μkat/L), and elevated serum AST (1.52 μkat/L) with elevated serum direct and total bilirubin. Her serum glucose was 3.38 mmol/L (on dextrose infusion), and her total serum bile acids level was normal (6 μmol/L). Blood film showed hypochromic microcytic anemia, few schistocytes and acanthocytes, neutrophilia with toxic granulation of neutrophils, a majority of neutrophils that were hypersegmented, and thrombocytopenia. She received 2 U of PRBCs, 2 U of FFP, and 4 U of cryoprecipitate and was started on dexamethasone 4 mg intravenously every 8 hours.
+In the afternoon, after transfusion of blood and blood products, her blood platelet count was 38 × 109/L, blood Hb 97 g/L, and blood WBC 14.9 × 109/L. Other tests revealed plasma PT 17.5 seconds, blood PTT 29.7 seconds, and INR 1.4 (corrected by the infusion of the blood and blood products).
+An abdominopelvic computed tomographic (CT) scan without contrast enhancement revealed only hyperdense free fluid (ascites). A chest x-ray (CXR) showed congestive pulmonary changes and blunted bilateral costophrenic angles. She was started on furosemide 20 mg intravenously every 4 hours, intravenous fluid dextrose 25% 50 ml/hour, and N/S 0.9% 50 ml/hour.
+On the fifth day postpartum (the third day in the ICU), the patient still felt unwell with epigastric and right upper quadrant abdominal pain and recurrent attacks of hypoglycemia. She had no skin rash at all. She had normal BP readings with mild epigastric and right upper quadrant tenderness. Her laboratory tests showed anemia, thrombocytopenia, hypoglycemia, leukocytosis, renal impairment, hyperbilirubinemia, and elevated serum LDH. Urinalysis showed 1+ proteinuria and hematuria. The result of a viral hepatitis screen was negative.
+An abdominal U/S scan showed a marked amount of free fluid in the abdomen, liver span 17 cm, spleen span 14 cm, and a normal hepatobiliary tree with no stones or dilatation. A CXR was normal. She was given 5 U of FFP and kept on the antibiotic because of the ascitic fluid.
+On the sixth day postpartum (fourth day in the ICU), the patient showed significant clinical improvement with stable vital signs (V/S). Her blood tests showed persistent anemia, thrombocytopenia, leukocytosis, elevated serum creatinine, elevated serum LDH, mild elevation of serum bilirubin, normal serum glucose, and normal liver enzymes and coagulation. A repeat blood film showed hypochromic microcytic anemia with mild anisocytosis, neutrophilic leukocytosis, few hypersegmented neutrophils and thrombocytopenia with large forms. She was prophylactically given 5 U of FFP as suggested by the multidisciplinary team.
+On the seventh day postpartum (fifth day in the ICU), the patient started to show much clinical improvement (very mild nausea, occasional vomiting, and mild abdominal pain) with stable V/S. Blood tests showed Hb 98 g/L, blood platelet count 60 × 109/L, blood WBC 16 × 109/L (76% neutrophils and 16% lymphocytes), serum glucose 6.1 mmol/L, serum creatinine 251.6 μmol/L, serum urea nitrogen 52.1 mmol/L, and serum LDH 11.6 μkat/L with normal electrolytes and liver enzymes.
+A CXR showed reticular shadowing bilaterally, a blunt left costophrenic angle, and a clear right costophrenic angle, which further supported the continuation of the antibiotic. She was given 4 U of FFP.
+On the eighth day postpartum (the sixth day in the ICU), the patient was very well with no nausea, vomiting, or abdominal pain. Her dextrose infusion was disconnected. She was started on oral intake of fluids. She remained normoglycemic. She was prophylactically given 5 U of cryoprecipitate, 5 U of FFP, and 2 U of PRBCs for of her mild thrombocytopenia and anemia. In the evening, repeat blood test results were normal apart from mild elevation of serum creatinine. A decision was taken to discharge her from the ICU.
+On the ninth day postpartum (the first day in the obstetric ward), the patient was very well with no complaints. She resumed breastfeeding in addition to artificial supplement. Her laboratory test results were normal. Her full septic workup result was negative. Imipenem/cilastatin was discontinued.
+On the tenth day postpartum, the patient was very well and had no complaint. The results of her blood tests were normal apart from very mildly elevated serum creatinine.
+The patient’s 11th postpartum day was unremarkable; she had no complaints and normal laboratory test results.
+On the 12th day postpartum (4th day in the obstetric ward), the patient was very well with stable vital signs and no complaints. She had normal serum glucose, normal serum electrolytes, and normal liver enzymes and serum bilirubin (total and direct). Her serum LDH was 10.1 μkat/L, blood Hb 105 g/L, blood platelet count 584 × 109/L, blood WBC 11.6 × 106/L, and serum creatinine 1.43. In the afternoon, she was discharged to home receiving no medications.
+The patient was seen in the clinic 1 week later. She was doing well with no complaints and was seeking contraception.
+One month later, she and her baby were doing well with no complaints. In the clinic, she had an intrauterine contraceptive device inserted. The chronological order of her symptomatology and laboratory results are shown in Tables and , respectively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1603_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1603_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..94c31fa1f60923429e9b7f9cbd67c8d5bc295062
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1603_en.txt
@@ -0,0 +1,6 @@
+A 57-year-old Caucasian woman reported a decrease in visual acuity for 2 weeks. Her best-corrected visual acuity for her right eye was 20/20 and for her left eye 20/100. A slit-lamp examination and intraocular pressure were unremarkable in both eyes. Fundus examination of her left eye revealed temporal intraretinal infiltrates and vitreous opacities . Her right eye was unremarkable.
+Fluorescein angiography showed hyperfluorescence of her optic disc, leakage along the vessels, and chorioretinal hyperfluorescent infiltrates . The diagnosis of OT was based on the typical morphology of her ocular lesions and a positive serological testing for Toxoplasma gondii (immunoglobulin G concentration = 537IU/mL).
+She was treated with clindamycin (Clindamycin® H) 4 × 300mg daily over 3 days without any significant improvement of visual acuity. On the fourth day of hospitalization, she received 100mg prednisolone-21-hydrogensuccinate (Solu-Decortin® H) intravenously in addition to her treatment with clindamycin (Clindamycin® H). Within 2 minutes she developed an acute erythema, particularly of her legs and abdomen , angioedema, hypotension (blood pressure 80/40mmHg), tachycardia (heart rate 140/minute), hyperthermia (38.8°C), and respiratory distress. Subsequently, she was transferred to the Intensive Care Unit to be monitored and treated with clemastine fumarate (Tavegil®), ranitidin (Ranitic®), and intravenous fluids. After 1 hour she recovered and after 12 hours she was transferred back to the ophthalmological ward. Her erythema and angioedema persisted for 32 hours. She had no history of previous steroid use. Subsequent allergy testing was conducted after 3 months in the Department of Dermatology in our hospital. The testing showed a positive skin-prick test for prednisolone and methylprednisolone in the form of a 5mm wheal, and negative results for dexamethasone and hydrocortisone , which confirmed her suspected allergy to prednisolone. Because of her allergic reaction to class A (prednisone-type) corticosteroids and possible complications due to cross-reactions to class D2 (prednicarbate-type) corticosteroids, we avoided any further treatment with systemic or intravitreal corticosteroids.
+In addition, an oral exposure test with a step-by-step elevation of doses up to 2.0mg of dexamethasone (Fortecortin®) and 1.5mg betamethasone (Celestamine®) was conducted to find alternative corticosteroids for future treatments. For both substances, no local or systemic side effects were observed.
+After 1 month of treatment with clindamycin (Clindamycin® H) monotherapy without any increase in visual acuity, the patient underwent a vitrectomy with balanced salt solution filling because of heavy vitreous opacities, and to obtain a sample of the vitreous body. The polymerase chain reaction (PCR) on the sample was positive for Toxoplasma gondii.
+The postoperative examination of her left eye revealed chorioretinal scars and infiltrates . Her right eye was still unremarkable. Fluorescein angiography of her left eye also revealed hyperfluorescent intraretinal infiltrates of the temporal hemisphere and a scar of the inferotemporal retinal vein branch . Her visual acuity recovered to right eye 20/20 and left eye 20/40.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1628_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1628_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b0ae60273971ff7930ca35884beb45cd386fdde3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1628_en.txt
@@ -0,0 +1,3 @@
+A 20-year-old nulliparous woman presented to our gynecologic department because of intermittent abdominal pain and a 3-month history of dysmenorrhea. She had a history of 2 right ovarian teratomas that were managed surgically. At the age of 16 years, she experienced lower abdominal pain for 2 weeks. A subsequent pelvic sonography showed a complex, right ovarian cyst, of approximately 5.36 × 4.3 cm in size; her carbohydrate antigen (CA) 125 level was 23.4 U/mL (normal, 0–25 U/mL, at our hospital). We performed a laparoscopically assisted ovarian cystectomy, and the subsequent pathologic analysis revealed a mature cystic teratoma. During the laparoscopy, the left ovary was visually examined, and morbid findings were not noted. One month after the surgery, her symptoms had improved and no residual tumor was observed on pelvic sonography. The patient was subsequently lost to follow-up. After 1 year, she presented to our out-patient department with a 2-month history of prolonged menstrual periods; a right ovarian complex mass, approximately 3.7 × 4.3 cm, with a solid component, was noted during a pelvic ultrasound examination (Figure ). Her CA125 level was 11.9 U/mL. She, again, underwent laparoscopically assisted ovarian cystectomy in our hospital, and the pathological report revealed another mature cystic teratoma. However, no abnormal findings were noted for the left ovary.
+She received regular follow-up care every 6 months and had been well for the next 3 years. However, at the age of 20 years, she presented with intermittent abdominal pain as well as dysmenorrhea that had persisted for several months. A complex mass, that had an approximately 10% solid component, was detected on sonographic examination. In addition, her CA125 level was 103.1 U/mL. Based on the findings of serological tests, we suspected the presence of a malignancy. The patient underwent a contrast-enhanced abdominal and pelvic computed tomography (CT) scan, which revealed an 8.9 × 5.7-cm, complex, cystic tumor of the left adnexa, with compression and displacement of the urinary bladder. Moreover, a 5.1 × 3.9-cm, complex, cystic, partially solid tumor was noted on the right adnexa (Figure ).
+Due to the presence of bilateral adnexal lesions and the suspicion of malignancy, the patient underwent an exploratory laparotomy, bilateral ovarian cystectomy, and pelvic adhesiolysis. During the laparotomy, a capsulated, enlarged, 9 × 6 cm, left ovarian tumor was detected, with abundant sebaceous and hair-containing tissue. The right mass appeared to be a teratoma, 5 × 4 cm in size. Histopathological findings confirmed the presence of bilateral, mature cystic teratomas, composed of sebaceous and keratinous materials as well as hair shaft components. No evidence of malignancy was found. After discharge, the patient underwent follow-up at 1, 3, 9, and 15 months. She did not report abdominal pain or menstrual abnormalities, and a pelvic sonography did not demonstrate any signs of recurrence or residual tumor.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1646_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1646_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0e46ed6e76ef315d28dfad8e3f2132afbb6f08f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1646_en.txt
@@ -0,0 +1,3 @@
+A 68-year-old man presented with acute-onset cognitive and memory disturbance 10 days before admission. He experienced disorientation and had a score of 12 points on the mini-mental state examination (MMSE). He had no headache, nausea, or visual disturbance, including a visual field defect. Endocrinological examinations revealed hyponatremia (119 mEq/L), serum hypo-osmolality (242 mOsm/L), urinal hyper-osmolality (475 mOsm/L), presence of serum antidiuretic hormone (1.6 pg/mL), continued renal excretion of sodium (93.6 meq/L), normal adrenocortical function, absence of clinical evidence of volume depletion, absence of other causes of hyponatremia, and correction of hyponatremia with fluid restriction, which met the criteria of SIADH. Computed tomography (CT) indicated a high-density mass located in the third ventricle that caused left unilateral hydrocephalus due to obstruction of the foramen Monroe . Intraventricular hemorrhage was not apparent. On magnetic resonance imaging (MRI), the tumor showed high intensity in both T1-weighted images (T1WIs) and T2-weighted images (T2WIs), low intensity in susceptibility-weighted images (SWIs), and a low intensity peripheral rim in T2WIs, suggesting subacute intralesional hemorrhage. The mass was not enhanced with gadolinium. Cerebral angiography revealed no mass stains.
+The mass was removed via a basal interhemispheric translamina terminalis approach . An old hematoma was suctioned after incision of the capsule. The mass adhered tightly to the left hypothalamus, which was supposed to the origin and was well circumscribed from the surroundings. We carefully separated the mass from the left hypothalamus and completely excised the mass. Histopathological examination indicated that the specimen was composed of variant vessels, hematomas, and hemosiderin according to hematoxylin-eosin staining . Elastica van Gieson staining showed thin blood vessel walls containing endothelium as well as a collagenous adventitia. CD34-immunoreactivity was identified in the endothelial-like cells. The histopathological diagnosis was CCM.
+Hyponatremia and serum hypo-osmolality improved (Na: 137 meq/L, serum osmolarity: 279 mOsm/L) without fluid restriction 7 days postoperatively. Diabetes insipidus did not appear. Postoperative T1WIs showed that the mass was completely excised and that the left unilateral hydrocephalus improved . However, disorientation and memory disturbance did not recover after the operation, and he was transferred to another hospital for rehabilitation of higher brain function. His MMSE score improved to 21 points, and he could perform indoor activities of daily living, however, he could not resume work at 1 year after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1651_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1651_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f86c99e3236d187abe3c7f0114d075f841c583fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1651_en.txt
@@ -0,0 +1 @@
+An 83-year-old male patient had no family history of hypertension, chronic obstructive pulmonary disease, or malignancy. He smoked for 40 years and had a smoking index of 20 pack-years. He was admitted to the hospital for a physical examination, during which a chest computed tomography (CT) scan revealed a left hilar occupancy measuring approximately 5.9x3.6 cm, obstructive atelectasis in the left lung field, and a small pleural effusion. Further fiberoptic bronchoscopy revealed that the left main bronchus was blocked by new organisms, the surfaces of which oozed blood. This location was the site of the biopsy, which revealed lung squamous cell carcinoma . P40 (+), CK56 (-), ki-67 > 25%, TTF-1 (-) in immunohistochemistry. The patient ceased chemotherapy because he could not endure the adverse effects of nausea and vomiting after one cycle of perfusion chemotherapy (40 mg nedaplatin via bronchial artery infusion administration) and paclitaxel systemic intravenous treatment. After 7 months, the patient developed hemoptysis with a daily volume of about 10-20 mL, and chest CT scan revealed a left deviation of the mediastinum, left lung consolidation and atelectasis, a soft tissue mass in the left hilum with a size of about 8.1x4.6 cm, left main bronchial obstruction, and enlarged lymph nodes in the left cervical root and mediastinum. No obvious metastatic lesions had been found after head MRI, whole-body bone imaging, whole-abdomen enhancement CT. We took the disease’s progression into consideration (Clinical Stage, cT4N3M1a, stage IVA). Subsequently, the BRCA2 EXON15 G25085 mutation was detected by blood next-generation sequencing, and the tumor mutation load TMB was 5.98 mutations/Mb. Based on the sequencing test results, we immediately started aggressive treatment and decided to use the PARP inhibitor Olaparib (300mg twice a day) with the PD-1 inhibitor Cindilimab. After one week, the patient’s hemoptysis stopped. A repeat chest CT revealed that the left hilar mass was substantially smaller than before, with a long diameter of around 4.5 cm, and that the left lung was recruiting and the pleural effusion was absorbed after receiving Olaparib for two months and PD-1 inhibitor for two immunotherapy sessions. At this time, the patient appeared new symptoms, puffy eyelids, decreased urine volume, and generalized weakness. In further testing of common serological indicators, we found that blood creatinine increased from normal value at the beginning of the disease to 163.90μmol/L. Meanwhile, urine precipitation microscopy showed urine protein (+) without a tubular pattern. Routine blood, liver function, inflammation indicators, tumor indicators were normal, and autoantibodies were negative. Following the multidisciplinary team’s discussion, we took into account the kidney damage caused by immune checkpoint inhibitors, which was graded as 2, and stopped using the PD-1 inhibitor in accordance with the Chinese Society of Clinical Oncology (CSCO) 2022 recommendation. One month after quitting the PD-1 inhibitor, the serum creatinine level was back to normal. Six months after starting Olaparib monotherapy, the patient was more advanced. The therapy options, disease response, and PFS for each treatment line are summarized in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1663_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1663_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6e1b7df9a44601d96a08dde1eef0fde0e2774b4e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1663_en.txt
@@ -0,0 +1,2 @@
+A 23-year-old man presented with nausea, imbalance, occasional urinary and fecal incontinence and a severe headache for 1 month. The patient was a farmer with an unremarkable past experience for his relatives. Neurological examination was completely normal. Magnetic resonance imaging (MRI) demonstrated a left cerebellar mass lesion of 3×2×1.5 cm in size with marked peripheral contrast enhancement . Computed tomography (CT) examination of the chest and abdomen were performed for a primary origin. Multiple calcified mass lesions with lobulated contours were shown in the right upper lobe of lung, right liver and another solid tumor between right kidney and liver. Suboccipital craniotomy was performed and a left intracerebellar pale yellow mass was excised grossly as total. The tumor was almost avascular and it was easily dissected from the surrounding cerebellar tissues. Postoperative course was unremarkable without any neurological deficit. Histopathological examination revealed PAS (+) cuticular membrane with wide areas of necrosis and inflammation which were typical for EM . Serological tests at the postoperative period confirmed the presence of EM with indirect hemagglutination test.
+Albendazole (800 mg, bid, 3 cure, 28-day cycle followed by a 14-day albendazole-free interval) and cephotaxime (4 g, bid) were prescribed for postoperative treatment. A further operation was performed to resect the lesion in the lung a month after intracranial surgery. Postoperative early CT examination and MRI performed 6 months after surgery showed no recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1670_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1670_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..059c2cf80d59790cb346e9d0e785430e87d062ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1670_en.txt
@@ -0,0 +1 @@
+A 64-year-old woman with a past history of type 2 diabetes mellitus (under medical control by sitagliptin 100 mg per day for 5 years) experienced progressive voiding difficulty without fever for 2 mo. She had not undergone any previous urological or gynecological surgery. Urinary analysis showed pyuria, and she was admitted to our ward for further treatment. Bladder ultrasonography revealed urinary retention and a pelvic cystic lesion with a mass effect on the bladder . During admission, she also complained of perineal pain when she started to sit on a chair. Therefore, we arranged a pelvic computed tomography and the report showed a cystic lesion (9.1 cm) in the right lower pelvic region . Urologists were consulted and urodynamic studies were arranged. Uroflowmetry revealed an interrupted flow pattern with elevated post-void residual urine. Video urodynamics showed fair cystometric capacity and detrusor contraction, but the sphincter did not open during the examination. The results of the examinations all supported a diagnosis of bladder outlet obstruction due to a pelvic anatomical lesion. We consulted a gynecological expert, and a mass bulging from the right vaginal wall was found during pelvic examination. Transvaginal ultrasound revealed a pelvic cystic lesion originated from the vaginal wall. A vaginal abscess causing voiding dysfunction was diagnosed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1671_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1671_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d4a7337579aad82033a5cd7625ad09e27c47e773
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1671_en.txt
@@ -0,0 +1,9 @@
+A 45-year-old man presented to the outpatient clinic at our hospital with abnormal electrocardiogram (ECG) findings.
+The patient underwent ECG as part of a regular health check, and had no cardiac symptoms such as chest pain or shortness of breath.
+He had no specific comorbidities and no history of trauma.
+The patient had a smoking history of 20 pack-years and an alcohol consumption history of 3–4 bottles of soju per week. His younger brother was diagnosed with a myocardial bridge, and there was no other family history of cardiovascular disease.
+The patient had a height of 176 cm and weight of 73 kg, and his vital signs were stable, with a blood pressure of 121/74 mmHg and pulse of 100 beats/min. There were no other significant findings on physical examination.
+Blood tests revealed no abnormalities, and cardiac markers were normal. The ECG showed T wave inversion in the anterior lead, and chest radiography findings were unremarkable.
+Echocardiography revealed that the LV was divided into two compartments by myocardial muscle fibers, along with tears in the apical lateral and inferior segments . There were no other significant abnormalities. Based on these findings, LV aneurysm dissection or LV pseudoaneurysm secondary to myocardial infarction (MI) were suspected.
+Coronary angiography was performed to assess for coronary artery disease (CAD) such as MI. However, no significant luminal narrowing was observed. Although the findings regarding CAD did not appear, treatment was discussed with a thoracic surgeon in light of the possibility of aneurysmal dissection. After consulting with the surgeon, it was decided to prioritize a definitive diagnosis because surgical treatment in cases of asymptomatic aneurysm dissection is not urgent.
+CCTA was performed for a more detailed evaluation of the anatomy and myocardial condition. On CCTA, it was shown that the LV was divided into two. A separated accessory chamber (AC) was connected to the LV by a narrow slit-like communication in the LV apical-mid posterolateral wall . No other abnormal findings, such as coronary artery anomaly, were seen, and no findings were suggestive of myocardial ischemia. Together, these findings indicated DCLV as a more likely diagnosis than LV pseudoaneurysm or aneurysm.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1672_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1672_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dcb472f7728d2c9747eaf84547a54229534f7708
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1672_en.txt
@@ -0,0 +1,5 @@
+Patient is a 90-year-old Caucasian female with a past medical history of gastroesophageal reflux disease symptomatically managed with pantoprazole 40 mg daily, hypothyroidism, depression, anxiety, and peripheral neuropath; who presented to the emergency department (ED) with nausea, vomiting and abdominal pain. She also had a fever of 101.5 F and was complaining of chills. She initially went to a local ED where laboratory evaluation revealed a urinary tract infection. She was found to have elevated serum amylase (890 U/L) and lipase (3500 U/L) levels as well. Her white blood cell count was 11,000/mcL. Total bilirubin, alanine aminotransferase and aspartate aminotransferase levels were normal. Her blood cultures grew Gram-negative rods and Gram-positive cocci for which she was started on vancomycin [1250 mg every 12 h] and Zosyn® [3.375 gm every 6 h].
+A computed tomography (CT) scan of the abdomen and pelvis without intravenous contrast was performed which showed a very large hiatal hernia compressing and deforming the heart amongst other structures. The majority of the stomach along with the body and tail of the pancreas were herniated into the mediastinum. There was a large amount of free fluid in the mediastinum. There was dependent cholelithiasis and a distended gallbladder with signs of acute cholecystitis. A right upper quadrant ultrasound (RUQ US) showed intra and extra-hepatic biliary ductal dilation with possible echogenic material within the common bile duct. There was gallbladder wall thickening and peri-cholecystic fluid, these findings were thought to represent either acute cholecystitis or secondary to pancreatitis. The patient underwent an echocardiogram which showed left ventricular ejection fraction of 74%. There were no regional wall motion abnormalities.
+Based on the findings of RUQ US, an endoscopic retrograde cholangiopancreatogram (ERCP) was performed which showed a normal esophagus, large hiatal hernia with most of the stomach above the diaphragm and a duodenal diverticulum. The major papilla was located entirely within the diverticulum. The entire main bile duct was dilated. Choledocholithiasis was found.
+A repeat CT scan of the chest, abdomen and pelvis with intravenous contrast was performed. The body and tail of the pancreas was found to be herniating into the mediastinum .
+The patient was continued on vancomycin and Zosyn®. The bacteria were found to be ampicillin-sensitive Enterococcus durans and a pan-sensitive E. coli. She was switched to ampicillin [2 g every 6 h] for the next 2 days and finally to oral amoxicillin PO [500 mg every 8 h]. Given the findings of large hiatal hernia, General Surgery was consulted. Given the chronicity of the patient’s symptoms, her age and relatively good symptom control with proton pump inhibitors, a conservative approach to therapy was recommended with no surgical consideration for hiatal hernia repair. An elective cholecystectomy was offered to the patient and she elected to discuss this at a clinic visit in the upcoming weeks. On the day of discharge, the patient was tolerating a diet, had no pain or nausea, and was feeling well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1673_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1673_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..59d661ff00dc8929c02f8a2a64a02fa49f0b4ec9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1673_en.txt
@@ -0,0 +1,2 @@
+Three years ago, a 59-year-old male Moroccan presented to the hospital with a dyspnea, dry cough, and a chest pain that had started 6 months before. He had smoked about 30 cigarette packs a year. He was diagnosed non-insulin dependent diabetes 1 year before and was under oral anti-diabetics. He had undergone a successfully surgical intervention for priapism 4 years before the current episode of sickness. His sister is known to have a breast adenocarcinoma. Physical examination at admission revealed a patient with performance status according to World Health Organization (WHO) quote one, and dyspnea type II according to NYHA (New York Heart Association). The pulmonary examination was poor. Head and neck examination found a right thyroid nodule without clinical signs of hypothyroidism or hyperthyroidism. Chest and neck computed tomography (CT) scan were performed and revealed a tumor in the left upper lobe of the lung, in contact with the pulmonary artery . The pulmonary tumor measured 5.5 × 6 cm without mediastinal lymph nodes . The neck CT-scan showed one nodule in the right lobe of the thyroid plunging into the superior mediastinum measuring 8 × 4 cm with homolateral cervical lymph nodes . The level of the thyroid stimulating hormone (TSH) was normal. For the pulmonary tumor, we performed transbronchial biopsies. Pathological examination of the biopsy revealed an adenocarcinoma of the lung, positive thyroid transcription factor (TTF-1).
+Other explorations conducted such as brain CT and bone scan and abdominal ultrasound were normal. We concluded a diagnosis of pulmonary adenocarcinoma classified T4N0M0 with a suspected nodule of the thyroid right lobe. We performed a repeated fine needle aspiration biopsy (FNAB) of the thyroid right lobe but the anatomopathologic results were negatives. We decided to performed a total thyroidectomy and lymph node dissection after extemporaneous anatomopathologic exam, confirming the malignancy of the thyroid right lobe nodule. The pathologic examination revealed a moderately differentiated tubulopapillary adenocarcinoma and three lymph nodes with extracapsular effraction. The immunohistochemistry showed positive tumor cells with TTF1 and cytokeratin (CK) 7 but negative tumor cells with thyroglobulin and CK20 . Thus, the pulmonary tumor was classified stage IV (T4N0M1) according to the 2009 UICC (Union for International Cancer Control) staging. The multidisciplinary team found that lung tumor was inoperable because it was in contact with the pulmonary artery. The decision to administrate chemotherapy followed by the chemoradiation was retained because there was lack of places on the linear accelerator. A chemotherapy based on the combination of cisplatin and etoposide was administrated along with supportive care. The chemotherapy consisted of the combination of cisplatin and etoposide that were administered according to the following schema: for every cycle, cisplatin 75 mg/m2 on day 1 and etoposide 100 mg/m2 on day 1–3. The length of time between the treatments was 21 days. In total, two cycles of this chemotherapy were performed. We didn’t report any side effect regarding this chemotherapy. After the two cycles, the patient presented dizziness and headaches. A brain magnetic resonance imaging (MRI) was performed and showed multiples brain metastases. The cranial palliative radiotherapy 10 × 3 grays including five fractions per week was realized with best supportive care. This radiation therapy was well tolerated. Particularly, there was no deleterious effect on cognition. After the radiation therapy, we decided to go on with the chemotherapy administration. But the performance status of the patient was poor. Unfortunately, despite reanimation measures and best supportive care, the patient died 2 months later after brain radiotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1685_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1685_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..26c497295ddcd0a87d2e8a2e6fc650d860c0a7ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1685_en.txt
@@ -0,0 +1,4 @@
+A 5-year old, previously healthy female was admitted to the hospital in December 2020 with a 2-week history of periorbital swelling, with progressive involvement of abdominal and ankle swelling. Prior to admission, the child had developed isolated left eye swelling which was not associated with any other symptoms or vision changes. A week later, evaluation at her primary care physician (PCP)‘s office was notable for 4+ protein on urinalysis. The child was then referred to pediatric nephrology for further evaluation and management. In the renal clinic, on examination she was noted to have moderate abdominal swelling with ascites and pretibial edema. She had further gained 2 kg of weight since her visit to the pediatrician’s office 1 week prior. The child’s mother denied any recent illnesses such as fevers, chills, cough, rhinorrhea, congestion, nausea, vomiting, sore throat, gross hematuria, or diarrhea, and there were no known sick contacts. There was no known family history of kidney diseases.
+Urine analysis revealed 3+ proteinuria with no blood . Spot urine protein was greater than 2 g/dL and urine protein-to-creatinine ratio greater than 12 mg/mg, which suggested the presence of nephrotic-range proteinuria. The patient had mild hyponatremia with serum sodium of 133 mmol/L. Serum creatinine was 0.27, and BUN was 20. Serum albumin was 2 g/dL, total cholesterol elevated at 307 mg/dL, elevated triglycerides at 644 mg/dL, with normal complements C3 and C4 at 87 mg/dL and 21 mg/dL, respectively. Our patient’s blood work was also notable for elevated D-dimer 2.49 (normal < 0.4 Ug/mL) and partial thromboplastin time (PTT) 39.1 (25.6–32.4) seconds. She had a mildly elevated TSH (5.6 IU/mL) with a normal free T4 (0.9 ng/dL), a low 25-hydroxy vitamin D level, and a low ferritin of 29. Of note, the surveillance COVID-19 testing (RT-PCR, performed via nasopharyngeal swab), which was performed as part of the general hospital admission process during the time of this case report, returned positive for SARS-CoV-2, and further immunoglobulin (Ig) testing was positive for both IgM and IgG antibodies. The SARS-CoV-2 RT-PCR nasopharyngeal swab test was performed using the Hologic Aptima SARS-CoV-2 Assay (approved for emergency use authorization by the US FDA), and the SARS-CoV-2 immunoglobulin testing was performed on the Abbott Architect i1000 platform (approved for emergency use authorization by the FDA).
+The patient received intravenous 25% albumin and furosemide for diuresis, with excellent response. In addition to a fluid and sodium restriction, she started on oral vitamin D supplements and following a negative purified protein derivative (PPD) skin test, she started corticosteroid therapy at 2 mg/kg per day. Throughout her four-day hospital stay, patient remained asymptomatic from COVID-19 perspective. Her vital signs were stable throughout admission (temperature: 36.1–36.9 C, pulse: 79–107 beats per minute, respiratory rate: 14–22 breaths per minute, SpO2: 97–100% on room air). Although our patient was at an increased risk for hypercoagulability from both nephrotic syndrome and COVID-19 infection, we did not initiate anticoagulation therapy. Patient was discharged home after 4 days at only 700 g (0.7 kg) above her baseline weight, as estimated by her recent weight at a PCP visit 2 months prior to admission.
+Patient was in complete remission within 3 weeks of starting corticosteroids and urine protein was still negative after 6 weeks of therapy. Her coagulation profile and thyroid studies normalized without intervention; however, she remains positive for both IgM and IgG SARS-Cov-2 antibodies. Despite these positive results, she had still remained asymptomatic from a COVID-19 perspective at her follow up visit.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_168_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_168_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..85f0eb0b16c43ef375912ea1c65dfd192b82046c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_168_en.txt
@@ -0,0 +1,4 @@
+A 32-year-old female with non-diabetic chronic kidney disease was on regular hemodialysis for 3 years, via a right forearm arteriovenous fistula. The patient was admitted to our department due to involuntary movement for 5 days. Starting 5 days prior to admission, the patient’s shoulder and neck displayed a resting tremor, which became increasingly severe, with the limbs beginning to move uncontrollably. The patient’s vital signs were stable, with no complaints of headache, fever, blurred vision or mental disorder. Myodynamic examination and deep tendon reflexes in both legs were normal, and the Babinski reflexes were suspiciously positive. Significant fluctuation of blood creatinine levels (predominantly due to inadequate dialysis), along with altered hyperthyroidism [intact parathyroid hormone (iPTH) levels of almost 3200 pg/mL], were reported 1 week ago with no accompanying history of hypertension, DM, respiratory tract infection, fever, stoke, liver disease, hypoxia or toxic fume exposure. Brain magnetic resonance imaging (MRI) was performed 5 days after the onset of symptoms in the local hospital, and showed symmetrical T2-weighted imaging (T2WI; Fig. ) and T2/fluid-attenuated inversion recovery (T2FLAIR; Fig. ) hyperintense non-hemorrhagic lesions in bilateral basal ganglia, as well as corona radiata lesions showing mild diffusion restriction. Both T1-weighted imaging (T1WI) and diffusion-weighted images (DWI) were normal.
+Blood analysis immediately after admission revealed high levels of uremic toxins (urea nitrogen 25.80 mmol/L, serum creatinine 1206 μmol/L, uric acid 548 μmol/L, phosphorus 1.88 mmol/L, calcium 2.33 mmol/L,anion gap 23.9 mmol/L), and severe hyperthyroidism (iPTH 2487 pg/mL). Bicarbonate, arterial blood gas indices, hemoglobin, albumin, lactic acid, B-vitamins and liver function were all normal.
+The patient was diagnosed with UE as a symptom of bilateral basal ganglia lesions. She did not suffer from DM or other diseases such as cerebrovascular events, intoxication or hyperlactacidemia. Thus, UE was possibly due to a combined effect of uremic toxins and hyperthyroidism. The patient was treated with high frequency and high flux dialysis (4 h hemodiafiltration with APS 15 uc dialyzer, 4 times per week), hyperbaric oxygen therapy (1.5 h per day), declining parathyroid hormone (1 μg of calcitriol injection every 2 days), and treatment for symptom relief (2 mg of haloperidol, 2 mg of clonazepam and 2 mg of benzhexol administered orally twice per day). Gradually, the symptoms reduced in frequency, and the amplitude of involuntary movement decreased. Fourteen days after admission, a subsequent brain MRI revealed high signal in the bilateral basal ganglia on T2WI and T2FLAIR , which were significantly weaker compared to the initial MRI signal.
+About 1 month later, the patient achieved complete remission and restoration of normal body movement, and was discharged. Upon discharge, blood test results showed relatively stable uremic toxins (urea nitrogen 10.48 mmol/L, serum creatinine 641.5 μmol/L, uric acid 435 μmol/L, phosphorus 1.43 mmol/L, calcium 2.30 mmol/L,anion gap 15.9 mmol/L), and relieved hyperthyroidism (iPTH 1609 pg/mL). Brain MRI was performed again upon follow-up, with T2WI and T2FLAIR showing an almost complete resolution of the lesions with slightly hyperintense signal in the bilateral basal ganglia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1694_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1694_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..643f356b910bc3498984997f2beafe984c75486c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1694_en.txt
@@ -0,0 +1,2 @@
+A 72-year-old White man with an 8-year history of CLL previously treated with four cycles of fludarabine, cyclophosphamide, rituximab in 2012, and ibrutinib since 2014, presented to the oncology clinic with 2 weeks of low-grade fever and chills, night sweats, fatigue, dysphagia, and new-onset rapidly increasing cervical lymphadenopathy. The interval workup revealed worsening of lymphocytosis (61% at presentation vs. 40.2% at 6 months before the presentation) and thrombocytopenia (42 vs. 92 K/mm3). A positron emission tomography scan showed bulky confluent hypermetabolic adenopathy throughout all bilateral neck, chest, abdomen, and pelvis portions. The patient was subsequently admitted to the hospital with suspected CLL progression and possible transformation to a more aggressive type. Lymph node biopsy revealed that high-grade diffuse large B-cell lymphoma (DLBCL) had transformed from CLL (Richter syndrome; Fig. ). The patient was started on DA-R-EPOCH chemotherapy. However, the patient's course was complicated by tumor lysis syndrome, acute kidney injury, and neutropenic fever with Pseudomonas aeruginosa bacteremia. Therapy with broad-spectrum antibacterials and antifungals and with granulocyte colony-stimulating factor (G-CSF) was initiated.
+Despite an improvement in cervical lymphadenopathy, on day 9 of hospitalization, the patient developed severe airway obstruction and immediately underwent emergency intubation for airway protection, following which he was transferred to the intensive care unit (ICU). Magnetic resonance imaging (MRI) of the neck demonstrated significant neck soft-tissue edema, for which he received high doses of hydrocortisone, but with no improvement. On day 10, the patient remained unresponsive after sedation was weaned off, and he subsequently developed two episodes of generalized seizures. Computed tomography of the head showed no acute abnormalities. An electroencephalogram did not demonstrate any signs of focal or generalized seizure activity. Brain MRI revealed edema in the cortical gray and subcortical white matter of the bilateral occipital and inferior temporal lobes, consistent with posterior reversible encephalopathy syndrome . The patient experienced recurrent seizure episodes refractory to lorazepam, levetiracetam, valproate, but responsive to midazolam and propofol. Of note, additional blood cultures became positive for Klebsiella oxytoca; thus, tigecycline was added to the antibiotic regimen. However, considering the overall grim prognosis, the decision was made, in conjunction with the family, not to escalate care. Unfortunately, the patient's condition deteriorated further, resulting in cardiac arrest. We concluded that the nature of PRES, in this case, was multifactorial and related to the recently initiated combination chemotherapy, with acute kidney injury and sepsis being essential additional risk factors.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1699_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1699_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..be8e4036a1fa44d840987e37594fd66700c05371
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1699_en.txt
@@ -0,0 +1 @@
+A woman in her early 20s presented initially with cervical and thoracic back pain and left-sided numbness, during the second trimester of pregnancy, in April/2011. A week later, she had paraplegia that progressed to tetraplegia and bladder/bowel incontinence. At the nadir, 2 weeks after onset, she was wheelchair dependent. A cerebrospinal fluid (CSF) study revealed 10 cells/mm3 (49.5% lymphocytes, 47.5% neutrophils, 2% monocytes, and 1% eosinophils), protein of 42 mg/dL (normal, 0 to 45 mg/dL), and negative oligoclonal bands (OCBs). Serum cell-based assay AQP4-IgG was positive. She was treated with a 5-day course of intravenous methylprednisolone (IVMP) 1 g daily with some improvement in her upper limbs paresis. In July/2011, the patient had a severe bilateral optic neuritis relapse. In October/2011, she had worsening upper limbs' paresis, which repeated on July/13 and December/14, reaching an expanded disability status scale (EDSS) of 8.0. Cervical spine MRI showed a focal enhancing lesion at the C2-3 level and spinal cord atrophy (–). In August/2013, she started to attend our outpatient clinic and was diagnosed with NMOSD, and commenced azathioprine (2.5 mg/kg/d) until August/2016, when she presented severe macrocytic anemia. At this time, the treatment was switched to the chimeric anti-CD20 monoclonal antibody (mAb) (rituximab). In November/2017, she presented a persistent EDSS of 8.0 and agreed to participate in our study. Similarly to the protocol mentioned , a blood sample was collected, and peripheral blood mononuclear cells (PBMCs) were obtained to investigate cytotoxic-related functions in circulating T- and B- cells using flow cytometry analyses. In March/2019, the patient died due to pulmonary thromboembolism (PTE) and lower extremity deep vein thrombosis (DVT) (clinical history is summarized in ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1721_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1721_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..31e7ddfb8bb8f89328023c37dfa503261ea9f7fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1721_en.txt
@@ -0,0 +1,12 @@
+A 13-year-old young man was admitted to our hospital with non-sustained ventricular tachycardia episode, noticed during routine athletic evaluation.
+Resting ECG was normal, with sinus rhythm, normal heart rate in the absence of significant alterations of the ventricular repolarization phase (QTma × 413 ms, QTmin 383 ms, QTd 39 ms, QTcd 44 ms). Exercise stress test (treadmill) didn’t show signs of inducible ischemia through maximal effort (METS 21, HR max 194 beats per minutes), but induced asymptomatic non sustained ventricular tachycardia, with left bundle branch morphology an inferior axis with a rate of 150 beats per minute during the second minute of the recovery phase .
+Standard echocardiographic views showed a not clearly normal coronary pattern. Indeed, the right coronary artery appeared with high take-off from the aortic wall, without clear identification of right coronary artery ostium.
+As a result of genetic screening for catecholaminergic tachycardia, beta-blocking therapy with nadolol was started and continued until the first cardiological follow up.
+In order to exclude the presence of a possible coronary artery anomaly and disease, coronary computed tomography angiography was performed.
+The scan showed anomalous origin of the all three branches of coronary arteries of a single origin from left coronary sinus with malignant course of the right coronary artery, squeezed between the pulmonary trunk and the proximal ascending aorta. The distal part of the artery took its normal course. The left anterior descending artery and the circumflex artery calibers appeared to be normal. All the data were confirmed by cardiac magnetic resonance .
+Myocardial scintigraphy with protocol of two days steps and treadmill stress test (exercise) was performed, without significant evidences of perfusion defects. Catheter coronary angiography was performed to decide the tailored treatment plan. The coronary angiography showed the rare coronary anomaly pattern .
+Furthermore, the exam showed a significant milking effect at the middle segment of the left anterior descending artery, with borderline value of indices of intracoronary pressure and coronary flow reserve measured by Fractional Flow Reserve (FFR 0,74) and invasive Fractional Flow Reserve (iFFR 0,83) analysis.
+On intravascular ultrasound (IVUS) both a slit like right coronary ostium and eccentric systolic compression in the proximal bridge segment of vessel were evident.
+The depth and the length of the bridging muscle segment were measured as 16 mm and 25 mm, respectively .
+Planned on pump surgery was discussed. We performed a surgical unroofing of the right coronary artery intramural section and resuspension of the intercoronary commissure, that resulted in relocation of the coronary artery into the appropriate aortic sinus. Surgical myotomy involving resection of the overlying muscle fibers on middle segment of the left anterior descending artery was performed.
+The patient's postoperative course was uneventful. He stayed overnight in the intensive care unit and left the hospital on postoperative day 7. No complications occurred during the first six months of follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1730_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1730_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b3013cb49b8d8709a5dd38aa2c7a14343fc3ccf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1730_en.txt
@@ -0,0 +1,10 @@
+In February 2021 (day 0), a 56-year-old Ugandan woman presented to the Infectious Disease Unit of Kiruddu National Referral Hospital, Uganda, with a two-month history of mild-to-moderate, on-and-off headaches, which were worse in the mornings and were associated with neck pain, nausea, and blurred vision. She denied any history of convulsions, fever, vomiting, photophobia, diplopia, altered level of consciousness or impaired hearing.
+Her past medical history is significant for HIV-1 infection diagnosed in 2006 for which she was commenced on Zidovudine (AZT), Lamivudine (3TC) and Efavirenz (EFV) as first-line antiretroviral therapy. She was also diagnosed with systemic arterial hypertension in 2014, managed with bendroflumethiazide (5 mg once daily). She reported good adherence to antiretroviral therapy as well as her antihypertensive medication.
+Her initial antiretroviral therapy regimen (AZT/3TC/EFV) was programmatically switched to Tenofovir Disoproxil Fumarate (TDF), 3TC, and Dolutegravir (DTG) regimen and her cotrimoxazole (CTX) prophylaxis discontinued in May 2019 since she had undetectable HIV RNA viral load and her CD4+ T-cell count at the time was 767 cells per microliter. In January 2020 (day −364), she was diagnosed with asymptomatic cryptococcal antigenemia (she had a positive serum CrAg and a negative cerebrospinal fluid CrAg). She completed 24 weeks of fluconazole and was well and asymptomatic. Eight months prior to admission (day −224), she received isoniazid as tuberculosis preventive therapy.
+On admission (day 0), her vitals were as follows: axillary temperature - 36.0°C, pulse rate - 83 beats per minute, blood pressure - 130/74mmHg and respiratory rate - 14 breaths per minute. On further physical exam, she was in fair general condition, conscious and alert, and fully oriented in person, place and time.
+Neurological exam revealed a Glasgow coma scale of 15/15, no obvious craniopathies, her neck was stiff. However, both Kernig’s and Brudzinski’s signs were negative. Muscle tone, bulk, tendon reflexes, and sensation were normal. Other systemic examination was unremarkable.
+On day 0, both serum and cerebrospinal fluid CrAg lateral flow assay tests (IMMY, Oklahoma, USA) were negative, despite serial dilutions. CD4+ T-cell count was 766 cells/microliter and HIV RNA viral load was undetectable abdominal ultrasound and chest x-ray were normal and the Urine lipoarabinomannan lateral flow assay was negative. Given the high index of suspicion, a lumbar puncture was ordered and results are as shown in .
+Her admission hemoglobin was 12.8g/dL, platelet 219 ×10^3/µL and white cell count of 5.5 ×10^3/µL with normal differentials. The rest of the full hemogram parameters were normal. Baseline renal and liver biochemistries were within normal limits.
+India ink preparation and quantitative cultures on Sabouraud agar were suggestive of Cryptococcus spp, supporting the diagnosis of cryptococcal meningitis.
+On day 1, she was commenced on intravenous amphotericin B deoxycholate (1mg/kg) for 3 days (considering 10 CFU growth of Cryptococcus spp) in combination with oral flucytosine (100mg/kg) for 7 days and then fluconazole 1200mg once daily for the next 11 days.
+By day 7, she was symptom free and quantitative cerebrospinal fluid culture was negative for Cryptococcus spp. She was discharged on day 9. At 10 weeks (day +40) and 18 weeks (day +72), she was well and adherent to her antiretroviral therapy and on maintenance phase of cryptococcal meningitis on fluconazole at a dose of 400mg once daily.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1747_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1747_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fdf31b7a92e543f65ba5e0b77e54575cc58b0a4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1747_en.txt
@@ -0,0 +1,5 @@
+The patient was a 43-year-old man with a fecal specimen that was positive for occult blood during a routine check-up. He underwent a colonoscopy, which revealed a type I serrated polyp (SP) in the sigmoid colon 20 cm from the anal verge. He was referred to our hospital for an endoscopic mucosal resection (EMR). The histopathologic assessment of the resected specimen showed infiltration into the submucosal layer and he was referred to the Department of Digestive Surgery for an additional resection.
+The medical history included hypertension, hyperlipidemia, and elevated hepatobiliary enzymes. He was 158 cm tall and weighed 53.2 kg. Blood tests showed elevated liver enzymes, but no other abnormalities, and tumor markers were within the normal ranges. A preoperative CT scan was negative for distant metastases and enlarged lymph nodes, and colonoscopy revealed a scar at the site of the EMR in the sigmoid colon 20 cm from the anal verge.
+Surgery was performed under general anesthesia in the lithotomy position. A laparoscopic sigmoidectomy was performed. The sigmoid colon was transected 10 cm from the anal side of the tumor, and after a small laparotomy, the sigmoid colon was extracted from the abdominal cavity. ICG (Diagnogreen; Dai-Ichi Pharm, Tokyo, Japan) was injected as a 12.5-mg bolus (0.25 mg/kg) from a peripheral vein, and ICG /TG was used to evaluate blood flow. We used a T530 thermal camera (FLIR Systems, Tokyo, Japan) and analysis software (ResearchIRMAX; FLIR Systems, Tokyo, Japan).
+After confirmation of the boundary between ischemic and non-ischemic colon tissues at the level of the mesenteric processing site, the colon was resected; however, a diverticulum was noted at the anastomotic site when the anvil head of the circular stapler was inserted and attached to the oral side of the colon when performing the anastomosis. Because there was a risk of suture failure if the anastomosis had been performed using a double stapling technique (DST), additional resection (2 cm of colon on the oral side) was needed. After further manipulation of the mesentery, ICG was administered again, and fluorescence due to the remaining ICG from the previous administration was observed in the colon that was thought to have interrupted blood flow . Blood flow in the colon was confirmed by TG, and a transitional zone of serosal surface temperature was observed at the mesentery processing site, which corresponded to both the tissue where blood flow had been preserved and the ischemic tissue. Therefore, additional colon resection was performed along the boundary between the ischemic and non-ischemic tissues.
+After the anvil head was re-attached and the colon returned to the abdominal cavity, a DST anastomosis was performed between the oral side of the colon and the rectum. A leak test performed immediately after the anastomosis was negative, and the anastomosis appeared to have been performed successfully without any problems. A closed-suction drain was placed on the back side of the anastomotic site and the wound was closed. The postoperative course was uneventful and the patient was discharged to home 5 days after the surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1767_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1767_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..82f56391f1dddff4c1a4a595b6b2804fe754777b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1767_en.txt
@@ -0,0 +1,11 @@
+We report the case of a 15-year-old Lebanese (Arab) boy who was stung by a jellyfish on 27 September 2018 while on a beach of the Arabian Gulf. He was initially treated with pain medication and local creams; however, his condition deteriorated, with associated excruciating pain and forearm edema. He visited our pediatric emergency service 24 hours later with severe pain, forearm edema, and blue and cold fingers. On examination, the left forearm was swollen and very tense with cellulitis, and there was a large reddish patch on the dorsal aspect of the forearm where the sting occurred. The skin was muffled and cold compared with the right side. The capillary refill was sluggish. The child was able to actively extend the fingers .
+There was no palpable radial or ulnar pulse on the left side.
+The brachial artery showed a good signal on a portable Doppler scan, but no signal was retrieved at the level of the radial and ulnar arteries .
+The main concern was compartment syndrome with the occlusion of the arterial blood supply, which could affect the function of the arm and hand. Informed consent was obtained. Decompression fasciotomy was performed by making a curvilinear incision at the volar aspect of the left forearm. The subcutaneous tissues were dissected. The superficial and deep compartments were both incised and explored. All muscle groups were intact with minimal swelling. The muscle appeared pink and contractile. The cubital and radial arteries were normally pulsating. The wound was left open, and progressive closure was planned depending on the patient’s progress from the vascular point of view of the surgery team.
+On day 2, finger perfusion was impaired, and there was no visible pulse in the area of the mid-forearm. Diluted nitroglycerin was applied to the wound directly over the radial artery in an attempt to resolve the arterial spasms, and the carpal tunnel was decompressed.
+The patient was kept in the Pediatric intensive care unit (PICU) for the following week on low-molecular-weight heparin (LMWH) and an intravenous antibiotic, nitroglycerine, and morphine infusion. Arm perfusion improved over the next few days. The Doppler signal started to improve on the radial arch and then later on the palmar arch and the fingers. On day 5, the patient was taken to the Operation Room (OR), and both forearm and wrist incisions were closed with no difficulty.
+The patient was transferred to the regular ward on the day of surgery and was discharged on day 8 in good condition, with a palpable radial pulse and good triphasic Doppler signals on the fingers.
+The patient was advised to continue LMWH for two more weeks, along with oral antibiotics and pain control medications. He was followed-up in the vascular outpatient clinic weekly for the following 4 weeks with normal wall-to-wall color flow and a triphasic waveform.
+On day 17, a nerve conduction velocity (NCV) study showed reduced CMAP amplitudes for the left ulnar and radial nerves along with normal distal motor latencies, conduction velocities, and F-wave latencies.
+The patient continued to complain of pain in the left shoulder and elbow, with tenderness, muscle spasms, left elbow flexor weakness, and a limited range of motion at the elbow and wrist joints. His motor function improved after he received ten sessions of physiotherapy over a period of 6 weeks.
+The patient and his parents found the time to come to the hospital to thank the vascular surgery, pediatric intensive care, and physiotherapy teams after the patient’s complete recovery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1768_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1768_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..775b54bac01767523ae3f4b744e5da2e2dccd02f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1768_en.txt
@@ -0,0 +1,2 @@
+Three years ago, an 11-year-old girl presented to the hospital with pain in the right jaw after becoming aware of a mass in her right cheek. After detailed examination, the patient was diagnosed with ASPS with primary tumor in the right cheek and multiple lung metastases, and chemotherapeutic treatment was initiated. After receiving 1 cycle of VAC therapy (vincristine [2 mg], actinomycin D [0.045 mg/kg], and cyclophosphamide [1.2 g/m2]), the patient developed grade 4 neutropenia. After this treatment, the patient received 1 cycle of the treatment regimen prescribed for rhabdomyosarcoma (vincristine [2 mg], pirarubicin [60 mg/m2], cyclophosphamide [1.2 g/m2], cisplatin [20 mg/m2]) and 1 cycle of ifosfamide (1800 mg/m2), etoposide (100 mg/m2), actinomycin D (0.045 mg/kg), and vincristine (2 mg); however, the development of severe neutropenia made it difficult to continue administration of these drugs. The patient was then treated with oral administration of 800 mg/day of pazopanib for 1 year, and clinical benefit was achieved. Upon stabilization of the disease, oral administration of pazopanib was discontinued; however, 1 year later, fluorodeoxyglucose accumulation was observed in the right front of the skull (maximum standardized uptake value [SUV-max], 2.8) and in the left breast (SUV-max, 2.4) using fluorodeoxyglucose-positron emission tomography/computed tomography.
+An elastic, soft tumor, approximately 3 cm in size, was palpated in the lower lateral region of the left breast. Ultrasonography revealed a hypoechoic, internally heterogeneous mass measuring 22.4 × 16.2 × 21.1 mm with a rich blood supply , while magnetic resonance imaging showed a 3-cm sized tumor that was larger than the one found on prior imaging . Examination of a core-needle biopsy specimen from the same site showed proliferating tumor cells with abundant foamy cytoplasm, clear nucleoli, and oval nuclei . The tumor cells tested positive for AE1/AE3, CAM 5.2, vimentin, S-100, α-actin, desmin, and HMB 45. The specimen showed negative periodic acid–Schiff (PAS) staining after diastase digestion ; furthermore, the specimen then tested positive for transcription factor E3, resulting in a pathological diagnosis of ASPS . Based on the above information, we established a diagnosis of ASPS with left mammary, lung, and cranial metastases. Due to chemoresistance, surgical excision was selected as the mode of treatment; resection of the cranial bone showing metastasis was performed first and partial mastectomy of the left breast was performed in two stages. The mammary tumor was 25 mm in size, and the cut surface was solid with a reddish gray color . Histological findings similar to those of the needle biopsy specimen were also obtained in the final pathological diagnosis and resection margins were negative. Postoperative conditions were good, and we are currently monitoring the patient through regular follow-ups (visual palpation every 3 months and semi-annual mammary gland ultrasonography).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1780_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1780_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..78b30b14e8a255d4a0d8cd427a9476f7316e6ab1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1780_en.txt
@@ -0,0 +1,3 @@
+A 79 year old male with history of atrial fibrillation (previously on apixaban and switched to aspirin only), type II diabetes mellitus, asthma (well controlled on home inhalers), hypertension, and tested positive for coronavirus disease 2019 (COVID-19) on April 7th, 2021 and fully vaccinated with Moderna presented to the emergency department with progressive worsening of bilateral lower extremity edema and dyspnea over one month. Patient had a chronic two-pillow orthopnea, and at baseline performed all activities of daily living independently. In addition, this work has been reported in accordance with SCARE .
+At presentation, the patient denied chest pain, fever, nausea, vomiting, diarrhea, dysuria, travel, trauma, drug use, and cough. Vital signs were all within normal limits on admission. Physical exam was notable for bibasilar crackles in the lungs, bilateral lower extremity 2+ pitting edema, and jugular venous distention up to 9 cm. Labs were notable for a pro B-type natriuretic peptide of 8458 pg/mL (reference range 1–450 pg/mL), a significant increase from 3301 pg/mL during a previous admission. In addition, the D-dimer was unremarkable. A chest radiograph obtained during admission showed bilateral ground glass opacities from prior COVID-19, pulmonary congestion, and interposition of the right hepatic flexure of the colon between subdiaphragmatic space and the right dome of the liver (Chilaiditi's sign) . The comparison was made from a prior chest radiograph that showed normal anatomy of the right subdiaphragmatic space . Electrocardiogram demonstrated atrial fibrillation with low voltage and no acute ischemic features. Echocardiogram showed an ejection fraction of 40%, reduced from 70% only a year ago, with normal right ventricular (RV) size, reduced RV contractility, and a dilated right atrium. In addition, the patient did not have any prior COVID-19 complications including intubation, development of pulmonary embolism or requiring supplemental oxygen. A negative D-dimer and CT chest without contrast showed no evidence of embolism, effectively ruling out acute pulmonary embolism.
+The patient was subsequently admitted for congestive heart failure exacerbation, for which he was started on furosemide 40 mg IV twice a day with daily weight trend and strict intake and output documentation. Patient had an excellent response to diuretics with a net negative urine output of 6.8 L over 48 hours since admission. His home medications were resumed, including Losartan 25 mg daily, carvedilol 3.125 mg twice daily, atorvastatin 40 mg, aspirin 81mg, albuterol inhaler as needed every 6 hours and montelukast 10 mg daily. He was diuresed for 3 days, successfully achieving euvolemic status, resolution of bilateral leg edema, and improvement of jugular venous distention. Cardiology was consulted for a new reduction in ejection fraction to rule out acute coronary syndrome. Given an electrocardiogram showing no ischemic features and negative troponin on three separate assessments, it was concluded that the patient did not have acute coronary syndrome. Patient received coronary angiography and was found to have non-obstructive coronary artery disease. Patient continued to have persistent dyspnea with some mild pleuritic chest pain on the right subcostal region without any need for supplemental oxygen. The aforementioned medications were continued for a total of 5 days. Community or hospital acquired pneumonia was ruled out given normal cultures, absence of inflammatory response, no fevers, normal procalcitonin, and no imaging findings concerning pneumonia. Computed tomography scan of the chest without contrast was repeated to rule out other causes of dyspnea and pleurisy, and subsequently showed colonic interposition between the diaphragm and right lobe of the liver . Given the patient's dyspnea and pleurisy due to diaphragmatic irritation, as well as the imaging findings, surgery was consulted for potential Chilaiditi syndrome. Despite this, the patient refused to undergo any surgery and preferred to be discharged from the hospital. The patient was discharged with guidelines for long-term medical treatment for heart failure (Lasix 40mg by mouth twice daily, carvedilol 3.125 mg twice daily, Losartan 25mg daily), atrial fibrillation (carvedilol 3.125 twice daily, aspirin 81mg), hypertension (carvedilol 3.125 mg twice daily, Losartan 25mg daily) and asthma (albuterol inhaler as needed, montelukast 10mg daily).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_178_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_178_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..29296d2e73c910167bbbbd54ba33790fa75aa908
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_178_en.txt
@@ -0,0 +1,5 @@
+A 42-year old man suffered from fever, sore throat, mild bilateral headache, and runny nose for 5 days. An acute onset of occipital headache and vertigo occurred one day before admission. He had transient diplopia and confusion for several hours on the day of admission, and received intravenous drip of penicillin. Shortly after the relief of confusion, he experienced dysphagia, hoarseness, as well as ataxia of the left upper and lower extremities. He had no coughing or vomiting during this period. The patient was healthy previously, and denied any head or neck trauma and chiropractic manipulation. He smoked 10 to 15 cigarettes daily, without any use of alcohol or recreational drugs.
+On physical examination, his temperature was 37.6°C, pulse 72 beats/min, blood pressure 130/80 mmHg. No remarkable positive signs were detected by the lung, cardiac, and abdominal examinations. Neurologic examination revealed that the pupils were equal and reactive to light, but horizontal nystagmus, hoarse voice and decreased movement of the left soft palate were noticed. He had normal strength in all limbs but decreased pain sensation on the left face and right limbs. In addition, he had left-sided finger-to-nose and heel-knee-shin dysmetria. Neck stiffness was mild, but Kernig's and Brudzinski's signs were not observed.
+Admission laboratory studies showed normal serum electrolyte and metabolic panel. The blood count showed 13,760 white blood cells (WBCs) per cubic millimeter with 91% polymorphonuclear leukocytes (PMN). Coagulation tests and erythrocyte sedimentation rate were normal. Venereal Disease Research Laboratory (VDRL) and human immunodeficiency virus (HIV) antibody test were negative. High sensitive C-reactive protein (hs-CRP) (3.72 mg/dL) and fibrinogen (4.1 g/L) were elevated. Connective tissue disease work-up was negative. He had normal chest X-ray and electrocardiography. Lumbar puncture on admission showed an opening pressure of 190 mmH2O. It was a traumatic tap, so three serial samples of fluid were taken. Being clear and colorless, the third one was analyzed. The CSF study showed 84 WBCs per cubic millimeter with 90% lymphomonocyte and 10% PMN, 236 red blood cells per cubic millimeter, normal glucose concentration (3.3 mmol/L), increased protein concentration (744 mg/L), increased IgA and IgG concentration (11.0 mg/L and 38.3 mg/L respectively), and normal IgM level (0.23 mg/L). The IgG index was 78%. CSF cytology, smear for acid-fast bacilli, Gram stain and Indian ink were all negative. Viral immunological reactions were negative (herpes simplex virus I and II, Epstein Barr virus and cytomegalovirus), so were CSF polymerase chain reactions for enterovirus, herpes simplex virus I and II.
+CT of the head and electroencephalography were normal. T2-weighted MRI of the brain on the second day showed hyperintense signal in the left lateral medulla and narrowing of the lumen of the left vertebral artery. DWI images also showed hyperintense signal in the left lateral medulla and hyperintense signal of left inferior turbinate, suggesting medullary infarction and rhinitis . DSA showed focal luminal dilatation involving left V4 segment of the artery just proximal to posterior inferior cerebellar artery (PICA) and insufficient blood flow to its distal portion. Dissection of the left vertebral artery at the level of V4 segment was confirmed .
+Intravenous heparin was administered to the patient. After 24 hours of treatment, his vertigo was relieved. Ataxia and headache alleviated by day 4. He was discharged 10 days later after admission with only symptom of dysphagia. At one-month follow-up, the patient recovered completely, and repeated CSF study was normal.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1811_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1811_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c66dbe92010f9765d47e66ece30400fdeaa01c21
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1811_en.txt
@@ -0,0 +1,2 @@
+This study involved a 62-year-old male who had undergone scleral buckling surgery 40 or more years ago for rhegmatogenous retinal detachment, as well as trabeculectomy 20 years ago for primary open-angle glaucoma in his left eye at another hospital. He presented to our hospital complaining of blurred vision in that eye. The patient reported that although the previous retinal reattachment surgery had resulted in a favorable outcome, he had experienced persistent conjunctival hyperemia, conjunctival edema, and low levels of ptosis during the subsequent recovery period. He reported that he had recently become aware of blurred vision in his left eye and subsequently consulted a local doctor. Upon examination at that facility, iritis and proliferating changes in the fundus had been identified in that eye, and he had been referred to our hospital.
+Upon examination, his visual acuity was 1.0 × S-3.5D C-1.5D A × 30° OD and 0.5p × S + 2.0D C-2.25D A × 160° OS, and his intraocular pressure was 20 mm Hg OD and 11 mm Hg OS. Iritis was observed in the anterior chamber of the left eye, as well as a great number of pigment cell keratoprecipitates on the posterior surface of the cornea . Minor cataracts were observed beneath the posterior capsule, and mydriasis was somewhat poor. In the ocular fundus of the left eye, extensive atrophy of the retinal pigment epithelium and partial hyperpigmentation were observed, accompanied by subretinal strands, yet the retina remained reattached. Around the entire peripheral area of the retina we observed a high, ring-shaped protrusion, but we also saw a shiny, filamentous material in the vitreous cavity that penetrated the sclera and choroid, completely extending from the 4- to 8-o'clock position of the protrusion . During a B-mode ultrasound scan, we observed a high-luminance image on the edge of the buckle protrusion with an acoustic shadow . We also observed slight opacity and inflammatory cells in the vitreous cavity. Thus, we diagnosed this patient as a case of intraocular erosion and intrusion by an Arruga suture, and for the iritis in the left eye we began to administrate low-concentration steroid eye drops, after which the inflammation disappeared. A previous doctor had performed a trabeculectomy on the left eye 20 years previously to treat primary open-angle glaucoma, and we recognized a filtration bleb in the upper part of the corneal limbus, but we saw no particular abnormalities in the middle optic media or fundus in the right eye.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1840_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1840_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d2609030bbadb3d912bb9e50bce12ede23496fe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1840_en.txt
@@ -0,0 +1 @@
+A 67-year-old female underwent bilateral truncal vagotomy, cholecystectomy, Billroth-2 gastrectomy, and Roux-en-Y procedure for pyloric stenosis twenty years ago due to early dumping syndrome and sliding-type hiatal hernia. The liver left lobe was mobilized by dissecting the left triangular ligament (appendix fibrosa hepatis) to release the cardioesophageal junction and stomach fundus. The hiatal hernia defect was repaired with a constrictive primary suture. Roux-en-Y anastomosis was externally constricted, and the antidumping procedure was applied. There was no other procedure in the abdomen that could injure the bile ducts such as liver hilar and duodenal stump dissection. A penrose drain was placed under the left lobe of the liver at the level of the cardioesophageal junction. There was a 150 mL bile leak in 24 hours after the first day of surgery. Bile leakage was detected with MRCP on the left side of the left triangular ligament of the liver . The patient was reoperated, and no pathology was observed except for aberrant bile duct (a 3 mm diameter) with bile leakage at the site where the left liver triangular ligament (appendix fibrosa hepatis) was dissected at the observation by following the drain . The injured bile duct was ligated with the 3/0 prolene suture. On 7 day after the operation, all complaints resolved, and the patient was discharged without any problems in the postoperative period.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1844_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1844_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dac5a5a1bf715236c6e5eff5c3daea2374b403d7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1844_en.txt
@@ -0,0 +1,6 @@
+A 33-year-old Japanese woman first visited Okayama University Hospital in February, 2011 to evaluate numbness in her bilateral lower limbs, a condition that had developed since the age of 29, when she had a cervical spinal cord injury due to a car accident. The patient had no other previous medical history.
+General medical and neurological examinations showed no other particular findings except for decreased vibration sensation and increased tendon reflexes in her bilateral lower limbs, which were present 4 years after the car accident.
+Biochemical blood tests showed no abnormal findings. A brain MRI revealed no lesion in fluid-attenuated inversion recovery (FLAIR; Figure A-D). However, a brain magnetic resonance angiography (MRA) incidentally found a 3.7 × 3.3 mm unruptured cerebral aneurysm (CAn) in her basilar artery located at the origin of the right superior cerebellar artery . When approximately 80 mL of nondiluted iopamidol (Iopamiron, Bayer Healthcare Inc., Leverkusen, Germany) was intravenously injected as the contrast medium (CM), a computed tomographic angiography (CTA) confirmed the CAn. An MRI revealed a small old lesion in the C5/6 level of the spinal cord, which was responsible for her leg symptoms. With extensive informed consent, endovascular coil embolization was performed through the right femoral artery under general anesthesia in which the patient became fully heparinized by 4,000 units of heparin sodium. Approximately 70 mL of nondiluted iopamidol was used throughout the procedure, distributed in one rotational acquisition of 14 mL as 10 standard vertebral injections of 5 mL each (to monitor parent vessel patency and aneurysm occlusion). The aneurysm was framed with a Microplex-10 complex 3/7 coil (Terumo, Isehara, Japan) and filled with 2 Micrus Deltaplush (Micrus Endovascular, San Jose, CA) coils. A HyperForm 4 × 7 balloon (Micro Therapeutics Inc, Irvine, CA) was intermittently inflated and deflated between coil placements. Postcoiling contrast angiography showed complete obliteration of the aneurysm . During the procedure, CM was injected only into the right vertebral artery. The right groin was closed by manual compression. There were almost no changes in vital signs such as blood pressure, heart rate, and respiratory rate during and after the operation. The patient awoke from anesthesia neurologically intact and was discharged from the hospital 72 hours after coiling.
+Although the patient did not develop any clinical symptoms, a follow-up brain MRI at 1 month showed several white matter lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe without a positive signal in the diffusion-weighted image (DWI; Figure H-O, arrowheads). A further follow-up MRI at 2 months after coiling revealed the enlargement of each lesion , although she did not show any symptoms such as visual disturbance. Thus, she was re-admitted to our hospital for a detailed examination in July, 2011. However, blood and cerebrospinal fluid (CSF) biochemical tests showed no abnormal findings.
+At 4 months, 2-deoxy-2-[F-18]fluoro-D-glucose (FDG) and 11C-methionine (MET) PET studies showed that glucose uptake in the lesion with areas enhanced by gadolinium-enhanced MRI (Gd-MRI; Figure E-H, arrowheads) increased slightly or remained at the baseline level , while methionine uptake increased . 1H-MRS showed a slight increase in the choline (cho) peak with a mean cho/creatine (cr) ratio of 1.10 versus 0.89 in the control. The mean N-acetylaspartate (NAA) peak was reduced with a mean NAA/cr ratio of 1.29 versus 2.34 in the control. An elevated lactate peak was also noted .
+A follow-up MRI at 6 and 12 months showed a gradual decrease in the initial hyperintense lesions in the left cerebellar, bilateral occipitotemporal and left parietoccipital lobe .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1849_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1849_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c41582a2e9634d811a1fc6723a75fcc01b7452a0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1849_en.txt
@@ -0,0 +1 @@
+A 56-year-old female patient was admitted to our hospital with a 2-year history of neck pain. No obvious abnormalities were detected on neurological or physical examination, and laboratory findings were all within normal limits. Computed tomography (CT) demonstrated low density in the seventh cervical vertebra, with high-density hardening visible around the edges. Magnetic resonance imaging (MRI) of the cervical spine indicated an expansile lytic lesion with isointensity on T1-weighted imaging and hyperintensity on T2-weighted imaging. These findings were explained to the patient as the possible causes of neck pain, and options for continued conservative observation or surgical treatment were provided. The patient refused to continue conservative observation treatment and requested surgery. The preoperative treatment team communicated sufficiently about the case, considered the existing clinical data of benign bone tumors, and recommended two surgical treatment options: (1) open biopsy with direct excision and internal fixation, which would involve extensive trauma and a long recovery time, or (2) open biopsy with bone cement injection, with later treatment options to be determined according to the pathological results after surgery and reoperation to remove the lesion, if necessary. The patient chose the scheme 2. C7 VP was performed after inducing general anesthesia. Imaging examinations were performed at 3 days, 6 months, and 1 year after surgery . The postoperative pathological results supported the diagnosis of FD , and the patient was ultimately diagnosed with MFD. At the 12-month follow-up visit, the patient reported no clinical symptoms, and no signs of tumor recurrence were detected.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1870_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1870_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0accf1c7c5f0eb7a48b3fd86ecb9981a5efb3210
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1870_en.txt
@@ -0,0 +1,4 @@
+A 1-year 9-month-old female patient with non-significant past medical or surgical history, a full-term product of a non-complicated vaginal delivery with no neonatal intensive care unit admissions was referred to our center for further investigations regarding the diagnosis of an intraabdominal mass versus an abdominal abscess. The patient complained of abdominal pain and fever for 10 days duration. The pain was located in the epigastric area radiating to left upper quadrant, and associated with nausea, vomiting and anorexia. The pain was severe enough to awaken the patient from her sleep. The fever was intermittent in nature with maximum recorded value of 39 °C orally, responded well to paracetamol. Upon physical examination, an epigastric tenderness was observed associated with left upper quadrant guarding to palpation. Otherwise, the abdomen was soft and lax. The suspected mass could not be palpated.
+Laboratory investigations , abdominal X-ray and ultrasonography were performed . Ultrasonography revealed a well-defined, multiloculated, cystic lesion seen in the epigastric region and extending into the left upper quadrant with foci of calcification seen with posterior acoustic enhancement, with no hyperemia seen on Doppler images. The largest locule measured about 4.8 × 4.0 × 5.6 cm seen in the epigastric region containing swirling debris. Findings highly suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma. Liver, spleen and pancreas were all homogenous with no focal lesions. The long axis of the liver and spleen was 8.7 and 6.7 cm, respectively. Both kidneys appear normal in size, shape and echotexture with no hydronephrosis. The long axis of the right and left kidneys was 7.2 and 7.1 cm, respectively. Gallbladder had a smooth outline with no stones. No intra- or extra-hepatic biliary dilatation were seen. Subsequent computed tomography (CT) imaging with intravenous contrast revealed a multiloculated thick enhancing-walled fluid collection seen in the mesentery anteriorly and extending to the left upper quadrant and flank region. The largest locule is seen in the anterior abdomen measuring 6.7 × 6.2 cm containing two tiny foci of calcifications which caused a mass effect to adjacent small and large bowel loops displacing them posteriorly and laterally. The lesion was associated with sub-centimetric enhancing locoregional lymph nodes with the largest measuring about 0.5 cm in the short axis. A mild amount of fluid was seen in the pelvis. CT scan finding along with ultrasonography results suggest an organized abscess secondary to infected mesenteric cyst or a lymphangioma. A trial of true-cut biopsies performed by an interventional radiologist was not informative in which the histopathological examination of three needle core biopsies measuring 1.5, 1.5 and 0.5 cm indicated fragments of fibrinoid material with no viable cells and composed of skeletal muscles and fibrous tissue, precluding proper diagnosis.
+A Multidisciplinary team decision was made to excise the mass by the pediatric surgery team. Intraoperative findings include : multiloculated fused cystic lesions (8.0 × 5.0 × 4.0 cm) on the descending mesocolon. Descending colon loops were healthy and viable. Complete excision of the mass was performed with preservation of the attached descending colon through a midline laparotomy incision. Histopathological examination of the excised mass revealed a variably sized thin-walled vascular spaces almost devoid of blood and containing pale pink fluid mostly representing lymph. Such spaces are surrounded by loose fibrous tissue with inflammatory cellular infiltrate (mainly eosinophils and plasma cells) with lymphoid follicles (A). The spaces are lined by a layer of endothelial cells highlighted by CD31 and CD34 immunohistochemical staining (B and C). No evidence of malignancy was observed.
+Postoperatively, a nasogastric (NG) tube was inserted, and the patient was on the following medication: vancomycin (165 mg, Q6h), piperacillin/tazobactam (1 g, Q6h), diclofenac suppositories (12.5 mg, Q12 h) and paracetamol (pro re nata). Medications were stopped at day 5 and the NG tube was removed at day 3 postoperatively. The patient was doing well, vitally stable, passed flatus on day 2, passed stool at day 4 and discharged after 5 days postoperatively. The patient was followed 1 week after the surgery in an outpatient clinic, the wound was healthy, not infected with normal bowel motion and no fever spikes, abdominal pain or abdominal distention.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1899_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1899_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..164879b12de6df63d52908a55bc0995b846d403b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1899_en.txt
@@ -0,0 +1,3 @@
+A 31-year-old previously healthy Sri Lankan woman from southern parts of Sri Lanka presented with fever for 3 days and altered level of consciousness for 1 day. The fever was associated with headache and myalgia and she did not have nausea, vomiting, or skin rashes. On admission to our hospital she was afebrile and nuchal rigidity was present. She was conscious but aphasic. Her Glasgow Coma Scale was 11/15 (E 4, V 1, M 6). There were involuntary conjugate fast eye movements in all the directions of gaze without a saccadic interval, suggestive of opsoclonus. There were no ophthalmoplegia or other cranial nerve palsies. Her pupils were equally reacting to light. Fundoscopy revealed papilledema. There were involuntary twitching movements on the right side of her face, mandible, and tongue, which increased with movement and disappeared during sleep. Both upper and lower limb tone were normal and she was able to move her limbs against gravity, but not against resistance (power 3/5). The deep tendon reflexes were present. Bilateral plantar responses were flexor. Her other vital signs were stable with a heart rate of 68 beats per minute (bpm), blood pressure of 130/80 mmHg, and blood oxygen saturation (spO2) on air was 96%. All other system examinations were unremarkable.
+Her full blood count revealed a neutrophil leukocytosis: white blood cells, 14 × 103/μL; neutrophills (N), 78%; lymphocytes (L), 11%; eosinophills (E), 02%; basophills (B), 5%; platelets, 280 × 103/μL; and hemoglobin, 13 g/dl. Her erythrocyte sedimentation rate was 66 mm in the first hour but her C-reactive protein was less than 6 mg/dl. Her serum electrolytes and renal and liver profiles were normal: sodium (Na), 133 mmol/l; potassium (K), 4.5 mmol/l; serum calcium, 2.3 mmol/l; magnesium, 0.99 mmol/l; aspartate aminotransferase (AST), 40 U/l; and alanine aminotransferase (ALT), 47 U/l. Her thyroid stimulating hormone was 0.34 IU/L. Blood and urine culture, blood film for malaria parasite, rheumatoid factor, antinuclear antibody, and human immunodeficiency virus serology were negative. Thyroid microsomal antibody was less than 10 IU/ml and N-methyl-D-aspartate (NMDA) receptor antibody was also negative. A non-contrast computed tomography of her brain showed cerebral edema. Cerebrospinal fluid (CSF) opening pressure was 180 mmH2O and full report showed high level of proteins of 130 mg/dl with 60 lymphocytes/mm3. Polymorphs and red blood cells were absent in CSF. CSF glucose was 3.4 mmol/l (corresponding random blood sugar was 5.5 mmol/l). Herpes simplex virus polymerase chain reaction in CSF was negative. IgM for JE became positive in both serum and CSF. Magnetic resonance imaging (MRI) of her brain showed symmetrical bilateral high signal intensities in basal ganglia, head of the caudate, and midbrain in T2 and fluid-attenuated inversion recovery (FLAIR) without diffusion restriction . Serial electroencephalograms (EEGs) were done which showed various epileptiform discharges. Initial EEG showed bilateral periodic lateralized epileptiform discharges and the second EEG after 2 days showed left-sided lateralization with background slowing.
+She was given supportive care and once JE was confirmed we administered methylprednisolone pulses intravenously (1000 mg per day) for 5 days. With this, she improved gradually with reduction in opsoclonus and myoclonic movements. Her limb muscle power and speech also improved slowly. After approximately 2 weeks of the disease duration, epileptic discharges and background slowing in an EEG showed improvement. During the course of her illness she became rigid and a quarter of a tablet of levodopa-carbidopa (250/25 mg) was started at a frequency of three times a day to alleviate the extrapyramidal symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_191_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_191_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..65ad3c00f5769704604a66a2c1d6fa69b7c5abf8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_191_en.txt
@@ -0,0 +1 @@
+A 33-year-old male smoker with no prior medical history came to the emergency department with sudden onset dyspnea and hemoptysis associated with lower limb edema. The physical examination found: heart rate 125 bpm, regular sinus rhythm with no added sounds, blood pressure 240/130 mmHg, polypnea at 45 breaths per minute, normal oxygen saturation, limited bilateral air entry with crepitation, lower limbs pitting edema, hepatojugular reflex, no evidence of deep vein thrombosis, normal abdominal examination. Biological markers were hemoglobin 15 g/dl, white blood cells 16 G/l, CRP 87 mg/L, ProBNP 3612 pg/mL, stable troponin at 76 ng/ml, sodium 133 mmol/L, potassium 4.7 mmol/L, creatinine 100 μmol/L.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a7f96664ee0c3d1b45552425007228f8d0281b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1_en.txt
@@ -0,0 +1,5 @@
+A 59-year-old man with a three-year history of hypertension presented with a one-day history of growing TP increasing stomach pain and frequent projectile vomiting, followed by absolute constipation for one day and abdominal distension six hours before presentation. No history of fever, malaise, jaundice, hematemesis, or melena was available. There was no family history of TB. He had a similar attack previously six months ago, which was conservatively controlled and he was discharged. He was alert, oriented, afebrile, and mildly dehydrated upon inspection. Abdominal examination revealed tenderness throughout the abdomen and increased bowel sounds. However, there was a palpable abdominal swelling. Rectum was found to be empty on digital rectal examination (DRE). He was originally managed by maintaining nothing by mouth, using O2 inhalation, nasogastric aspiration, and Foley catheterization. Intravenous fluid resuscitation was initiated, as well as empiric antibiotics. Blood tests revealed normal hepatic and renal profiles during laboratory workup. His coagulation profile was slightly abnormal, and he had metabolic alkalosis as determined by ABGs. LDH and CEA levels were within normal limits. Simple abdominal X-rays indicated Distended small bowel loops with varying air-fluid levels and an absence of rectum gas shadow, as shown in . Ultrasound of the abdomen was inconclusive.
+Contrast-Enhanced Abdominal CT scan (CECT) showed Dilated fluid-filled Small Bowel loops (mainly Jejunal) with max. diameter of 4.5 cm, arranged strangely. Loops were enclosed in a thick membrane while a transition zone appears outside the enclosing membrane. A provisional diagnosis of Abdominal Cocoon Syndrome as given in . Keeping in mind the CT scans, consultant opted for exploratory laparotomy.
+Preparation for exploratory laparotomy was performed on the patient by the Consultant Surgeon.
+A midline incision was used to expose the abdomen and visualize the interior anatomy. Numerous jejuna and proximal ileum loops were discovered to be in a strong, thick, white membrane , which consisted of two layers. Within the sac's thick, fibrous outer membrane was a thin, avascular membrane. The liver, stomach, and jejunal/ileal loops were all covered in a dense sac. The Encasing Membrane was opened, adhesiolysis was performed, and the membrane was completely removed as Illustrated in a, b & c. The entire colon was healthy except for two locations where the gut wall had thinned out and friable, necessitating primary bowel repair. Additionally, the membrane was sent for histopathology. The abdomen was cleansed completely with normal saline and then closed with a drain friable.
+The patient was released without difficulties on the fourth postoperative day and advised bed rest for a week. His osteopath's report revealed the following: Peritoneal tissue: A kind of fibrosis that is densely hyalinized, with mild chronic inflammation and dystrophic calcification. One of the surgery main complications is “bowel injury” and extra care should be taken in consideration.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2017_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2017_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a4b4dbe8c3716afbb94eb1a3e9a6b5c345d76c4e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2017_en.txt
@@ -0,0 +1,7 @@
+A nine-month-old male infant, was admitted with an 8-day history of watery, non-bloody diarrhea, vomiting and decreased oral intake. The baby was previously healthy and had a negative medical history.
+On physical examination, the patient was pale and irritable with generalized body edema, tachypnea (rate 36/min) and tachycardia (HR140/min) but no rales or murmurs were heard. No other abnormalities were noted.
+Initial investigations revealed leukocytosis (19 × 103), anemia (hemoglobin 7.7 g/L, hematocrit 22%) and thrombocytopenia (platelets 62× 103). Serum creatinine was 2.5, BUN, 57 uric acid, 7.6 mg/dl respectively, LDH 2293 IU/L. (reference value 265 I U/L). Peripheral blood smear revealed evidence of microangiopathic hemolysis with schistocytes and helmet cells. Abdominal ultrasound showed echogenic but normal sized kidneys. The patient was admitted to the pediatric intensive care with the diagnosis of hemolytic uremic syndrome for possible dialysis.
+During his stay, the patient had persistent diarrhea, decreased oral intake, oligoanuria and generalized body edema and hypertension. There was no response to high doses of intravenous furosemide (urine output less than 0.5 ml/kg/hour). Because of progressive deterioration in kidney function (creatinine reaching 5.2 mg/dl, blood urea nitrogen 88 mg/dl), persistent oligoanuria and worsening microangiopathic hemolysis and thrombocytopenia (hemoglobin of 5.4 g/dl and platelets of 23× 103) peritoneal dialysis was started after 48 h of hospitalization. The patient also received one unit of packed RBC transfusion.
+Stool studies with Multiplex Qualitative reverse transcriptase PCR were negative for Salmonella, Shigella, Campylobacter, Yersinia, enterohemorrhagic E coli; enteropathogenic E coli (EPEC), enterotoxigenic E coli (ETEC), enteroinvasive E coli (EIEC) and Shiga-like toxin-producing E.coli (STEC) stx1/stx2, Rotavirus A, Adenovirus, Astrovirus, but were positive for Norovirus GI/G II.
+Additional relevant laboratory studies included massive albuminuria with an Ualb/Cr 97 mg/mg (ref value < 0.2), low C3 and C4 complement of 0.56 g/L (ref value 0.9–1.8 g/L) and 0.07 g/L (reference value 0.1–0.4 g/L) respectively.
+After 48 h of continuous peritoneal dialysis, the patient improved clinically with progressive decrease in edema and gradual increase in urine output. Peritoneal dialysis was continued for 5 more days and his kidney function improved steadily and normalized by the 10th day when his serum creatinine was 0.3 mg/dl, and albuminuria was down to 0.13 mg/mg creatinine. Three weeks after the onset of the disease, C3 and C4 had returned to normal levels at 1.16 g/L and 0.31 g/L respectively. The patient’s hospital course and laboratory data are depicted in Figs. a and b. The patient has been followed for 11 months since the onset of his illness and shows no evidence of residual damage with normal renal, hematologic and complement profile. He is normotensive and has no microalbuminuria.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2020_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2020_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b2b4c6f03036457a9399d94760fa41fb3932890
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2020_en.txt
@@ -0,0 +1,3 @@
+This is a case of a 14-year-old Arab boy, non-smoker, with no known food or drug allergies, known to have congenital single kidney and tuberous sclerosis with cognitive deficits, brain lesions, and dermatological features. Initially, the boy was diagnosed prenatally with heart rate abnormalities (bradycardia) and a single kidney. At the age of two years, the boy started having multiple myoclonic seizures treated with levetiracetam in which EEG was performed by a neurologist along with an MRI study which confirmed the presence of cortical and subcortical hamartomas in the brain and led to the diagnosis of tuberous sclerosis.
+During the course of the 14 years, the boy was never admitted to hospital for any serious complication but developed mental retardation and typical skin manifestations which include facial angiofibromas and hypomelanotic macules. Kidney morphological features were assessed in 2010 by Kidney US and confirmed normal left kidney with normal cortical thickness and good corticomedullary differentiation. The seizures were controlled using Sodium Valproate and Levetiracetam, with regular creatinine checkups that never showed a value of creatinine clearance more than one, and annual follow-up brain MRIs were done which confirmed typical findings of subtentorial subcortical and cortical hamartomas in addition to subependymal lesions suggestive of benign giant cell tumour.
+On the 15 March 2023, the boy presented to the outpatient clinic with flank pain. Vital signs were within normal range and no significant unusual findings were noticed on the physical exam except for the skin lesions . Creatinine level was tested and was normal at 0.71. Moreover, an abdomino-pelvic computed tomography (CT) scan with IV contrast was done and showed a single left kidney which had several nodular lesions with fat density which are typical for angiolipomatosis, besides, it showed enlarged kidney dimensions with no corticomedullary differentiation . No signs of bleeding were reported and therefore the boy was only planned for surveillance for bleeding risk or malignant transformation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2062_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2062_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0cb86e20255b563145a492f0028cb05f90c6b10b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2062_en.txt
@@ -0,0 +1,8 @@
+The case was a 25-year-old MG3L1ab2 woman with a history of infertility, complaining from irregular uterine bleeding and she was diagnosed with a pelvic mass in MRI. She got married 7 years ago.
+All of her pregnancies were by induction and ovulation and the first and second pregnancies were aborted spontaneously between 6 and 8 weeks. The third pregnancy, 3 years ago, was terminated by cesarean section and resulted in the birth of a healthy baby.
+The patient who had menorrhagia for the last 6 months was examined for irregular uterine bleeding. She also complained about occasional pains under the abdomen and in the right upper quadrant abdomen. In MRI, the retroperitoneal uterus and endometrial thickness was 5 mm, and a mass with an abnormal heterogeneous signal and heterogenic enhancement of about 95×80 mm in the anterolateral and right border of the hip with the extension to the hypogastric region was reported suggesting tumoral lesions in the right ovary or endometrium .
+According to the report of the ovarian mass in MRI, the patient became a candidate for laparoscopy.
+The laparoscopic surgery was planned in the operating room of Mehr Hospital in Mashhad on January 10, 2018. Initially, to enter the abdominal cavity, there was no possibility of passing the veress needle through abdominal wall from the umbilicus and the Palmer’s point, so the decision was made to enter the abdominal cavity through open laparoscopy. After creating a 2 cm incision in the umbilicus, and touching with finger, a solid and abnormal texture in this place was observed. Therefore, the decision was made to continue the operation by laparotomy.
+The abdomen was opened with a midline incision and a solid mass was in the midline of the abdominal wall adhering to the rectus muscles and the fascia with 12 cm in size. First, the mass was dissected from the rectus muscles and the peritoneum below it. After complete dissection, it was observed that the mass was connected to the abdominal wall with a relatively thick bundle (2 cm) in the suprapubic region .
+The mass was similar to uterine fibroids in shape and consistency. After complete removal of the mass, in the examination of the abdominal wall, the visceral peritoneum was completely healthy. The visceral peritoneum was opened to check the abdominal cavity. No specific pathological findings were observed in the examination of the abdomen and pelvis. The uterus and adnexa were completely healthy and there was no evidence of adhesion, mass or ovarian cyst or uterine fibroids. So, the surgery was terminated.
+Pathology report of the abdominal wall mass was leiomyoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2104_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2104_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1f38ac675ae0f69a59aff9af759a7a6d8a51365f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2104_en.txt
@@ -0,0 +1,9 @@
+A 25-year-old female professional dancer presented to the sports medicine department due to increasing pain in the left iliac crest with radiation to the left leg. She initially noticed the pain after chiropractic treatment 6 months before (see timeline in Additional file ). Further medical history of the patient was unremarkable. After the clinical diagnosis of lumbar syndrome was established, the sports physician prescribed acupuncture and physiotherapy. Both did not ease the pain. Next, a swelling of the left hip region appeared. Ultrasound showed no signs of arthritis but raised suspicion of a soft tissue mass. The patient was then referred to the adult oncology department.
+Magnetic resonance imaging (MRI) of the pelvis revealed a large tumour of the left iliac bone with infiltration of periosteal muscles and soft tissue. Left-sided pubic bone, sacrum and sacroiliac joint were infiltrated . Skeletal scintigraphy revealed no further osseous lesions , computed tomography (CT) of chest and abdomen excluded metastases. A biopsy was performed, which resulted in diagnosis of OS, grade III of chondroblastic subtype. Despite recommendation for chemotherapy, the patient decided to perform a fasting cure and lost 6 kg weight.
+A further MRI was done a couple of weeks later due to increasing, intolerable pain, despite treatment with opioids, cox-2-inhibitors, non-steroidal anti-inflammatory drugs and coanalgesics. Tumour size remained stable. The patient then decided to start chemotherapy according to recommendations of EURAMOS-1/COSS protocol in the paediatric oncology department.
+Under chemotherapy the pain subsided within 2 months and the tumour size decreased without relevant side effects except for nausea. Due to her profession as a dancer, the patient refused to undergo local therapy by surgery or radiation and discontinued chemotherapy after 4 months. We discussed the very poor prognosis of OS without local therapy in detail with the patient.
+Much to our surprise, we found no signs of tumour relapse or metastases within the next year. Imaging studies displayed a stable residual tumour mass of the left iliac bone with further decline of contrast enhancement and soft tissue portions .
+Unfortunately, 16 months after the end of chemotherapy the patient first recognized a lump in her left breast. Clinical examination revealed enlarged lymph nodes (2 cm) of the left axilla. The patient refused mammography; ultrasound indicated possible breast cancer. A couple of weeks later, ultrasound-guided biopsy of the breast lump was performed resulting in the diagnosis of invasive ductal carcinoma (G2, B5b, ER/PR 0%, HER2/neu score 3, MIB-1 30%). Again, the patient declined biopsy of the lymph nodes. MRI of the chest revealed destructive carcinoma of the complete left mamma without signs of pulmonary metastases (TNM: cT2, cN1, cM0). Skeletal scintigraphy neither displayed activity of the pelvic OS nor of other bone lesions. Head MRI ruled out an initially suspected parietal metastasis with slightly increased tracer uptake . Ultrasound of the abdomen displayed a hypo-echogenic nodule of the liver.
+Once again the patient refused any further treatment. Two months later, she was admitted to the gynaecologic department with severe headaches and intermittent visual field loss. The gynaecologists interpreted findings as migraine headaches due to spontaneous improvement of pain and unremarkable MRI of the head. A couple of days later, she presented to the emergency department with sudden deterioration of her general condition, dyspnoea and decreased oxygen saturation. A CT of chest and abdomen revealed diffuse pulmonary consolidations, pericardial effusion and several hypodense hepatic nodules consistent with disseminated end-stage breast cancer. Upon further deterioration, the patient and her family agreed to withhold invasive procedures and the patient soon died of respiratory failure.
+After establishing the diagnosis of breast cancer, we performed genetics for Li-Fraumeni syndrome and confirmed the diagnosis (common TP53 mutation: DNA binding domain, c.733G > A, p.Gly254Ser, heterozygous). Family history of the patient was unremarkable regarding classical Li-Fraumeni criteria, the patient’s father died from a pulmonary tumour at old age.
+To elucidate the very uncommon course of the OS without signs of vital tumour, despite absence of local therapy and incomplete chemotherapy, we performed array-comparative genomic hybridization (aCGH) of the tumour material according to routine protocols . Table compares common CNA in OS with the individual CNA of our LFS patient.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_212_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_212_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..947a51bcc2844094847c07846a871f43765a0a78
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_212_en.txt
@@ -0,0 +1,9 @@
+An 80-year-old woman noticed bloody discharge from her left nipple and palpated a lump in her left breast, and was referred to our hospital. Her mother had a history of breast cancer. Physical examination revealed a hard and immovable mass without skin adhesion in the upper lateral quadrant of the left breast. Cytologically, no malignant cells were found in the bloody discharge from the nipple. Laboratory data on admission were within normal limits. There was no elevation in serum levels of any tumor marker including CEA, CA15-3, NCC-ST-439, ICT, and CA19-9. Mammogram showed a focal asymmetry in the left CC-O and left MLO-M area . Ultrasonography revealed a hypoechoic mass measuring 19 × 17 × 11 mm with an irregular margin, acoustic enhancement, and interruption of the posterior border of the mammary gland in the upper lateral quadrant of the left breast. It was connected to the surrounding mammary ducts . The mammogram and ultrasonography were classified into the Breast Imaging Reporting and Data System (BI-RADS) 5th edition category 3 and 4, respectively. Contrast-enhanced magnetic resonance imaging (MRI) confirmed a mass with early enhancement. The mass had a relatively high intensity, and a peritumoral low-intensity capsule-like signal was noted on T2-weighted images . MRI also showed early arterial enhancement, gradual washout, and two lengths of linear enhancement between the mass and nipple . Core needle biopsy of the lesion demonstrated a solid, proliferating, and invasive tumor with adipose tissue involvement. These findings suggested invasive ductal carcinoma. The tumor was negative for estrogen receptor (ER) , progesterone receptor (PgR) , and HER2/neu . Positron emission tomography-computed tomography (PET-CT) revealed the breast tumor with a maximum standardized uptake value of 4.4 and also showed a 55-mm mass in the cervix uteri . Biopsy from the latter finally confirmed a diagnosis of cervical carcinoma. After radiotherapy for the cervical carcinoma, the patient underwent partial mastectomy and sentinel lymph node biopsy. She was not treated with neoadjuvant chemotherapy for her triple-negative breast carcinoma due to her great age and advanced cervical carcinoma.
+Macroscopically, the breast mass measured 35 mm in its greatest diameter and had no connection to the overlying skin or nipple . Histologically, the tumor revealed solid growth of small, round uniform cells with clear cytoplasm. In part, aggregates of large tumor cells with clear and vacuolated cytoplasm, indicative of sebaceous differentiation, were seen . The intraductal spread of the tumor was observed with bleeding in dilated ducts. A part of tumor nodule was surrounded by the fibrous tissue. No metastatic deposits were identified in the axillary lymph nodes. On frozen sections, most part of the tumor cells contained abundant Sudan Black B-positive lipid droplets in the cytoplasm . Immunohistochemically, 90% of the cells were positive for adipophilin . The cells were negative for ER, PgR, Her2/neu, and androgen receptor (AR); positive for cytokeratin 7 and Ber-EP4; and partially positive for epithelial membrane antigen (EMA). In addition, the tumor cells were negative for the neuroendocrine markers such as synaptophysin and chromogranin A. Therefore, the present case was diagnosed with sebaceous carcinoma of the breast. She had no complications of surgery and was discharged from the hospital on post-operative day 7.
+Sixteen months after her breast surgery, the patient was admitted to the palliative care unit of another hospital due to her metastatic cervical carcinoma. There have been no signs of recurrence of breast malignancy.
+Sebaceous carcinoma of the breast is a distinct variant of invasive ductal carcinoma, characterized by a lobular or nested growth pattern of tumor cells variably admixed with cells displaying sebaceous differentiation . According to the World Health Organization histological classification of tumors of the breast, the definition of the sebaceous carcinoma of the breast is that a primary breast carcinoma of the skin adnexal type with sebaceous differentiation at least 50% of cells and there should be no evidence of derivation from cutaneous adnexal sebaceous glands . The present case fulfilled the necessary condition.
+Pathological diagnosis of sebaceous carcinoma of the breast is considered to be difficult when sebaceous differentiation is morphologically obscure. In such cases, it is necessary to show intracytoplasmic lipid by Oil Red O or Sudan Black B stain, or to demonstrate expression of adipophilin by immunohistochemistry. However, lipids are extracted during the organic phase of tissue processing and lipid staining cannot be performed in formalin-fixed paraffin-embedded material. Accordingly, lipid staining can vividly demonstrate intracytoplasmic lipid only when fresh frozen material is available . In the present case, intracytoplasmic lipids were identified through Sudan Black B and the tumor cells were immunohistochemically positive for adipophilin.
+Sebaceous carcinoma should be differentiated from other rare types of breast carcinoma composed of vacuolated or clear cells, such as glycogen-rich carcinoma and lipid-rich carcinoma. Glycogen-rich carcinoma can be differentiated easily from sebaceous carcinoma by lack of lipids in the cytoplasm of neoplastic cell. Moreover, neoplastic cells of glycogen-rich carcinoma have a water-clear cytoplasm at light microscopy level, whereas sebaceous carcinoma is composed of vacuolated or foamy cells [, ]. Regarding lipid-rich carcinoma, at least 90% of tumor cells have abundant clear or vacuolated lipid-rich cytoplasm . Sebaceous carcinoma shows a compact lobulated solid growth pattern and finely vacuolated cells. In contrast, lipid-rich carcinoma infiltrates like conventional ductal carcinoma and the vacuolization is much less conspicuous.
+There is no specific imaging finding that are useful in diagnosis of sebaceous carcinoma of the breast. In MRI of the present case, linear enhancement between mass and nipple and capsule-like signal were observed. The linear enhancement indicates intraductal spread of the tumor. It was identified pathologically with bleeding in dilated ducts that caused bloody discharge from her nipple. The capsule-like signal was pathologically consistent with the fibrous tissue surrounding the tumor nodule. However, they are not specific for sebaceous carcinoma.
+The number of previously reported cases of sebaceous carcinoma of the breast is limited, and their clinical and pathological features are available in 12 cases [–]. According to the reported cases including ours, 12 patients were women with ages ranging from 25 to 80 years. ER, PgR, and HER2/neu showed positivity in 7 of 12, 8 of 12, and 3 of 9 cases, respectively. Although some hormones or the HER2/neu oncogene may have some role in the development of sebaceous carcinoma, the details are unknown.
+It has been reported that sebaceous carcinoma of the breast might be high-grade malignant neoplasm because three of four patients had axillary lymph node metastases and two patients experienced an aggressive clinical course with distant metastases . On the other hand, seven eighths of the cases whose prognoses were available was alive with or without evidence of breast malignancy after operation. The clinical course is not generally known due to its rarity. Further study is warranted to elucidate the pathology and prognosis of the patients with sebaceous carcinoma of the breast.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2132_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2132_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..754a21bed04b4974c500bfa0670bfbbbb48970b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2132_en.txt
@@ -0,0 +1,3 @@
+The 28-year-old Taiwanese woman whose condition is reported herein had an uneventful birth and developmental history. She exhibited suboptimal performance in exercise since elementary school age, especially in long-distance running. She experienced one episode of reversible proximal limb weakness for 3 days when she was 21 years old. She denied any weakness at baseline. She used antiobesity drugs, and in the preceding 4 months, her body weight decreased from 60 to 47 kg, with a corresponding reduction in body mass index from 22.3 to 17.5. The regimen of antiobesity drugs included metformin, triiodothyronine, topiramate, pseudoephedrine, hydrochlorothiazide, fluoxetine, and oxazolam. She was not prescribed diet change or caloric restriction. After weight loss, she exhibited poor appetite; poor oral intake; dyspnoea on exertion; and progressive weakness and soreness in the four proximal limbs, the neck, and the trunk. She was aided by a wheelchair upon admission.
+On examination, the patient had intermittent tachycardia and dyspnoea on minimal exertion but had otherwise normal vital signs. She had reduced muscle strength in the proximal limbs (manual muscle power: bilateral deltoid: 3; bilateral finger abduction: 5; bilateral hip flexion: 4; bilateral dorsiflexion: 5), neck, and trunk, with positive Gowers’ sign and myopathic gait. Generalised muscle wasting involving the neck, trunk, shoulder girdle, pelvic girdle, and proximal and distal limbs but not the facial muscles was observed . No percussion myotonia was noted. The patient had mildly decreased memory and calculation abilities compared with healthy individuals of an equivalent age. Examinations for cranial nerve, deep tendon reflex, sensory, and coordination function revealed unremarkable results. She had no hepatosplenomegaly, goitre, or skin hyperpigmentation.
+Laboratory exams indicated elevated serum creatinine kinase (496 U/L), elevated aspartate aminotransferase (102 U/L), elevated resting serum lactate (4.7 mmol/L), and borderline elevated serum calcium (10.2 mg/dL) levels. Blood count, estimated glomerular filtration rate, serum electrolyte levels (including sodium, potassium, and magnesium), and thyroid function were unremarkable. An arterial blood gas test revealed no hypoxemia, hypercapnia, or acid–base problems. A nerve conduction study yielded no evidence of polyneuropathy. Electromyography demonstrated myopathic motor unit action potential with early recruitment pattern as well as no spontaneous activity in all sampled muscles in the four proximal and distal limbs. An aerobic forearm exercise test revealed elevated mixed venous oxygen saturation after 3 min of aerobic exercise, suggesting defective oxidative metabolism in the muscles . Muscle magnetic resonance imaging of the bilateral thighs was unremarkable. Muscle pathology of the right rectus femoris muscle suggested lipid storage myopathy . Tandem mass spectrometry of serum acylcarnitine revealed elevated short-, medium-, and long-chain acylcarnitines with secondary carnitine deficiency . Urine organic acid analysis indicated glutaric aciduria. ETFDH gene analysis revealed compound heterozygous mutations c.250G > A / p.Ala84Thr and c.524G > T / p.Arg175Leu. Both variants have previously been reported to be pathogenic [, ]. MADD was therefore diagnosed. We treated the patient with riboflavin, carnitine, and ubiquinone, and her symptoms rapidly improved. She was able to walk without assistance within 2 weeks, and she became asymptomatic within 3 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2147_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2147_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a7826922efd9210bd489d6e4cf93a0f5e6882cf5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2147_en.txt
@@ -0,0 +1,6 @@
+A white, 33-year-old, previously healthy Finnish man came to the ED of our hospital in Finland because of intense abdominal pain. He was a nonsmoker and had no history of alcohol abuse. Our patient had had no previous medication and he denied any acute drug usage. He had undergone appendectomy 15 years previously. He had no history of traffic accident-related or other abdominal trauma. The acute pain was located on the left side of his abdomen, running down to the left inguinal area. He rated the pain as maximal, numerically 10 on a 1–10 scale. On clinical examination his abdomen was soft on palpation with no abdominal guarding, but our patient was struggling with pain. Peripheral pulses were palpable and there was no tenderness on palpation of the kidneys. The symptoms supported a diagnosis of urolithiasis.
+Our patient was treated with intravenous oxycodone and his pain was relieved. A helical CT scan showed no sign of urolithiasis and his kidneys were normal . Laboratory analysis showed an elevated white blood cell (WBC) count of 13.4 × 109/L. However, his serum concentration of C-reactive protein (CRP) was normal, as were other laboratory test results . Next morning, our patient was feeling well and had no abdominal pain. His WBC count had decreased to 10.0 × 109/L. Otherwise the results were still normal. Our patient was discharged and advised to return should the pain reoccur. He returned to the ED the next evening because of rapid-onset intense abdominal pain located in the lower left quadrant of his abdomen, radiating to the left testicle. A urologist was consulted because of the possibility of testicular torsion, but our patient's clinical findings did not support this. The provisional diagnosis was still urolithiasis. Owing to the intense pain, explorative surgery was planned in order to assess the testicles and kidneys. Before any definite decision, contrast-enhanced abdominal CT was carried out. This revealed renal infarction of the left kidney . The renal artery was open. After consultation, our patient was admitted to the nephrology ward.
+Our patient was started on enoxaparin, 100 mg twice daily, and examined for the possible source of emboli or a thrombophilic state. An electrocardiogram (ECG), transthoracic echocardiography and 48-hour continuous ECG monitoring did not indicate cardiac disease, arrhythmia or any other reason for suspected emboli. The results of laboratory tests for anticardiolipin antibodies and other markers of thrombophilic states including antithrombin III, protein C, protein S, lupus anticoagulant, beta 2 glycoprotein 1 antibodies, factor V Leiden, and factor II prothrombin were negative. There were no systemic clinical symptoms in our patient’s medical history such as fatigue, weight loss, arthralgia, hemoptysis, epistaxis, or persistent nasal crusting that would have suggested possible vasculitis. No palpable purpura or other skin manifestations were found either. Neither were there any abnormalities in the usual laboratory tests for identifying vasculitis such as erythrocyte sedimentation rate, antinuclear antibodies, antineutrophil cytoplasmic antibodies against either protease 3 or myeloperoxidase, serum complement levels C3 and C4, and antiglomerular basement membrane antibodies. A biopsy examination of the involved tissue was not feasible. There was a typical increase of lactate dehydrogenase (LDH). His intense abdominal pain was treated with intravenous oxycodone delivered via a patient-controlled analgesia pump, and epidural bupivacaine anesthesia. Anti-factor Xa levels were measured to adjust the enoxaparin dosage and enoxaparin was paused during removal of the epidural catheter.
+On the seventh day of hospitalization, our patient had a fever of 38.4 °C, an elevated WBC count and his CRP level had increased to 301 mg/L . There appeared to be no focus of infection, but intravenous ceftriaxone was started because of possible secondary infection of the affected tissue. Invasive angiography of the left renal artery was performed on the fifth day of hospitalization. At first, the performing radiologist interpreted the finding as 10-mm-long stenosis of a segmental branch of the inferior renal artery, followed by 20 mm of poststenotic dilatation and obvious thrombosis . The diameter of the stenotic part was approximately 1.7 mm. Our patient’s kidney function remained stable and normal, so invasive evaluation of a potential pressure gradient (which might have been difficult) was not found necessary at that time. Another theory arose when the findings were reevaluated at the next radiology meeting: the segmental branch of the inferior renal artery was evaluated as being aneurysmatic, and it was thought to have been a possible source of emboli.
+Our patient was discharged on the tenth day of hospitalization. He was feeling well and the fever had subsided. Serum levels of CRP had decreased to 80 mg/L. Oral antibiotics (cephalexin), proton pump inhibitor, and 100 mg of enoxaparin once a day were prescribed for 1 week. Diuresis was normal. There was a slight rise in creatinine levels but his glomerular filtration rate (GFR) was normal (100 mL/min/1.73 m2). His clinical status was normal, with blood pressure (BP) of 136/80 mmHg.
+Magnetic resonance angiography (MRA) was carried out 15 months after the infarction to check for possible progression of changes in the left renal artery. There were slight changes of caliber in the arteries of his left kidney. Similar changes were also noticeable in the common hepatic artery and superior mesenteric artery. The arteries of his right kidney were normal. The findings were evaluated as being a consequence of fibromuscular dysplasia (FMD) and our patient was started on acetylsalicylic acid (ASA), 100 mg once a day. A carotid ultrasound was performed and there were slight irregularities in the wall of his right common carotid artery, a finding which was suggestive of FMD. Doppler findings were normal and the carotid arteries were otherwise normal. A follow-up visit took place a year after the MRA examination. His BP measured by a nurse was 149/79 and his GFR was still normal. Our patient was instructed to perform home blood pressure monitoring and he later reported that his BP was 130–140/70–80. There appeared to be no problems during follow-up and our patient continued in his normal work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2157_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2157_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9b5cb1c019cd127d1321492fcebe151ba6566189
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2157_en.txt
@@ -0,0 +1,11 @@
+A male, 72 years old. No physical discomfort, a physical examination, and gastroscopy are required.
+Due to a regular physical examination, the gastroscopy found that the lower end of the stomach was marked with shallow depression near the antrum, with surface flushing and a tuberosity bulge in the centre . Then a biopsy. The indigo carmine staining is shallow depression, and the surrounding boundary is clear . Consider the patient’s atrophic gastritis with gastric antrum erosion and gastric antrum body junction lesions.
+In the past medical history of patients, he had a history of hypertension and diabetes. Now blood pressure and blood glucose are perennial oral drug control. They denied others the history of chronic diseases, and the history of infectious diseases such as hepatitis, tuberculosis, and schistosomiasis.
+The patient denied any family history of malignant tumours. There is no history of Helicobacter pylori infection.
+Physical examination revealed no fever, heart rate 77 bpm, blood pressure 141/85 mmHg, and other examinations all have discomfort.
+After admission, the patient improved the examination of tumour indicators, and the results were negative .
+No obvious abnormality in the upper abdominal enhanced computed tomography (CT) revealed no concurrent lymph node and distant metastasis .
+Pathology revealed high-grade intraepithelial neoplasia in the mucosa. The patient was subsequently examined after admission. Narrow-band imaging (NBI) after admission revealed a station membrane hyperemia lesion on the posterior wall of the gastric antrum. The staining showed that the lesion was a shallow depression with an unclear boundary. At the outer layer of the tumor, the micro glandular tube structure was disorganized and variable in size. The microvessels were slightly tortuous and expanded, forming a bright boundary with the periphery, with an endoscopic lesion ranging from 5 mm × 6 mm .
+Endoscopic ultrasonography (EUS) was used to determine the source of the stomach wall. The local area is slightly thickened, the other levels of the stomach wall are continuous and complete, and there are no obvious abnormal echoes. The diagnosis was that the lesion was in the gastric mucosa .
+Immunohistochemical examination revealed Ki-67 positivity in tissue , partial MUC2 positivity , partial MUC5AC negativity and partial MUC6 positivity . Hematoxylin and eosin were detected , after which poorly differentiated adenocarcinoma cells were detected.
+Hematoxylin and eosin staining revealed that the lesions were at the level of the neck of the gland and continued with the surface epithelium. Determining the tumor boundaries is difficult. There were “crawling type” glands everywhere in the tumour’s vicinity. Moreover, it spreads laterally in the lamina propria, but not in the stomach glands.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2162_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2162_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d94c4006f777631ba1063bd5c0d8b7ea4e7181cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2162_en.txt
@@ -0,0 +1,5 @@
+An 83-year-old Caucasian man, in otherwise good health, was referred to our hospital with intermittent anal bleeding and irregular bowel patterns. A colonoscopy revealed a 1cm solitary rectal polyp, which was completely removed by endoscopic resection .
+Histological examination showed a tubular adenoma with low-grade intraepithelial dysplasia and focal localization in the stroma by highly proliferative large lymphoid cells . The base of the adenoma was not involved.
+Immunohistochemical stains demonstrated that the lymphoid cells expressed CD20 (clone 2B11 + PD7/26, DAKO; Figure d and e) and B-cell lymphoma 2 (clone 2B11 + PD7/26, DAKO; figure not shown), but not CD3 (clone F7.2.38, DAKO), CD5 (clone 4C7, DAKO), CD10 (clone 56C6, DAKO), CD23 (clone DAK-CD23, DAKO), CD30 (clone Ber-H2, DAKO), CD138 (clone MI15, DAKO) and cyclin D1 (clone EP12, DAKO). Approximately 90% of the neoplastic cells reacted positively when stained with an antibody to Ki-67 (clone MIB1, DAKO; Figure f).
+Finally, molecular genetic analysis detecting the rearrangement of the FR2/LJH/VLJH region of the immunoglobulin heavy chain was performed and a monoclonal amplicon of approximately 260 base pairs (expected band between 240 and 280 base pairs) was detected, demonstrating malignancy and clonal association of the lymphoma infiltrates in the adenoma . Molecular analyses were carried out as previously described [,] and according to the manufacturer’s instructions. Commercial reagents by DAKO Cytomation, Milan, Italy and by Diachem S.r.l., Naples, Italy to perform immunohistochemical and a B clonality assay were used, respectively. All used products are compliant with the requirements of the in vitro diagnostic directive 98/79/EC.
+The patient underwent full staging for lymphoma. Dawson’s criteria were used in the differential diagnosis between primary colorectal involvement and GI tract involvement secondary to systemic lymphoma . He had no fever, weight loss or night sweats. A physical examination revealed no alteration. There was no lymphadenopathy and hepatosplenomegaly. Blood-cell count, serum biochemistry and immunoglobulins were either within normal limits or negative. A bone marrow biopsy showed no evidence of lymphoma. His chest X-ray was unremarkable. Computed tomography (CT) of his total body revealed no evidence of extraintestinal involvement. A diagnosis of primary DLBCL was made. Ann Arbor stage 1A was established. Subsequently, he was referred to a hematologist for further management. Since the lymphoproliferative lesion was limited and there was no evidence of disseminated disease, and accounting for the advanced age of patient, it was considered inappropriate to perform surgical resection. He did not receive chemotherapy, but he was referred to follow-up with clinical examinations and CT scans at 6-monthly intervals only. He showed no clinical or radiologic recurrence at the time when we wrote this paper (1 year past).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_217_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_217_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..22d950dbcce327a588f3ae0425ecb39c99090464
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_217_en.txt
@@ -0,0 +1 @@
+A 72-year-old man was referred to Tishreen University Hospital in 2021 to perform a radical cystectomy due to Urothelial carcinoma with muscularis propria invasion, which was confirmed by histopathological biopsy. Laboratory tests showed a low hemoglobin level; 10.2 g/dL with hematuria. Other Routine blood values were normal. The patient medical history shows that he underwent transurethral resection of bladder tumor (TURBT) followed by intravesical BCG (Bacillus Calmette-Guerin) therapy administered for 3 years. The patient has smoked 5 cigarettes daily for the past 40 years. He had never used alcohol. He had no allergy to any drugs. There was no tumor history in his family; particularly no history of bladder tumors. Computerized tomography (CT) of the abdomen and pelvis with contrast was performed. Coronal contrast-enhanced CT image shows a mass occupying almost the entire bladder cavity, in addition to the presence of a heterogeneous mass in the right lower quadrant in the expected location of the appendix with tiny peripheral calcifications (A). That mass was suspected of being a right common iliac artery aneurysm, but the CT angiography (CTA) showed the integrity of the artery (B). The patient underwent a radical cystectomy and appendectomy. Both specimens were sent to the pathology department for histopathological study. Pathological examination of the bladder specimen showed the tumor was a high-grade invasive carcinoma that invaded all layers of the bladder and reached perivesical tissue. On the other hand, the gross examination of the appendix specimen revealed a cystic dilation at the distal tip, measured 5.5 cm × 4.5 cm x 5 cm, filled with gelatinous mucus, and some calcifications were seen in the lumen. The serosa was smooth. . Microscopically, we found mucinous epithelial proliferation with extracellular mucin (A), and the epithelium rests on mural fibrosis (B). Foci of mucin and calcifications are seen (C). While the base of the appendix is within normal limits (D). The patient was stable and discharged 15 days later, without any complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2210_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2210_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..393deda36c666928da8d4e71b962f50dc0397580
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2210_en.txt
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+A previously healthy 36-year-old Chinese man presented to the emergency department with a 1-month history of fever. He had consulted a nearby doctor before arriving at our hospital. Symptomatic treatment was given but did not work. Chest computed tomography (CT) showed diffused bilateral infiltration . Abdominal CT showed multiple focal lesions in the liver , without hepatosplenomegaly. Because of rapidly clinical deterioration with onset of acute respiratory failure, he was transferred to the medical intensive care unit.
+On admission, his vital signs were: temperature, 37.2 °C; heart rate, 119 beats/min; blood pressure (BP), 90/48 mmHg; and respiration rate, 38 breaths/min with oxygen saturation of 88%. The patient appeared to be acutely ill. A pulmonary examination revealed rales in both lungs. His abdomen was soft, with no hepatomegaly and splenomegaly. Routine laboratory tests results were: white blood cell (WBC) count, 5.32 × 109 cells/L; hemoglobin, 94 g/L; platelet count, 70 × 109/L; aspartate aminotransferase (AST), 121 U/L; alanine aminotransferase (ALT), 47 U/L; total bilirubin (TB), 48.4 μmol/L; direct bilirubin (DB), 40.9 μmol/L; blood urea nitrogen (BUN), 11.35 mmol/L; creatinine, 106.0 μmol/L; lactic dehydrogenase (LDH) 508 U/L; serum ferritin, 17,208.98 ng/ml. Even with continuous high-flow oxygen inhalation, arterial blood gas analysis showed pH 7.45, PO2 57 mmHg, PCO2 35 mmHg and lactate 2.0 mmol/L. Coagulation tests demonstrated prothrombin time (PT) 16.9 s, prothrombin activity (PTA) 62%, and fibrinogen level 1.74 g/L. Autoimmune antibody blood tests were negative. Microbiological and serological work-up for HIV, hepatitis A, B, C and E viruses, EBV, cytomegalovirus, dengue virus, malaria, Leptospira, and scrub typhus was negative. Bacteriological assays as well as serology for respiratory viruses (adenovirus, and influenza A and B, parainfluenza and respiratory syncytial viruses), Mycoplasma pneumoniae, Chlamydia pneumoniae and Legionella were also negative. Repeated sputum smear samples were negative for acid-fast bacilli. The patient had no significant past medical history, specifically no prior TB infections, chronic illnesses, liver or kidney disease, transfusions, malignancy, or immune diseases. He was not taking any regular prescription and he had not travelled abroad.
+After admission, the patient was initially diagnosed with fever of unknown origin, pulmonary infection. According to chest and abdominal CT findings, pulmonary TB and hepatic abscess were highly suspected. Malignancy was excluded by positron emission tomography. Considering possible multisite infections due to hypervirulent Klebsiella pneumoniae, we started an antibiotic regimen with meropenem and amikacin. Non-invasive positive pressure ventilation was applied for respiratory support. However, the patient continued to present with recurrent high-grade fever. Peripheral blood TB ELISPOT assay was positive, which suggested TB. Anti-TB therapy with rifapentine (0.6 g once a week), isoniazid (0.3 g daily), ethambutol (0.75 g daily) and moxifloxacin (0.4 g daily) was administered.
+The patient’s clinical course was notable for obvious dyspnea, intermittent fever, worsening pancytopenia, and hyperferritinemia during observation . On day 4, examination of bone marrow aspiration was undertaken, which revealed increased macrophage activity with hemophagocytosis . Additional blood tests showed low NK cell activity (11.9%, normal value: ≥15.1%) and high-soluble CD25 levels (> 44,000 pg/ml, normal value: < 2400 pg/ml). Accordingly, a diagnosis of HLH was made. However, the patient refused to undergo genetic testing. Following consultation with a hematologist, intravenous etoposide was started on day 7 (0.1 g twice a week for 2 weeks, 0.1 g once a week for the following 6 weeks). The patient responded well to the therapeutic strategy, with marked improvement of fever and cytopenia. On day 17, he was successfully withdrawn from the ventilator.
+Once the patient was stable and free of symptoms of respiratory failure, he was transferred to the respiratory department on day 19. Anti-TB therapy with isoniazid, rifapentine, ethambutol and pyrazinamide was administered. After platelet recovery, ultrasound-guided percutaneous lung biopsy was performed on day 22. The pathological result was positive for acid-fast bacilli , which suggested differentiating between Mycobacterium tuberculosis (MTB) and non-tuberculosis mycobacteria (NTM). Re-examination of bone marrow aspiration showed no hemophagocytosis. After discharge in good condition on day 67, he was followed up for 3 months in our hospital and treated with a course of four standard anti-TB drugs. The patient has stayed systemically well. Six months later, the repeated chest CT findings in another tertiary hospital revealed fibrous proliferation, calcification and pleural thickening, which still indicated tuberculosis .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2211_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2211_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ccfa329d564e92f581087430dd6f2d47f226254c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2211_en.txt
@@ -0,0 +1,11 @@
+A 40-year old male presented to hospital with pleuritic chest pain with radiation to the back 3 days after his first dose of the Pfizer-BioNtech mRNA COVID-19 vaccination. The patient had neither past medical history nor any regular medications. He lived with his wife and was employed as a school teacher.
+The patient’s initial ECG demonstrated sinus rhythm with PR- and ST-segment changes consistent with acute pericarditis . Initial blood tests revealed a normal high sensitivity troponin level of 4 ng/L (upper limit of normal value of 20 ng/L), C-reactive protein of 2.4 mg/L, and a normal D-dimer level. Viral polymerase chain reaction performed on a nasopharyngeal swab was negative for common respiratory viruses including COVID-19. An echocardiogram demonstrated no pericardial effusion and preserved left and right ventricular functions. The patient underwent CT aortography given the radiation to the back, which was normal. The patient was admitted to the hospital for analgaesia with fentanyl and oxycodone due to the severity of the pain before down-titrating to ibuprofen 400 mg three times a day for one week. Given an improvement in pain and stable vital parameters, the patient was discharged from the hospital after 5 days of admission with the plan for follow-up with his general practitioner.
+Within 24 h, the patient represented with chest pain. Repeat ECGs taken in the emergency department demonstrated mild ST-segment elevation in the inferior leads. In light of this, the patient proceeded to emergency invasive coronary angiography that demonstrated angiographically smooth coronary arteries. The patient’s repeat blood tests demonstrated a normal troponin level and C-reactive protein. A repeat bedside transthoracic echocardiogram demonstrated no pericardial effusion and a normal left ventricular ejection fraction. The patient was treated for acute pericarditis with colchicine 500 μg twice daily and high dose ibuprofen at 800 mg three times daily. He was discharged after 3 days with decreasing pain.
+Over the next 2 months, the patient had three admissions with recurrent chest pain despite good compliance with medications. During these admissions, he had a peak C-reactive protein of 208 mg/L and a transient mild raise in troponin of 42 ng/L. The patient had two further transthoracic echocardiograms, one of which demonstrated early features of constrictive pericarditis manifested by a trace pericardial effusion, interdependence of the ventricular septum, and annulus reversus assessed by tissue Doppler imaging. Subsequent to this, the patient was commenced on immunotherapy and discharged on prednisolone 50 mg daily, trimethoprim–sulfamethoxazole 160–800 mg three times weekly, pantoprazole 40 mg daily, colchicine 500 μg three times daily, and ibuprofen 600 mg three times a day.
+One week later, the patient represented with recurrent chest pain as well as significant weight gain, mood disturbance, and insomnia related to glucocorticoids. Repeat TTE demonstrated no features of constriction. Cardiac magnetic resonance imaging with LGE demonstrated extensive pericardial enhancement with no myocardial fibrosis ( and ) and no features of constrictive physiology. During admission, azathioprine 25 mg was added to his medical regime prior to discharge after a 10-day admission.
+The patient represented 10 days later with chest pain and a C-reactive protein level of 103 mg/L despite good compliance to medical therapy. After multi-disciplinary discussion, anakinra 100 mg daily was commenced. The patient was also reviewed by the psychiatry team with a diagnosis of adjustment disorder in the setting of multiple hospital presentations. The patient was discharged after a 5-day admission with significant improvement on prednisolone 20 mg daily, anakinra 100 mg daily, trimethoprim–sulfamethoxazole 800 mg/160 mg daily, colchicine 500 μg twice daily, naproxen 1 g daily, pantoprazole 40 mg daily, and a fentanyl transdermal patch.
+The patient represented with chest pain and dyspnoea after 2 months of only occasional mild chest pain and one presentation to the emergency department that did not require admission. Given the recurrence of pain, despite successful biochemical response, a repeat CMR with gadolinium was performed. Compared to the initial CMR, there was some improvement, however, there was persistence of diffuse pericardial enhancement with mild pericardial thickening ( and ). There were concerns regarding central sensitization that was treated with a continuous ketamine infusion over 5 days under the guidance of a pain specialist. This therapy provided temporary relief of pain, however, there was recurrence of pleuritic chest pain after cessation of the ketamine infusion despite substantial medical therapy.
+Given the case complexity and the persistence of debilitating chest pain despite maximal medical therapy, a heart team decision to proceed with pericardiectomy was reached. This involved a sternotomy that revealed a moderately thickened pericardium with soft adhesions between the pericardium and epicardium over the anterolateral, inferior, and diaphragmatic surfaces . The parietal pericardium and inflammatory tissue attached to the visceral pericardium were subsequently resected prior to two drain tubes being inserted and the chest closed with sternotomy wires. Subsequent tissue histology demonstrated areas of focal fibrosis without features of malignancy. Acid-fast bacillus (AFB) staining was negative.
+The patient was discharged Day 7 post-pericardiectomy with mild sternal pain but resolution of his pericardial pain. He was discharged on anakinra 100 m daily, azathioprine 175 mg daily, colchicine 500 μg, gabapentin 600 mg three times daily, indomethacin 50 mg three times daily, tapentadol 100 mg twice daily, and paracetamol 1000 mg four times a day.
+The patient has now been managed in the community for 4 months since the previous admission with complete resolution of chest pain. He has begun down-titration of immunosuppression. Exercise capacity is now unlimited, and there is no current analgaesia requirement.
+The patient described this experience as immensely frustrating with a clear impact on his mental health, and loss of independence as well as inability to remain employed. This was compounded by the temporary benefit and then relapse of attempted therapies. Relief of symptoms has resulted in a slow and steady improvement in his mental health .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2216_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2216_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af78c9c8f0e979780cc87dc39c2b864b92f6c756
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2216_en.txt
@@ -0,0 +1,3 @@
+A 36-year-old female patient with a history of “cardiac cyst (70 × 30 mm)” presented to our hospital for treatment of recurrent episodes of chest pain. The “cardiac cyst” was discovered 3 years earlier by echocardiography when the patient experienced slight dyspnea and palpitation at 37 weeks’ gestation. At that time, the electrocardiogram was normal, and blood coagulation function tests revealed slightly increased fibrinogen and D-dimer levels (4.10 g/L and 1252 μg/L, respectively). Before parturition, these values were 4.07 g/L and 1875 μg/L, respectively. Because uterine inertia could not be resolved during natural delivery, cesarean section was performed. Delivery was successful, and the patient was asymptomatic. Annual check-ups during the following 3 years revealed no abnormity other than an enlarged heart shadow on chest radiographs. Anticoagulation therapy was not administered during the 3-year follow-up period.
+Two months before presentation at our hospital, the patient developed gradually worsening chest pain. The electrocardiogram remained normal; however, transthoracic echocardiography (iE Elite, Philips Healthcare, Bothell, WA, USA) revealed a long oval structure attached to the left atrium (LA) adjacent to the left ventricle (LV) and compressing the anterolateral left ventricular wall during the entire cardiac cycle . No other structural abnormalities were observed. Contrast echocardiography showed that the long oval structure and the LA were enhanced simultaneously with no filling defect . Transesophageal study confirmed a 3.9-cm2 channel between the LA and the structure, which measured 96 mm in length and 55 mm wide . Migration of blood along the channel was observed with Doppler imaging . LAAA was diagnosed definitively, with no thrombi or spontaneous echo contrast observed. Computed tomography (CT) was performed to evaluate the status of the pulmonary veins and other surrounding structures .
+The patient was hospitalized and scheduled to undergo cardiac surgery. Preoperative blood testing, including coagulation function tests, were normal. Median sternotomy was performed, exposing the giant LAAA with intact overlying pericardium. During cardiopulmonary bypass, the base of the LAAA was simply clamped and then resected with a stapler (Echelon 60, Johnson & Johnson, Guaynabo, Puerto Rico, USA). No thrombus within the LAAA or other cardiac anomaly was detected. Anatomical pathology identified the LAAA as a thin-walled and dilated aneurysm of the left atrial appendage. Histopathology described the wall as being composed of myocardium and fibrotic tissue, indicating a true atrial aneurysm . The patient’s postoperative course was uneventful. At the 6-month follow-up, the patient remained asymptomatic and in sinus rhythm, and transthoracic echocardiography (Vivid E9; GE Healthcare, Strandpromenaden, Horten, Norway) revealed good correction of the LAAA and a normal size for the LA, with no evidence of abnormality .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2225_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2225_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..86a8807116a7f2816c7fcd4c4bfca9cc63ff5abb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2225_en.txt
@@ -0,0 +1,7 @@
+A 75-year-old man was transferred to our emergency department for examination of abdominal pain and frequent vomiting. His medical history records reported hypertension, diabetes, mild dyslipidemia, and gastric cancer that was managed with a distal gastrectomy procedure 2 years prior to his admission to our hospital. Reconstruction by Billroth I anastomosis was performed on the stomach. The patient's vital signs were as follows: Glasgow Coma Scale score, E4V5M6; temperature, 36.6°C; blood pressure, 139/103 mmHg; heart rate, 108 b.p.m.; respiratory rate, 25 breaths/min; and oxygen saturation, 94%.
+The physical examination revealed that his abdomen was flat and soft, with sensitivity in the midline but no recurrent pain. His symptoms included nausea, regurgitation, and hematemesis, while jaundice and pallor were not detected.
+Complete blood count revealed the following: white blood cells, 14.4 × 109/L; hemoglobin, 193 g/L; and platelets, 161 × 109/L. The serum laboratory tests were all within the normal range except: total amylase, 1,363 IU/L; blood urea nitrogen, 44.9 mg/dL; creatinine, 2.25 mg/dL; glucose, 453 mg/dL; hemoglobin A1c, 7.6%; and C-reactive protein, 3.13 mg/dL. Total cholesterol, low-density lipoprotein cholesterol, triglycerides, and total bilirubin levels were also normal.
+Abdominal computed tomography (CT) indicated enlarged pancreas with fluid retention and a bezoar with air component in the duodenum, with the absence of stones in the gallbladder and common bile duct . Following the physical inspection, we undertook esophagogastroduodenoscopy (EGD) to identify the cause of frequent vomiting, hematemesis, and duodenal obstruction. We detected only mild bleeding caused by reflux esophagitis and a bezoar that had obstructed the duodenum.
+The patient's consumption of alcohol was low with no evidence of trauma, infections, or medications. Therefore, we concluded that the bezoar was the main cause of acute pancreatitis.
+In the absence of elevated bilirubin levels, we decided to follow a conservative treatment strategy, assuming that the common bile duct was impartially obstructed. The patient was admitted to the intensive care unit (ICU) where intravenous fluids were administered, and his urine output was monitored. It was difficult to maintain urine output, and he was started on ventilatory management because he developed respiratory failure on day 3 of hospitalization. The patient had gone into shock, which persisted. Vasopressors were administered. Antimicrobials were started because bilirubin levels were elevated, which can result in complications like acute cholangitis. Despite supportive care, his symptoms did not improve, and bilirubin levels continued to increase. Abdominal contrast-enhanced CT carried out on day 3 revealed the presence of residual duodenal bezoar and obstruction of the common bile duct . He had been admitted with acute pancreatitis due to papillary obstruction, but the bilirubin level was speculated to have risen over time. We reconsidered the papillary obstruction as the cause of the acute pancreatitis. We decided to remove the bezoar and open papillae. He presented with coagulopathy and poor clinical condition, and surgery was considered an unsafe treatment option. Therefore, we attempted to dissect the bezoar by undertaking EGD; forceps were used to crush the bezoar and attempt maximum removal. However, the bezoar was large and hard, and could not be removed in a single EGD. The procedure was repeated three times, on days 6, 7, and 9, to dissect and remove the bezoars . In a previous case, duodenal diverticulum had been noted as a cause of the bezoar, but no diverticulum was found in this case. Duodenal papillae unclogged and the bilirubin levels declined. Chemical analysis of the stone revealed that the bezoars mainly consisted of calcium oxalate (>98%).
+Following the bezoars' removal, the patient's clinical condition gradually improved, and he was extubated on day 7. On day 8 the patient left the ICU and on day 31 he was discharged from the hospital with no complications. A 6-month follow-up revealed no recurrence of the symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2234_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2234_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ba9527fc7a297afa283ee93148a77675d04ef3c9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2234_en.txt
@@ -0,0 +1,5 @@
+An 8-year-old male patient presented to the emergency department after a history of falling from height (3 m). On examination, the patient was well with mild abdominal pain and contusions in the upper and lower extremities. A focused assessment with sonography for trauma (FAST) was negative and serial complete blood counts (CBC) showed no drop in hemoglobin. The abdominal ultrasound performed the following day showed no intraabdominal fluid collections and the abdominal pain disappeared, so he was discharged in a good condition.
+Six weeks later, the patient presented to the emergency department complaining of pain in the right lower abdomen for two days’ duration. The pain increased gradually and was associated with fever (38.5 °C), anorexia, nausea, and vomiting; however, he had no trouble in passing stools and flatus. Otherwise, the vital signs were within normal. On examination, the patient looked ill and irritable. The abdomen was flat on shape with localized tenderness in the right iliac fossa. Rebound tenderness in the right lower quadrant was positive. Rigidity and guarding were not found, and examination of the genitalia was normal. The patient and his family don’t have any history of a bleeding disorder, and he is free of medications.
+Laboratory investigations showed leukocytosis of 13,000 cells/mm3 with a neutrophil predominance (73 %), normal Hb level (13.8 g/dl), and normal urine analysis. Abdominal ultrasound showed a poorly visualized appendix.
+At this point, the clinical differential diagnosis was acute appendicitis, and the patient was prepared for urgent appendectomy through a Gridiron incision. Intraoperatively, a subserosal cecal hematoma 10 × 8 cm extending from the antimesenteric to the mesenteric border of the cecum was found . The hematoma was not expandable or pulsatile and there was no extension to the ascending colon with the appendix grossly appeared normal. Appendectomy was performed and the cecal hematoma was evacuated, which showed dark blood with, many clots . After ensuring that there was no oozing following the evacuation, interrupted repair of the cecal seromuscular layer by vicryl 3-0 was executed and a pelvic drain was applied.
+Postoperatively, the patient was kept NPO for three days; so, intravenous fluid, parenteral ciprofloxacin, and metronidazole were given and also Pethidine when needed. On a postoperative day 2 (POD-2), the patient passed flatus. At POD-3, he was given sips of water and he tolerated them well, so oral intake was started gradually. At POD-5, the patient passed stool and the abdominal ultrasound was normal with no fluid collection. Then, he was discharged with no symptoms. Follow-up for the patient at POD 10 with history, exam, and abdominal ultrasound was normal. The patient had several follow-ups for two years and he was in good condition, without complications or recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2240_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2240_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..36c8ed3457ec07027813148cfa34788c9c004f20
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2240_en.txt
@@ -0,0 +1,2 @@
+A 44-year-old Chinese man presented with a 45-day history of diplopia. Before the onset of his condition, he reported no cold, nausea, dizziness, tinnitus, vomiting, headache, hearing impairment, or hair graying. Local hospital assessments previously identified panuveitis, choroidal detachment, DR, and bilateral macular edema. Macular OCT indicated both eyes had macular neuroepithelium thickening and elevation, along with intercystic low reflex and localized detachment of the neuroepithelium. Despite initiating treatment with corticosteroid eye drops and posterior subtenon injections of corticosteroids, his condition deteriorated progressively. The patient reported no prior trauma or eye surgery. He had managed type 2 diabetes for 15 years and received bilateral total retinal photocoagulation for DR two years earlier. Physical exam revealed BCVA: manual in both eyes, with intraocular pressure at 17 mmHg and 18 mmHg. Exam findings were bilateral conjunctival congestion, atrial flash (+), localized posterior iris synechiae, pupillary margin neovascularization, clear lens, grade II vitreous opacity, and white pompon-like opacities. Right eye fundus examination showed a disc-surrounding neovascular membrane, 360° peripheral retinal and choroidal bulges, dispersed old photocoagulation marks, neovascularization, and superior and inferonasal retinal hemorrhages, extending to the posterior pole. In both eyes, examination revealed the presence of circumferential peripheral retinal and choroidal protrusions. These were accompanied by scattered, pre-existing photocoagulation marks. UBM detected a detachment of the ciliary body in each eye. Utilizing B-mode ultrasonography, vitreous opacity, and detachments in the choroid, and retina were noted for both eyes. The axial length of the right eye is 22.68 mm, and that of the left eye is 22.50 mm.Furthermore, OCT identified a significant bulge in the peripheral retina and a lack of clarity in the macular area. FFA revealed twisted, enlarged retinal veins, pronounced dotted fluorescence, and hemorrhagic fluorescence shading in the retina, with patchy nonperfusion areas (refer to Fig. ). Orbital MRI and liver and kidney function tests were normal. Syphilis, HIV, and T-SPOT tests were negative. Intraocular fluid analysis ruled out microbial infection, with VEGF at 1614.3 pg/mL, BFGF at 478.3 pg/mL, IL-6 at 566 pg/mL, VCAM at 21845.2 pg/mL, and IL-8 at 135.7 pg/mL. HLA-DRB1 results indicated DRB1*04
+He was therefore diagnosed with probable VKH. He was administered intravenous methylprednisolone at 0.5 g per day, gradually transitioning to oral corticosteroid therapy. Subsequently, the patient’s subretinal fluid resolved, and normal choroidal and retinal architecture was restored. Upon discharge, the BCVA was 20/250 in the right eye and 20/500 in the left eye (refer to Fig. ). Post-discharge, despite several adjustments, the patient’s blood glucose levels remained poorly controlled. Consequently, oral cyclosporine at 100 mg per day was added to his regimen. However, the patient experienced general weakness and dizziness, leading to the discontinuation of cyclosporine after 12 days. At the follow-up examination, there was an improvement in retinal and choroidal detachments, with a BCVA of 20/200 in both eyes. Nonetheless, fundus hemorrhage in the right eye had worsened (refer to Fig. ). The patient was then switched to cyclosporine from different manufacturers.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2245_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2245_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..beb7e00d4badf08ea9e9f324c5b9c0156ea07e1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2245_en.txt
@@ -0,0 +1,10 @@
+A 12-year-old Italian boy, 34 kg body weight, was referred to the PED with a 24-hour history of intermittent chest pain, cough, wheezing, and mild fever. His medications prior to arrival consisted of 0.2 mg of inhaled salbutamol every 3 hours, initiated the previous day without medical advice (overall 1.4 mg/24 hours). The last administration had been performed 1 hour before arrival. No inciting exercise was reported, and use of hypoallergenic material was reported in his bedroom. Salbutamol inhaler had been prescribed by his pneumologist as part of patient’s asthma action plan. Noteworthily, montelukast treatment was discontinued 5 days earlier on the advice of his pneumologist, after a 3-month period without asthma exacerbations.
+Past medical history included intermittent asthma induced by exercise and by dust mites diagnosed 1 year earlier. Only one mild exacerbation occurred 9 months following diagnosis, which did not require hospitalization. At that time, hypoallergenic material was not available in his bedroom.
+At presentation, vital signs were as follows: heart rate 110 beats per minute, respiratory rate 38 breaths per minute, 94% oxygen saturation on room air, and temperature 37.1 °C.
+Physical examination showed intercostal and substernal retractions, diffuse reductions in normal breath sound, and end-expiratory wheezing. His ability to speak was not affected. A pediatric asthma score of 9 was then calculated . Blood gas test results at presentation as well as other blood examination results and vital signs are listed in Table .
+The patient was diagnosed with moderate asthma attack and was therefore treated with 40 mg intravenous methylprednisolone and 3.75 mg (0.11 mg/kg) nebulized salbutamol together with 0.5 mg ipratropium bromide at 20-minute intervals. Three oxygen-driven nebulizations were performed because of persistent wheezing, retractions, and moderate hypoxia (oxygen saturation between 90% and 95% on room air).
+Five minutes after the end of the third nebulization, a presyncope episode occurred. At onset, vital signs were normal, apart from tachycardia (140 beats per minute); on physical examination, he had tremor in his hands, looked pale, and was eupneic, with normal breath sounds and weak radial pulse. A 12-lead electrocardiogram (ECG) was obtained [aspecific alteration of ventricular repolarization, corrected QT (QTc) interval 467 ms], together with blood samples, showing normal troponin-T serum level. Therefore, a normal saline infusion was started.
+Clinical conditions swiftly worsened in the following 30 minutes as the patient suffered faintness, extreme pallor, and cold extremities. His vital signs revealed 84% oxygen saturation on room air, hypotension (90/40 mmHg), and tachycardia (140 beats per minute). A blood gas test was conducted, showing metabolic acidosis with elevated blood lactate levels, hypokalemia, and hyperglycemia. As these findings were consistent with β2-receptor-agonist side effects, salbutamol was discontinued. Consequently, two boluses of Ringer’s acetate were administered, each over 20 minutes, because of persistent hypotension; hypokalemia was treated with 500 mL normal saline and 40 mEq/L of potassium chloride at 70 mL/hour rate of infusion in 3 hours; oxygen supplementation was started with Venturi mask providing a maximum FiO2 of 0.3.
+The patient was subsequently admitted to our intensive observation unit. During the observation period, the patient remained eupneic without expiratory wheezing. Hypokalemia quickly reverted, whereas lactic acidosis (peak concentration 8.1 mmol/L) and lower DBP persisted for a longer time. Oxygen supplementation was discontinued overnight, maintenance normal saline was continued, and diuresis remained normal. Fluid boluses had been stopped because of persistent lower DBP with normal systolic blood pressure. Ipratropium bromide was administered alone as bronchodilator treatment at 4-hour intervals.
+Twenty-four hours later, another 12-lead ECG was performed (sinus rhythm, normal QTc). A pediatric cardiology consultation excluded any evidence of compromised left ventricular function and cardiac output and suggested that the aforementioned ECG alterations might have had a multifactorial origin (mild fever, hypokalemia, and β2-agonist toxicity).
+The patient was eventually discharged in good clinical condition with oral betamethasone 1 mg/kg for 3 days and nebulized ipratropium bromide 0.5 mg four times a day. A drug challenge with 0.2 mg of inhaled salbutamol with spacer performed 1 week later was uneventful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2269_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2269_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0d298b6221cb048488fe889d493024aeb780551c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2269_en.txt
@@ -0,0 +1,2 @@
+We report the case of an 8-year-old male child who presented to the neurology department with complaints of headache and vomiting for 3 months. Physical examination did not reveal any focal neurological deficits. The patient was referred to neurosurgery and underwent brain magnetic resonance imaging (MRI) . The imaging findings revealed a well-defined supratentorial cyst measuring approximately 4 × 5.5 × 6 cm located in the left occipital region. The cyst was isointense to CSF in all sequences, with faint isointensity in the fluid-attenuated inversion recovery (FLAIR) sequence, and was surrounded by a thin hypointense rim in T2* and T2WI. Minimal edema was noted anterior to the cyst, and there was no evidence of abnormal enhancement after contrast injection. However, the 3D thin slices showed meningeal enhancement around the upper margin of the lesion, suggesting that the cyst was located between meningeal layers. The posterior wall of the cyst appeared irregular and was associated with prominent enhancement at adjacent meninges, with irregular erosions of the adjacent occipital bone. The cyst was causing pressure effects on the straight and superior venous sinuses and the splenium of the corpus callosum and left lateral ventricle, and was deviating the midline to the right by approximately 8 mm. Radiological investigations of the chest and abdomen did not reveal any abnormalities.
+The patient underwent a craniotomy . While retracting the bone, a thin layer of periosteal layer of the dura covering a cyst was noticed. The dura was gently retracted, and the cyst was visualized. No rupture was noted, and the cyst was successfully removed, leaving the inner layer of the dura intact. This gentle maneuver during the craniotomy is essential to avoid any eventual rupture of any superficial cyst that could be located anywhere under the bone flap. Postoperatively patients had a completely normal neurological examination, he was referred to internal medicine for medical treatment by albendazole. The follow-up lasted for 3 months without any complications .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_229_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_229_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ce6795fce3b4a613f1ca52c0a695ac488b4d2729
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_229_en.txt
@@ -0,0 +1,7 @@
+Here, we present the case of a 59-year-old woman who developed a rapid onset dementia with salient frontal executive dysfunction beginning in February 2016. One month earlier, she had shown prodromal symptoms with a decreased energy level, increased rumination, sleep disturbances, and a loss of appetite with weight loss. No psychoactive causes were identified. In February 2016, she showed rapid worsening of symptoms with increasing loss of interest in daily activities, withdrawal from other people, and reduced spontaneous speech output. Over the next few days, she developed a stuporous state with catatonic features; she lost all personal initiative and moved rarely, her movements appeared to be frozen, she stopped speaking, and she stared blankly. Since then, she has no longer been able to communicate adequately. Verbal exchanges were reduced to answers to questions using one or two words and dramatically prolonged response latencies. Pharmacological treatment with various antidepressants (citalopram up to 20 mg/day, venlafaxine up to 150 mg/day), neuroleptics (amisulpride up to 400 mg/day, aripiprazole up to 15 mg/day, flupentixol up to 1.5 mg/day, quetiapine up to 200 mg/day, risperidone up to 4 mg/day), anxiolytics (lorazepam up to 5 mg/day), and methylprednisolone (5 mg × 500 mg for five consecutive days for presumed SREAT) were administered over the course of more than 6 months, until September 2016. However, all these approaches were unsuccessful. Steroid treatment led to worsening apathy and cognitive slowing. Therefore, the patient was continuously treated in an inpatient setting.
+Upon admission to our clinic (September 2016), she was still in a stuporous state and her perception, concentration, attention, and working memory were severely disturbed. She was aware of her state but negated emotional involvement. Mental fluency and judgment were compromised. She had no energy and was apathetic. However, hallucinations and delusional symptoms were not reported. The neurological examination showed evidence of primitive reflexes (orbicularis oris reflex) and a significantly disturbed Luria’s three-step test. In addition, the patient reported a new micturition disorder.
+This patient’s developmental history was negative for in utero or birth complications, febrile convulsions, inflammatory brain diseases, and cerebral contusions. There was no evidence of any neurodevelopmental or personality disorders. The premorbid personality was described as vivacious, cheerful, and outgoing. She smoked but did not consume alcohol or illegal drugs. Until the onset of the symptoms at age 58, she was mentally healthy. Her somatic medical history included only complex regional pain syndrome of the right upper extremity (in 2005) and Hashimoto thyroiditis. Her family history of neuropsychiatric or malignant diseases was unremarkable.
+This patient’s serum anti-TPO and anti-TG antibodies were increased; however, no antineuronal antibodies against intracellular antigens were found. The CSF analyses showed normal findings; antibodies against neuronal cell surface antigens and markers of dementia were negative. A screening for rheumatological autoantibodies was negative. The cMRI showed multiple lesions in deep and peripheral white matter whithout diffusion restriction or contrast enhancement, while intermittent slow activity was detected in the EEG . [18F]fluorodeoxyglucose positron emission tomography (FDG-PET) showed mild-to-moderate medial and superior dorsolateral frontal hypometabolism, which did not allow a clear distinction between early-stage frontotemporal lobar degeneration and secondary non-specific changes (e.g., due to reduced consciousness/apathy, atrophy). An additional [123I]FP-CIT-SPECT revealed a normal striatal dopamine transporter availability . Neuropsychological test batteries for dementia, following the Consortium to Establish a Registry for Alzheimer’s Disease (CERAD), showed deficits in verbal fluency, word list memory, constructional praxis, and trailmaking A/B . The Behavioral Assessment of the Dysexecutive Syndrome (BADS) showed severe impairment (sum-score: 6; average: 16–20; range: 0–24). More complex tasks, like the zoo map test and the modified six elements test, were nonexecutable, as the patient did not understand the instructions.
+The dysexecutive syndrome (e.g., loss of motivation and ability to judge), cognitive deficits (e.g., working memory deficits), neurological signs (orbicularis oris reflex, Luria’s three-step test), new urinary incontinence, neuropsychological testing, and frontal hypometabolism on FDG-PET were all compatible with a behavioral variant of frontotemporal dementia (FTD). However, the initial clinical course with rapid deterioration within days to weeks was highly unusual for neurodegenerative pathology like FTD; and the trailmaking tests A/B and verbal fluency (in the CERAD) would be adversely affected by the patient’s prevailing conscious state. Therefore, the patient’s conscious state might have influenced the comparability of the serial neuropsychological assessments. However, the cooperation was comparable at the three times of investigation. Alternatively, immunological encephalopathy seemed to be plausible regarding the rapid onset, increased antithyroid antibodies, EEG slowing, white matter lesions, and secondary non-specific FDG-PET alterations. Furthermore, an idiopathic depressive stupor could not be completely ruled out; however, the combination of slowed EEG and frontal FDG-PET hypometabolism is atypical for this differential diagnosis.
+For optimal antidepressant treatment, lithium therapy was started in September 2016 (450–675 mg/d, serum levels: 0.39–0.69 mmol/l, reference: 0.4–0.8 mmol/l). There was only a questionable minor response to this treatment attempt over a period of 7 weeks. In parallel, we discussed options for immunosuppressive treatment strategies. Although high-dose steroid therapy aggravated symptoms, we started off-label treatment with plasmapheresis (five sessions at the beginning of November 2016) 7 weeks after the initiation of lithium as a last-resort therapeutic attempt. At this time point, the patient’s hypothyroidism was adequately substituted with 0.075 mg/d l-thyroxine.
+A few days after the initiation of plasmapheresis, all the patient’s symptoms improved significantly. Although her oral fluency was still reduced, normal communication was again possible. Her mood improved, her cognitive deficits were reduced, the orbicularis oris reflex disappeared, and the Luria’s three-step test normalized. However, her energy level improved only slightly. This patient was discharged from our clinic in December 2016 (6 weeks after undergoing plasmapheresis) and lived with her husband as before. Her energy levels and micturition disorder gradually improved; however, while her oral fluency and planning skills were enhanced, she still showed slight impairment 6 months after plasmapheresis. The improvement was neuropsychologically documented . One month after plasmapheresis, the patient improved in almost all the initially impaired categories of the CERAD testing battery ; however, the BADS only improved slightly and remained significantly below average (sum score only increased from 6 to 8). Nearly 6 months after undergoing plasmapheresis, the CERAD and BADS (sum score of 8 points) findings were still stable. However, the verbal fluency was slightly reduced. Treatment with lithium (675 mg/d) and l-thyroxine (0.075 mg/d) continued unchanged. The follow-up FDG-PET showed normalization in July 2017 (i.e., the frontal hypometabolism was no longer detectable; Figure ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2313_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2313_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..faaccac68db043830d3c1319f7ef7180222534b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2313_en.txt
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+A 30-year-old Persian woman presented weakness, stress, low blood pressure, and low-grade fever. On the tenth day after the onset of the symptoms, she complained of chest pain, cough, and tachycardia.
+A chest computerized tomography (CT) scan revealed the presence of unilateral ground-glass opacities . Following gastrointestinal complications, including diarrhea, vomiting, and 78% oxygen saturation, the patient was hospitalized and moved to the intensive care unit for invasive ventilation. She was treated with hydroxychloroquine, antiviral therapy (remdesivir), and tocilizumab. After partial recovery, the patient was discharged home. However, 30 days after the onset of symptoms, the patient manifested neurological complications . She developed acute weakness in the lower limb, numbness and tingling, loss of touch and vibration sensation in the feet and, a few days later, in the upper limb and the hands. She also developed gait disorder and loss of balance. Subsequently, muscle stretch reflex examination revealed absent deep tendon reflexes in the upper and lower limbs. The patient also showed acute onset of unilateral eyelid ptosis (right), blurred vision (right), areflexia, dysphagia, vomiting, urinary incontinence (UI), and unilateral numbness of the chin and lower lip [numb chin syndrome (NCS)]. Electroneurography revealed severe sensory-motor axonal polyneuropathy with relative sparing of conduction velocities. The nerve conduction studies showed reduced or absent compound muscle action potentials (CMAP) and sensory nerve action potentials in the lower and upper limbs. Brain and spinal cord magnetic resonance imaging (MRI) did not reveal any abnormal and pathological findings. SARS-Cov-2 RNA was not tested in cerebrospinal fluid (CSF).
+The patient received intravenous immunoglobulin (IG) (0.4 g/kg/day for 5 days). The patient was highly responsive to treatment with the rapid clinical response on swallowing, strength, and eyelid ptosis. Also, the patient performed physical therapy successfully at her rehabilitation facility.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2316_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2316_en.txt
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index 0000000000000000000000000000000000000000..d20c3bdafd46756966c698d0df7fe474150321cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2316_en.txt
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+A 46-year-old never smoker Malagasy woman was referred by her family doctor to the emergency department due to dyspnoea with inspiratory stridor and inspiratory-expiratory wheezing with insidious onset over a 3-month period. The patient was treated for supposed asthma since 2 weeks without improvement. She had no fever, weight loss or night sweats. Physical examination revealed a heart rate of 96/min, a respiratory rate of 19/min, and an oxygen saturation of 89% on room air with normal chest auscultation. A non-tender mass was detected on the right side of her neck.
+CT scans of the neck and thorax showed a large thyroid mass causing tracheal stenosis , and multiple cystic lesions with thin walls in both lungs . Cysts had a diffuse localisation, including the costophrenic recesses. Neither pulmonary nodules nor ground glass opacities were observed. Abdominal CT scan did not show any sign of renal angiomyolipoma.
+Blood arterial gases showed mild hypoxemia (PaO2 82 mmHg). Laboratory investigations, including renal function, liver function tests, C-reactive protein, thyroid function tests, complete blood cell counts, and serum IgG4 levels were all within normal limits. HIV and immunological tests (anti-Ro/SSA and anti-La/SSB antibodies, rheumatoid factor and thyroid-stimulating hormone (TSH) receptor antibody) were negative. Plasma levels of vascular endothelial growth factor-D (VEGF-D) were low (347 pg/mL; normal range 0–450 pg/mL). Electrocardiogram (ECG) tracing and complete pulmonary function testing were normal (forced expiratory volume in 1 s - FEV1 94%, total lung capacity – TLC of 95% of predicted and normal carbon monoxide diffusing capacity - DLCO).
+Surgical removal of the thyroid mass with subtotal thyroidectomy, tracheal segment (3.5 cm) resection and multiple adenectomies were performed . Microscopic study revealed extensive infiltration of all lymph nodes and the thyroid with partial replacement of follicular parenchyma by a fibro-inflammatory process of mixed cellularity, rich in histiocytes . The latter exhibited epithelioid to xanthomatous morphology and formed ill-defined clusters or confluent sheets without granulomatous pattern. An important fraction of the histiocytic population showed emperipolesis of neutrophil granulocytes and lymphocytes . Immunohistochemistry revealed co-expression of the macrophage-related epitope CD68 along with S100 protein, in the absence of CD1a, thereby identifying the histiocytic elements as of non-Langerhans lineage . Remarkably, storiforme fibrosis with signs of vasculitis was also observed and immuno-phenotyping of the infiltrate revealed a substantial participation of IgG4-bearing plasma cells. While their absolute density reached up to 50 per high power field, the IgG4:IgG ratio did not exceed 20% . Histological examination of the tissue biopsies for the identification of infectious organisms using several stainings for pathogens were negative. Based on these findings, a histological diagnosis of RDD was made.
+Following surgery dyspnoea disappeared indicating that it was related to tracheal compression. The patient was asymptomatic in the absence of any specific treatment; clinical, functional lung testing and radiological follow up 4 years after surgery did not reveal any disease activity or progression underlining the excellent prognosis of the disease after resection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2351_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2351_en.txt
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index 0000000000000000000000000000000000000000..9851494f5995e2d2215f5117603165eb86cf9534
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2351_en.txt
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+A 76-year-old Asian male had a history of chronic coughing. A chest radiograph taken with the patient in standing position showed pleural effusion and tumor shadows in the right middle lung field . Scout imaging revealed that the tumor was located in the upper lung field, with a possibility that it had moved . Computed tomography (CT) showed a 13-cm tumor in his right upper lung lobe mainly located at S1-3 and massive pleural effusion in the right thoracic cavity . The patient was scheduled for investigation of suspected lung cancer or pleural tumor.
+Twelve hours later, he came to ER with sudden dyspnea and fever. Vital signs were blood pressure 156/87 mmHg, heart rate 117 bpm, temperature 39.0 °C, respiratory rate 20 breaths/min, and percutaneous oxygen saturation of 96% on 5 L oxygen flow. CT showed that the right upper lung lobe had shifted to the posterior thoracic space , causing the right middle and lower lung lobes to be pushed up toward to the apex; the right upper lung lobe had also rotated 90° counterclockwise toward the hilum . The pulmonary artery was not disrupted but was stretched in an arc. There was a thrombus in the upper pulmonary vein and non-contrast regions in the peripheral tumor; impediment to blood flow was suspected. Torsion of the right upper lung lobe was diagnosed, and emergency right upper lobectomy was performed through a right anteroaxillary thoracotomy.
+Intraoperatively, the right upper lung lobe had shifted to the posterior thoracic space; the middle lobe was compressed to the apex; and the lower lobe was distended in the hilar front. The right lung had rotated 90° counterclockwise toward the hilum. There was no color change of the pleura due to ischemia and congestion from the lung surface. There was about 1300 ml of serous pleural effusion, which was no malignant. The pulmonary vessels had been stretched but were not completely obstructed. There were no adhesions in thoracic space, but the oblique and horizontal fissures of the lung were incomplete by thickening of pleura due to inflammation. As concerned about thrombus and necrotic material in the right upper lung lobe, we first dissected the pulmonary vein, then the superior trunk of the pulmonary artery, before resolving the torsion and performing the lobectomy.
+The patient recovered uneventfully and was discharged. Pathological examination of the resected lung revealed a lung adenocarcinoma, pT3N2M0 stage IIIA. The patient is undergoing postoperative chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2361_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2361_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9b52b2f972a4f0d479bc9b6615e012fead4a9ecf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2361_en.txt
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+A 43-year-old Sinhalese woman with a history of anovulatory subfertility for 5 years presented to the gynecology clinic of the University Hospital – General Sir John Kotelawala Defence University complaining of heavy menstrual bleeding and secondary dysmenorrhea of 6 months’ duration. She had undergone treatment with clomiphene citrate for eight cycles. Previous imaging did not reveal an ovarian cyst. Her CA 125 had not been measured previously. She had no loss of appetite or loss of weight. Her past medical and psychosocial history was unremarkable. She had no family history of malignancy. On examination, she was afebrile and had a soft abdomen. Her cervix appeared normal upon speculum examination. Bimanual examination revealed that her uterus was of normal size and retroverted. She had a solid nontender adnexal mass extending from the left adnexa to the pouch of Douglas.
+Imaging (pelvic ultrasound and computed tomography of her abdomen and pelvis) revealed a hemorrhagic cyst (6 × 4 cm) on the right side and a multilocular cyst with solid areas (10 × 7 cm) on the left side. No peritoneal deposits and ascites were observed. The patient’s CA 125 level was 2715 U/ml. The case was discussed at a multidisciplinary team (MDT) meeting due to the patient’s history of subfertility and elevated CA 125 level.
+A fertility-sparing staging laparotomy was performed, which included right cystectomy, left oophorectomy, infracolic omentectomy, and peritoneal washings. Histology revealed a mucinous cystadenoma on the right ovary and a mature cystic teratoma on the left ovary . No malignant cells were observed in peritoneal washings. Following surgery, the patient’s CA 125 level dropped to 74.8 U/ml 1 month after surgery. She is currently being seen in follow-up and is receiving letrozole for ovulation induction. A timeline of events is shown in Fig. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2390_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2390_en.txt
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index 0000000000000000000000000000000000000000..0e3c75b900d9e60b388b83938e3b44209bf7dfb8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2390_en.txt
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+A 76-year-old man with a history of rheumatoid arthritis was admitted to our hospital because of cough, expectoration and fever for 10 days on September 20,2022. Before the patient took methylprednisolone intermittently. On September 10, 2022, the patient developed fever, body temperature up to 38.2ºC, accompanied by cough, yellow and black sputum, occasionally with blood in sputum, chest tightness and shortness of breath. The patient was administered cefalexin by intravenous drip at the local health center. He did not improve and was transferred to our hospital 10 days later.
+On admission, he presented with: fever, cough, yellow sputum, fatigue, body temperature of 38.5ºC, blood pressure of 152/91 mm Hg, respiratory rate of 23 breaths per minute, heart rate of 82 beats per minute, normal mental status, emaciation, thick breath sounds in both lungs, and wet rales in both lower lungs. Relevant examinations were as follows: arterial partial pressure of oxygen,71.6 mm Hg; oxygenation index, 217 mm Hg; white blood cell count of 4.28 × 109/L, neutrophil count of 1.8 × 109/L, lymphocyte count of 0.42 × 109/L, CD3 + lymphocyte count of 362.77/μL, CD19 + lymphocyte count of 70.52/μL, hs-CRP level of 162.00 mg/L, creatinine level of 38 µmol/L, albumin level of 20.3 g/L, prealbumin level of 45 g/L, procalcitonin level of 0.59 ng/mL, 1,3-β-d-glucan level of 193.63 pg/mL, galactomannan level of 1.2 S/CO. Liver and kidney function indicators were within the normal limits. Serological tests for HIV, CMV, Epstein-Barr virus, hepatitis C virus, COVID-19, parainfluenza virus, respiratory syncytial virus, influenza A virus, adenovirus, Chlamydia pneumoniae, Mycoplasma pneumoniae, Legionella pneumophila, and influenza B virus were negative. Chest computed tomography (CT) showed bronchiectasis and infection in both lungs .
+After admission, the patient was started on intravenous drip cefoperazone sodium/sulbactam sodium (3 g every 8 hours) combined with levofloxacin injection (0.5 g every day) to fight against infection Considering that the patient had bronchiectasis with infection, acetylcysteine atomization was used for expectoration. Bronchoscopic alveolar lavage was performed on the second day after admission, and bronchoalveolar lavage fluid (BALF) was collected for bacterial and fungal cultures and acid fast bacilli detection. BAL fluid galactomannan level of 1.3 S/CO. On the fourth day after admission, the acid fast staining of BLAF fluid was positive, showing 90º branched hyphae, similar to Nocardia, and BALF fluid showed gram-positive rods identified later on as Nocardia astrosus. The patient BLAF fluid culture was positive for A fumigatus. We replaced cefoperazone sodium/sulbactam sodium with ceftriaxone by intravenous drip (2 g every day), and administered Trimethoprim-Sulfamethoxazole (SMZ-TMP) by oral (960 mg every 6 hours) and voriconazole by intravenous drip (400 mg every 12 hours on the first day then 200 mg every 12 hours) for anti infection. The patient did not have fever again, and still had cough and expectoration on the 8th day. However, on the 17th day of treatment, the patient did not have fever again and still had cough, and the chest CT scan showed that the infection focus was absorbed more than before; inflammatory indicators: white blood cell count of 8.98 × 109/L, hs-CRP level of 3.9 mg/L, PCT 0.06 ng/mL, and body temperature were normal. The patient was discharged after 3 days. The patient continued to take SMZ-TMP and voriconazole, and was followed up regularly in the outpatient clinic.
+Three months later, the infection index was normal, liver and kidney function was normal, and lung CT showed infection focus was absorbed obviously . The patient recovered after 3 months of treatment. The patient was very satisfied with the treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2405_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2405_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4f69d7145c31a68a1dfe0fd49e9121d72e807c80
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2405_en.txt
@@ -0,0 +1,8 @@
+A 32-year-old man with a history of drug abuse presented to the emergency department with deterioration of paresthesia and limited movement of the left neck for 7 d.
+The patient had slight paresthesia of the neck for 5 years. Seven days before this admission, the symptom became intolerable and was accompanied by a limited movement of the neck after an acute upper respiratory tract infection. He perceived a foreign body existing on the left side of the neck and the feeling was severe while coughing or swallowing.
+The patient had no history of neck trauma, cervical spondylosis, or contagious diseases.
+The patient was a heroin abuser 5 years ago and achieved successful detoxification for 2 years. He had no family history of hereditary diseases.
+There was no abnormality in vital signs. Physical examination revealed only mild pain during the palpation of the left neck, and a rod-shaped solid substance was touched. Its location was parallel with the long axis of the left cervical artery.
+A blood test revealed a slightly elevated C-reactive protein level (1.53 mg/dL) and white blood cell count (10.94 × 109/L). Other blood test results were normal.
+The radiological examination showed that a rod-shaped foreign body was diagonally located in the anterior region of the neck and the lower end of the rod extended to the thorax and computed tomography revealed a high density extending from the cervical region to the upper mediastinal area .
+Because of the unexpected imaging findings, further medical history was acquired. He finally admitted that he deliberately swallowed a segment of mercury thermometer after he broke a mercury thermometer and poured out the mercury 5 years ago under the influence of drugs when he was alone. He was sent to the emergency department immediately to undergo an endoscopy after he told his family about the accident. But neither a foreign body nor trauma or perforation was found. He did not receive further examinations or treatments because the clinician thought that he was talking nonsense under the influence of drugs, and the patient’s symptoms were tolerable until 7 d before this admission.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2427_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2427_en.txt
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index 0000000000000000000000000000000000000000..032314e088dee9de37f76d5fb6ddfa0beb8185ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2427_en.txt
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+A 62-year-old Caucasian woman with a history of stroke, epilepsy, and peptic ulcer disease presented to our emergency department (ED) for increasing swelling and erythema over her left foot despite 7 days of oral antibiotic therapy for cellulitis. She denied fever, chills, and respiratory or gastrointestinal symptoms. She had no family history of cardiac diseases, nor did she have any previous cardiac workup or echocardiograms. She was an active smoker with a 50-pack year smoking history and denied alcohol or drug use. Physical examination upon admission was pertinent for erythema, swelling, and tenderness in the left lower extremity. Neurologic examination was intact except for left-sided hemiparesis from a previous stroke. Laboratory tests were notable for lactate of 2.5 mmol/L. Her serum creatinine increased from 0.6 to 0.92 mg/dL within 24 hours upon admission, consistent with a diagnosis of acute kidney injury. She was hospitalized under the diagnosis of cellulitis complicating sepsis with end-organ dysfunction and started on intravenous vancomycin 1000 mg daily.
+She was clinically stable until the third day of hospitalization, when she began to have intermittent episodes of hypoxia with a measured oxygen saturation of 88%, along with substernal chest discomfort. Physical examination was pertinent for diffuse wheezing in all lung fields which was alleviated after receiving nebulized albuterol. The following day, hypotension was noted, with a systolic blood pressure of 75 mmHg that resolved after fluid resuscitation. Her electrocardiogram (ECG) at the time showed sinus tachycardia. Serial troponin I levels were within normal limits. Computed tomography angiogram of the chest was negative for pulmonary embolism. Echocardiogram revealed an ejection fraction of 25%, left ventricular diastolic dimension of 4.6 cm, and multiple segmental wall motion abnormalities in the basal-to-mid anteroseptum along with basal-to-mid anterior, apical anterior, and apical septum.
+Repeat ECG 8 hours after the initial one was remarkable for sinus arrhythmia with deep symmetric T-wave inversions in leads V1–V4, consistent with Wellens syndrome . Emergency cardiac catheterization revealed patent coronary arteries without obstructive coronary artery disease (CAD) . Following her procedure, she was admitted to a cardiovascular intensive care unit due to alternating episodes of sinus bradycardia and tachycardia accompanied by hypotension which resolved spontaneously without medical management. Her chest pain resolved after day 6 of cardiac catheterization. After 17 days of hospitalization, she was discharged with metoprolol extended-release 25 mg daily, atorvastatin 80 mg daily, and furosemide 20 mg daily. An ECG prior to discharge showed normal sinus rhythm without T-wave abnormalities . An appointment was made to follow up with our cardiology clinic and a repeat echocardiogram was scheduled. However, she was lost to follow-up, and further attempts to reach the patient by phone were unsuccessful.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2429_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2429_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..165c3533a87215e6e72d881ecd21b68422bff5f2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2429_en.txt
@@ -0,0 +1,6 @@
+A five year old female presented, shortly after migration from Africa, with chronic scalp infection and otitis media. She was noted to have symptomatic hyperglycaemia, with a history dating back possibly to two years of age. She was observed to have several cutaneous and facial features typical of the RMS phenotype .
+Biochemical insulin resistance was documented, with elevated fasting plasma insulin level of 1836 pmol/L (normal laboratory value: 9–80 pmol/L). At age six, diabetes mellitus was diagnosed with the classical pattern of daytime postprandial hyperglycaemia, but paradoxical nocturnal fasting hypoglycaemia. Genetic testing demonstrated a homozygote mutation at position 119 of the mature alpha subunit of the insulin receptor, but a normal beta subunit. She is of African ethnicity, and was born of a consanguineous union between first cousins. There is no other family history of insulin resistance.
+Her diabetes was initially managed with Metformin (currently 3 grams/day) followed by a brief trial of added pioglitazone. She rapidly progressed to insulin, with a current insulin requirement of 2100 units per day (>50 units/kg/day). Despite this, her glycaemic control remains suboptimal, with an HbA1c of 75 mmol/mol (9%). She has a current weight of 36 kg, height of 148 cm (Z score −1.1) and BMI of 16.6 kg/m2.
+Enlarged kidneys were noted from six years of age. Ultrasonography revealed persistent renal sizes greater than two standard deviations for her age (11 cm diameter left, 10 cm diameter right), with poorly defined medullary renal pyramids, loss of normal cortico-medullary differentiation, and a mildly dilated right collecting system. There were no renal cysts or duplex system. Nephrocalcinosis was identified, and appropriate biochemical studies were done, revealing hypercalciuria . At age of eight years a mercaptoacetyl triglycine MAG 3 renogram demonstrated normal function bilaterally with an effective renal plasma flow (ERPF) from right kidney of 379 mL/min and left kidney of 404 mL/min (normal ERPF>300 ml/min).
+At the age of eleven years she presented with recurrent left flank pain, associated microscopic haematuria, and albuminuria on dipstick examination. There were no features to suggest an infective or traumatic aetiology to her symptoms. She was pre-pubertal. Ultrasonography showed a right kidney of 12.3 cm, left kidney of 13.2 cm, with multiple bilateral renal calculi, the largest 10mm in diameter. The right renal pelvis was dilated (1.2 cm), and a simple 10 mm cyst seen in the left kidney. The bladder was normal. A CT urogram revealed a 2 mm calcification seen to the left of the true renal pelvis, suggestive of an intraluminal ureteric calculus. Intravenous pyelogram further demonstrated paintbrush-like appearances of the renal pyramids, consistent with MSK . The patient had the most severe form of MSK, grade 4, with involvement of all the calyces in both kidneys .
+Her nephrocalcinosis was actively managed by optimising fluid intake and a trial of thiazide diuretic. Treatment was ceased at 3 months, at the request of the family as she remained asymptomatic from her nephrocalcinosis. No further acute episodes of nephrocalcinosis or pain have recurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2464_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2464_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..979de4f072b0192f74bbdb87bf6723c93d256612
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2464_en.txt
@@ -0,0 +1 @@
+An agitated 20-year-old boy without known past medical history, who had hallucinations referred to emergency toxicology department. He was reported to have abused 30 subcutaneous injections of somatropin, each containing 10 mg/1.5 mL all at once with the aim of enhancing performance for coming competition. He also had been using somatropin for the past 2 years for anabolic purposes. The initial vital signs were; BP = 145/96 mmHg, PR = 111/min, RR = 21/min, T = 37.10C and SPO2 with mask = 100%. He had been sedated in ED with midazolam. Laboratory tests revealed hypernatremia (157 mEq/L), hyperkalemia (5.3 mEq/L), high Lactate Dehydrogenases (LDH; 1448 U/L) and Creatine Phosphokinase (CPK; 2620 U/L) level which were all robustly signifying that a state of rhabdomyolysis had happened. Urine toxicology analysis was negative for all substances. The supine chest X-Ray had veiling opacities related to pleural effusion. In Electrocardiogram (ECG), left atrium (LA) abnormality was seen according to Romhilt-Estes criterion . The O2 saturation level dropped within hours and he had to be intubated. Brain CT scan demonstrated no pathologic changes. Consolidations in dependent sites of lungs were observed in his chest CT scan that were indicative of aspiration pneumonia . He experienced several episodes of hypertensive crisis during his admission and was then infused on trinitroglycerin drip. On the fourth day he had a temperature of 40 0C. The patient was evaluated for sepsis and samples of endotracheal tube were collected for culture which consisted of gram-positive staphylococcus aureus. Urine culture was also positive for klebsiella. Therefore, antibiotics including; ceftriaxone and clindamycin, were prescribed. As the consciousness level had not been improving up until then, and SPO2 levels had begun to decline, the decision was made to change the endotracheal tube and re-intubate him with suspicion of upper airway obstruction. In spite of no ischemic changes in electrocardiography, on the sixth day of admission; elevated troponin level (0.99 ng/ml) was detected. The case was consulted with cardiologists and considering his high d-dimer, they advised chest CT angiography with a high suspicion for pulmonary embolism, however, in view of his unstable condition CT angiography could not have been carried out. As a result, an alternative regimen of anticoagulant therapy with heparin was initiated. The next day he deteriorated with cardiopulmonary arrest, cardio pulmonary resuscitation was instituted but the cardiac rhythm remained unviable and he was declared dead after 40 min.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2469_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2469_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..db1059cae0f9d735ce2777e282823304167f9d5e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2469_en.txt
@@ -0,0 +1,3 @@
+A 64-year-old Indian man was referred with complaints of abdominal pain, vomiting and not passing flatus or feces for four days. Our patient's general condition was poor; he was febrile, with a pulse rate of 124/minute and blood pressure 90 mm/Hg. X-rays of his abdomen showed multiple air fluid levels suggestive of acute intestinal obstruction. With the provisional diagnosis of acute abdomen (acute intestinal obstruction) our patient was resuscitated and sent for an urgent laparotomy. On exploration, our patient had severely dilated small gut loops with the terminal ileal loop twisted around the omental band and adherent to his left pelvic wall. On releasing the omental band, the ileal loop was dissected free from his left pelvic wall. Once the loops had been released, we found a large, white, oval shaped, extra-luminal body in the region of his sigmoid colon . The body was soft to firm in consistency (resembling a boiled hen's egg) and attached (parasitized) to the omentum . In addition, part of the appendices epiploicae, attached to his sigmoid colon, were calcified with constricted stalks. The peritoneal loose body was largely parasitized to the omentum with a separate feeding vessel supplying it from the omentum.
+The body was an oval shaped mass, measuring 7 cm in length and 5 cm in width, and weighed 74 g. On the cut surface, it had classic appearance like a boiled egg, with a distinct white peripheral part and yellow central part . The white part was smooth and soft in consistency while the central yellow part was slightly firm in the periphery and hard (calcified) at the central point. The surfaces were smooth and shiny. On histological examination, it consisted of laminated strands of a fibrinoid substance with a large amount of proteinaceous material in the peripheral white part (boiled albumin with a high collagen deposition) and saponified fat with calcification in the central yellow part.
+Our patient did well post-operatively; he resumed his oral diet on the third post-operative day. He was discharged from the hospital five days after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2477_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2477_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3e3b60d91758d660b167f9a0663caadf13fe8de1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2477_en.txt
@@ -0,0 +1,7 @@
+A 57-year-old female patient suffered from irregular vaginal bleeding for 5 mo.
+No other abnormal clinical signs.
+The patient underwent cervical conization in 2000 because of atypical epithelial cells in the cervix. Postoperative cervical human papillomavirus (HPV) screening showed no abnormalities. Elevated carbohydrate antigen (CA) 125 and CA199 levels were found 9 years before.
+The patient denied any family history of malignancies.
+On physical examination, the patient’s body temperature, pulse, and breathing were normal, and vital signs were stable.
+Serum analysis showed elevated levels of CA125 (114.5 U/mL), CA199 (> 700 U/mL), and human epididymis protein 4 (HE4) (121 mol/L).
+Computed tomography (CT) examination in our hospital showed a solid cystic mass 5.9 cm × 8.3 cm × 6.7 cm in size in the left pelvis and a solid cystic mass 3.6 cm × 3.7 cm × 3.8 cm in the right adnexa .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2514_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2514_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9489a32b8d08989a1a2c86199f6c90b5a8b774f7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2514_en.txt
@@ -0,0 +1,6 @@
+A 47-year-old Caucasian male with a 10-year history of Crohn's disease presented with a 5-day history of fever, night sweats, rash over both legs and headache. The headache was localised at the left temporal area and associated with nausea, lethargy, general malaise, fever, night sweats and rigors but not photophobia. There was no history of previous upper respiratory tract infection. The medical history of the patient did not indicate anything relevant except Crohn's disease which was diagnosed in 1998. This was treated with a partial colectomy in 1999 and a total colectomy in 2006. He did not take any regular medication and reported no drug allergies.
+On initial physical examination upon hospital admission, the patient was afebrile (tympanic temperature 36.5°C). His skin revealed lesions that were purple-red, non-pruritic, tender nodules measuring 1-2 cm in diameter. They were asymmetrically distributed over both shins and inner knee areas resembling eryhthema nodosum . Neurological examination was unremarkable. He had no neck stiffness.
+Laboratory examination revealed a white cell count of 11.5 × 109/L with neutrophilic leukocytosis (79%). CRP was raised (234 mg/l). Both kidney and liver functions were normal.
+The next morning, the headache worsened and the patient began experiencing neck stiffness. On examination, the patient had a fever with temperature of 39.4°C. Mild neck stiffness was elicited. He did not have focal neurology. Further nodules had appeared on his shins.
+A computed tomography (CT) head scan was normal. We proceeded to a lumbar puncture. This showed clear fluid, an opening pressure of 36 cm H2O, no xanthochromia, total cells 366, polymorphs 294, lymphocytes 72, red blood cells <1, cerebrospinal fluid culture negative (also negative for acid-fast bacilli) and meningococcal polymerase chain reaction negative. Since these results initially suggested bacterial meningitis, 2 g of intravenous ceftriaxone twice daily was started. In addition, the patient received ibuprofen 400 mg three times daily and paracetemol 1 g four times daily for analgesia.
+On the third day of admission, further similar lesions appeared on both upper arms. Punch biopsies were taken from these lesions. Histology on the specimens revealed severe papillary edema. The dermis contained an infiltrate of neutrophils and nuclear dust was also present. These findings supported the clinical diagnosis of acute neutrophilic dermatosis (Sweet's disease.) On days 4-6 of admission, his symptoms started to improve. He was still having headaches and spiking temperatures of up to 38.9°C in the evenings but the skin lesions were settling with decreased tenderness and redness. By the seventh day, the patient was apyrexial, his headache had settled, and his CRP had fallen from 234 to 33. He was discharged from the hospital.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2518_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2518_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1be26f4ff07b978b246b971bafeabe158c60b7e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2518_en.txt
@@ -0,0 +1,4 @@
+A 38-year-old Caucasian man presented with worsening central vision OS of 1-week duration. His medical history was significant for recurrent tonsillitis but otherwise negative. He had been diagnosed as having “strep throat” twice in the last 3 months and prescribed amoxicillin 500 mg twice per day for 10 days both times without formal rapid strep testing. He recovered from each instance of tonsillitis within 5–7 days. He had no history of ophthalmic conditions or prior surgery. He denied taking any daily medications or using eye drops. He grew up in Kansas City, Missouri, United States of America, and owned a dog but denied recent travel or exposure to ticks. He and his wife have lived in Austin, Texas, USA, for several years. He works as an information technology specialist. He is a former cigarette smoker who quit 8 years ago, he drinks alcohol socially, and he denied any history of illicit drug use. His family history is significant for maternal diabetes and paternal hypertension.
+His uncorrected visual acuity was 20/20 in his right eye (OD) and 20/50 OS. His pupils were equally round and reactive, and intraocular pressures were normal. The ocular adnexa were normal on external examination. The anterior chamber and vitreous were quiet bilaterally. A dilated fundus examination OD was unremarkable. A dilated fundus examination OS showed a normal optic nerve, scant hyperpigmentation at the inferotemporal border of the disc, and a whitish sub-retinal lesion temporal to the fovea with a small associated hemorrhage. Ultra-widefield fundus photography is shown in Fig. . A general medical examination was unremarkable. He was afebrile with a temperature of 36.7 °C (98.0 °F), heart rate of 73 beats per minute, right arm cuff blood pressure of 113/70 mmHg, respiratory rate of 16 breaths per minute, and 98% oxygen saturation on room air. His oropharynx was clear without exudates, his lungs were clear to auscultation, his heart was without murmur or arrhythmia, he had no rashes, and all cranial nerves II–XII were intact with no gross motor or sensory deficits, and he had normal gait.
+Optical coherence tomography (OCT) showed a hyperreflective sub-retinal elevation with an associated small pocket of fluid. Fluorescein angiography showed a focal area of hyperfluorescence temporal to the fovea in late phase. Indocyanine green (ICG) angiography showed early blockage with mild late leakage and isolated focal hypocyanescent areas. OCT angiography showed a coralliform vascular complex in the outer retina that originated from within the choroid and traversed the RPE and Bruch’s membrane into the sub-retinal space. His examination and ocular imaging were consistent with inflammatory CNVM OS with associated fluid collection, so he was initially treated with an intravitreal bevacizumab 1.25 mg/0.05 mL injection OS. Regarding his laboratory findings, his white blood cell count was 8.4 × 103 per mm3, hemoglobin 12.5 g/dL, platelets 222 × 103 per mm3, prothrombin time 14.5 seconds, international normalized ratio 1.26, blood urea nitrogen 9 mg/dL, creatinine 0.8 mg/dL, aspartate aminotransferase 22 u/L, alanine aminotransferase 27 u/L, and total bilirubin 0.5 mg/dL. Rapid plasma reagin, QuantiFERON-TB Gold, antinuclear antibody profile, and toxoplasmosis titers were non-reactive or unremarkable. His chest X-ray showed a calcified nodule in the upper lung field of his right lung, later confirmed with chest computed tomography.
+One week after initial presentation and treatment with bevacizumab, his visual acuity improved to 20/25 OS, and OCT showed improvement of the sub-retinal fluid . A 2-week taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day was prescribed to treat the inflammatory component of the CNVM. He was referred to pulmonology, and an additional workup revealed elevated serum IgG4 levels at 248 mg/dL (reference 4–86). He was also referred to otolaryngology for his history of recurrent tonsillitis, for which he underwent bilateral tonsillectomy. The specimen showed significant staining for IgG4 on histopathology. After completion of the first orally administered prednisone course, he developed left upper eyelid blepharitis, which did not resolve after initial treatment with antibiotic ointment and warm compresses. During the next 4 months, he received two more intravitreal bevacizumab 1.25 mg/0.05 mL injections for recurrence of sub-retinal fluid associated with inflammatory CNVM in the setting of biopsy-proven IgG4-RD, as well as a 1-month taper of orally administered prednisone starting at 60 mg per day and ending at 5 mg per day, after which the blepharitis resolved. He experienced improvement in his visual acuity with each injection. Six months after initial presentation, he was started on rituximab infusions 1000 mg every 2 weeks in order to decrease circulating IgG4 levels. The CNVM had decreased in size by this point . He is seen by his retina subspecialist (CJ) every 2 months for examination and anti-VEGF therapy as needed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2523_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2523_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5a0a23ad393ccec915798ce2e12e30c908bb036
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2523_en.txt
@@ -0,0 +1 @@
+A 69-year-old female presented with chest and severe upper back pain, but neurologically intact. The first chest computed tomography (CT) was interpreted as normal . Over the next 2 months, she progressively developed anorexia and the inability to belch. Esophageal stricture and thoracic vertebra OVF were suspected based on the results of the second chest CT . Thoracic magnetic resonance (MR) and CT studies revealed a T7 OVF with a kyphotic deformity . Twice, she underwent esophagogastroscopy that showed no obstruction. As her symptoms were attributed, therefore, to the T7 OVF, she underwent a T7 BKP resulting in an improved kyphotic angle from 22.4 degrees to 17 degrees . In addition, this resulted in resolution of her symptoms.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2528_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2528_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cb1bbc0177bc3d62b858ae86ee727c34f95df02b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2528_en.txt
@@ -0,0 +1,2 @@
+A 45-year-old Caucasian man presented to our Urology department with a palpable left scrotal mass, known for two years, which had progressively enlarged during the last three months. He reported no history of epididymitis, torsion or trauma. On clinical examination the mass was painless, firm and mobile. His serum tumor markers, including alpha-fetoprotein, beta-human chorionic gonadotropin and lactate dehydrogenase, were normal.
+Sonographic examination showed a sharply-demarcated hypoechoic, vascular left paratesticular mass, located close to the head of his epididymis. A large left hydrocele, with low level echoes was also found. MRI evaluation of the scrotum was done on a 1.5-T magnet unit, using a pelvic phased-array coil. The study included fast spin-echo axial, sagittal and coronal T2-weighted sequences and spin-echo axial T1-weighted sequences. Diffusion imaging was performed in the axial plane, using a single shot, multi-slice spin-echo planar diffusion pulse sequence. The maximum b-value was 900 s/mm2. A multilobular left paratesticular mass , in close proximity to the testicular tunicae of the superoanterior aspect of his left testis was detected. The dimensions of the tumor were 33 × 34 × 32 mm. T1-weighted images demonstrated a mass isointense to his testicular parenchyma . The mass was heterogeneous on T2-weighted and apparent diffusion coefficient (ADC) maps, with areas of high T2 signal and ADC value of 1.56 × 10-3mm2/s, and others of very low T2 signal and ADC value of 0.86 × 10-3 mm2/s . A large, left hydrocele, with a few septa and ADC value of 2.93 × 10-3mm2/s was also revealed. Both of his testicles, his epididymis and his spermatic cords were normal. The mean ADC value of his testicular parenchyma was 0.94 × 10-3 mm2/s and that of the epididymis 1.37 × 10-3mm2/s. His left testicular tunicae were intact. Based on MRI findings, the diagnosis of a benign fibromatous paratesticular tumor was suggested. Therefore, our patient underwent local excision of the mass. Histopathology reported an adenomatoid tumor of the tunica albuginea, with abundant fibrosis. Our patient is now well, without signs of disease on clinical and sonographic examination, one year after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2532_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2532_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9bc532e971c034c21a9465b213ee7df0e69c98d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2532_en.txt
@@ -0,0 +1,6 @@
+A 74-year-old woman presented with a painless anterior neck swelling since 2 months. It was progressively increasing in size and was associated with dysphagia, which was non-specific to fluid or solid. A gradual reduction in the appetite and oral intake with worsening dysphagia lead to a significant weight loss within this short period of time. A few weeks prior to the presentation, the patient noticed that her voice started to become hoarse with occasional noisy breathing and shortness of breath. She had no history of neck irradiation or family members with thyroid cancer or any kind of malignancy. During physical examination, she appeared to be cachexic and mildly tachypnoeic with audible biphasic stridor. There was a palpable multilobulated thyroid mass that was hard in consistency. The largest mass was located on the right lobe measuring about 5 cm x 4 cm and extending retrosternally. The trachea was not deviated; however, the normal laryngeal crepitus sign was absent. Nasoendoscopy finding was unremarkable, while laryngoscopy revealed right vocal cord palsy in paramedian position. A panendoscopy was carried out with a negative finding.
+Fine needle aspiration for cytology (FNAC) revealed a colloid goiter with the presence of malignant cells. Computed tomography (CT) scan revealed the presence of a thyroid mass involving bilateral lobes and isthmus with bilateral cervical lymphadenopathy with evidence of lung metastases .
+Otherwise, no other features from the imaging could suggest the primary site of the lesion. While the treatment plan was carried out, the patient developed progressively worsening obstructive airway symptoms requiring an emergency tracheostomy. Total thyroidectomy was successfully performed in the following week once her general medical condition had been optimized. Intraoperatively, there were multiple, locally invasive thyroid nodules mainly of the left lobe infiltrating the anterior wall of the trachea into the lumen and laterally to the right lobe with tracheal ring defect. Selective neck dissection was performed to remove the paratracheal and jugulo-omohyoid groups of the lymph node bilaterally.
+Histopathological analysis of the lesion showed a moderately differentiated squamous cell carcinoma (SCC) whereby the tumor tissue was composed entirely of malignant squamous cells .
+These cells were cohesive and arranged in sheets, nests, cords, islands and trabeculae pattern. These malignant cells exhibited large, pleomorphic, hyperchromatic to vesicular nuclei with large, prominent eosinophilic nucleoli and abundant eosinophilic cytoplasm. Individual keratinization and intercellular bridges were noted as well as tumor cell spindling . Mitotic figures were brisk, including the atypical form, and tumor necrosis was also noted. This tumor was seen infiltrating the surrounding skeletal muscle bundles and destroying the thyroid gland parenchyma.
+The patient was closely observed in the intensive care unit (ICU) post operatively and showed good progress. However, 2 weeks post operatively, she contracted a hospital-acquired pneumonia which put her oncological treatment on hold. The infection unfortunately progressed into sepsis and eventually claimed her life a week later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2535_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2535_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1fadd20e22e7169ec2ba209d51c1cf23ab0e9e7f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2535_en.txt
@@ -0,0 +1,3 @@
+A 62-year-old man (175.6 cm 75 kg) was scheduled for sternum closure using the right latissimus dorsi muscle flap for mediastinitis. He had gone CABG using the bilateral internal thoracic arteries 8 months before. He underwent debridement and vacuum-assisted closure (VAC) of the infected wounds 1 month after surgery. Although sternum closure using an omental flap was performed thereafter, debridement and VAC were reintroduced because of infection. His medical history included diabetes mellitus with end-stage diabetic nephropathy. He has been receiving hemodialysis, and the right lower leg amputated for diabetic gangrene. He was receiving linagliptin and mitiglinide calcium hydrate and aspirin. His laboratory data showed renal dysfunction (estimated glomerular filtration rate 6.2 ml/min) and anemia (hemoglobin 9.6 d/dl), but no abnormal coagulation was observed, and the platelet count was 145,000/μl. He also complained of postoperative nausea and vomiting (PONV) probably due to fentanyl after multiple anesthesia histories.
+Considering the possibility of widespread surgical wound and he was taking aspirin, continuous ultrasound-guided ESPB was planned. Aspirin was continued until the day of surgery. He received no premedication. Standard monitoring and intra-arterial blood pressure monitoring were performed. General anesthesia was induced with propofol 70 mg, fentanyl 250 μg, and rocuronium 60 mg and maintained with 1.5% sevoflurane in an inhaled oxygen concentration of 60% with a total flow of 3 l/min and remifentanil 0.1–0.2 μg/kg/min. After tracheal intubation, he was placed in the left lateral decubitus position. After performing standard skin asepsis, the linear transducer (12 MHz, LOGIQ e; GE Healthcare, Chicago IL), within a sterile sleeve, was positioned on the patient in a transverse orientation and the T6 spinous process image was taken. The transducer was moved right laterally to identify the transverse process of T6 and then rotated 90° to visualize the right transverse process and the erector spinae muscles above it. A continuous nerve block set (Contiplex Tuohy Ultra set; B BRAUN, Melsungen, Germany) with an 18-G, 100-mm Tuohy needle was inserted in-plane in a caudal to cranial direction until contact with the right T6 transverse process was made. After confirming that there was no reverse blood flow, hydrodissection with 2 ml of 0.375% ropivacaine was used to confirm the correct needle tip position. Eighteen milliliters of 0.375% ropivacaine was injected, and a 20-G catheter was advanced through the needle. After injecting 20 ml of 0.375% ropivacaine again from the catheter 55 min after the initial injection, 0.2% ropivacaine was continuously infused at 5 ml/h before the start of surgery. Hemodynamic stability was achieved without the need for an additional bolus administration of fentanyl during surgery. One gram of acetaminophen was intravenously infused 30 min before the end of the operation. There were no other events of note during the operation. The operative time was 5 h and 49 min, and the anesthesia time was 8 h and 2 min.
+After extubation in the operating room and admission to the intensive care unit (ICU), the nerve blockade area and Numerical Rating Scale (NRS) were confirmed when sufficient consciousness was reached. Regarding nerve blockade, the cold sign was T2–T8, pinprick was T3–T8, and NRS at rest was 1/10 immediately after surgery. The main pain area was the wound where the right latissimus dorsi muscle flap was collected, but pain of the median sternum wound was not noted. Acetaminophen at 500 mg was administered orally because the NRS temporarily increased to 7/10 due to body movement. However, the NRS at rest was 1–2/10 and that while active was 4/10. For pain during movement, 3 ml of patient-controlled analgesia (PCA) consisting of 0.2% ropivacaine was flushed, and this was performed twice in the ICU. After leaving the ICU 24 h after the operation and being transported to the general ward, pain was not aggravated and the ESPB catheter was removed 56 h after the operation. After removal of the catheter, oral administration of acetaminophen during pain provided good pain control. No ESPB-related complications were observed during ESPB catheter placement or after removal. Regarding PONV, nausea was observed immediately after admission to the ICU and only a single intravenous injection of 10 mg of metoclopramide was administered. Thereafter, the patient had no PONV.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2538_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2538_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5084d043a511e25a6025591b8f0129a71d494ff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2538_en.txt
@@ -0,0 +1,6 @@
+We present a case of a 74-year-old man smoker patient with NSCLC with bone metastases (T2NXM1) and HCC (BCLC stage C). The patient had a related liver cirrhosis metabolic syndrome, good liver function (Child Pugh A5), and reported a diabetes mellitus type II in his past medical history. In July 2014 for chest and abdominal pain he performed a CT scan with evidence of lung and liver lesions, and bone metastasis. Lung biopsy performed on primary lung lesion showed pulmonary adenocarcinoma (TTF1 positive and p40 negative) and liver biopsy showed HCC (grade 2 Edmondson) . As the patient was not in good clinical conditions due to grade 2 asthenia, we decided to start with gemcitabine in monochemotherapy in August 2014. After 2 months of chemotherapy a further CT scan showed a disease progression in both the lung and the liver. We decided to initiate treatment with sorafenib with standard schedule (400 mg bid continuously).
+CT scan before therapy showed that the primary liver lesion measured 97 mm × 98.3 mm . The primary lung lesion measured 40.9 mm × 29.3 mm and the metastasis in the contralateral lung measured 27 mm × 25 mm . After 20 days we decided to reduce the dose of sorafenib to 400 mg per day for adverse events (hypertension grade 2 and mucositis grade 3). This dose was maintained until progression, without adverse events. CT scan after 2 months showed partial response in both lung lesions and stable disease in the liver and bone lesions. CT scan after 6 months of therapy showed partial response of the primary lung lesion and complete response of the lung metastasis . HCC was stable . After 13 months of therapy CT scan showed a disease progression in both the lung and the liver . Due to poor performance status of the patient we decided to treat patient with only best supportive care.
+The pulmonary lesion underwent routine diagnostic molecular characterization for EGFR, KRAS, NRAS, PIK3CA, BRAF, ERBB2, ALK, DDR2, MAP2K1, RET mutations using Myriapod Lung Status (MassARRAY Sequenom). Results revealed an exon 11 point mutation on BRAF gene (G469V).
+The same analysis was performed on the liver lesion, with no mutations in the different genes. Genomic DNA extraction from both lesions was performed starting from tumor sections composed of about 70 % of tumor cells.
+Taking into consideration our previous results obtained in HCC patients, in which we have demonstrated that specific polymorphisms of eNOS, VEGFA, VEGFC and HIF-1alpha seem to correlate with response to sorafenib [–], we performed the analysis of such polymorphisms on our patient. Results showed an homozygous status for eNOS VNTR (4bb) and HIF-1alpha rs12434438 GG. Both of these polymorphisms were associated with a worse prognosis in our previous studies [–].
+The molecular determinations performed on the liver lesion (not part of routine molecular diagnostics) and the polymorphism analyses, both part of an ongoing research protocol on liver cancer approved by our Local Ethics Committee, were carried out after obtaining written consent from the patient.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2586_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2586_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..572525fb8354fa379c31a4937450175157e0a6df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2586_en.txt
@@ -0,0 +1,2 @@
+A 48-year-old Japanese male was treated for uveitis of unknown aetiology in the left eye at a general ophthalmology clinic. Prednisolone (PSL) 40 mg/day was started due to the development of macula oedema (ME) in his left eye. Although ME improved temporarily, tapering of PSL to 20 mg/day resulted in relapse of ME. He then complained of blurred vision in the left eye due to recurrence of intraocular inflammation and was referred by the local ophthalmologist to Department of Ophthalmology, Tokyo Medical University Hospital. He has no medical history. At presentation at our facility, best-corrected visual acuity (BCVA) was 20/12.5 in the right and 24/20 in the left eye, and intraocular pressure was normal. Slit-lamp examination revealed 1 + cells in anterior chamber in left eye; fundus photographs showed diffuse vitreous haze and mild exudates in peripheral retina in left eye; fluorescent angiography depicted significant retinal vasculitis characteristic of Bechet’s disease at the posterior pole and periphery retina in left eye; and OCT confirmed ME in left eye . Peripheral blood test showed elevated white blood cell count, elevated percent neutrophils, elevated LDH, positive for HLA-A26, negative for HLA- B51, negative tuberculin skin test (TST) and negative T-SPOT.TB test . He was diagnosed with incomplete type of Bechet disease based on the ophthalmological findings, recurrent oral ulcer, erythema nodosum-like rash in his legs, and HLA-A26 positivity. After a screening test, ADA was started as steroid-sparing therapy. Following the initiation of ADA, ME improved gradually and tapering of PSL to 2 mg/day was achieved, resulting in favourable outcome.
+However, 8 months after starting ADA, the patient developed general malaise. Peripheral blood examination was positive for T-SPOT.TB at this time, and chest X-ray and computed tomography (CT) showed granular shadows in bilateral lungs . He was diagnosed with miliary TB by a respiratory physician. ADA and PSL were discontinued immediately, and 4-drug regimen for miliary TB consisting of isoniazid (300 mg/day), rifampicin (450 mg/day), ethambutol (750 mg/day) and pyrazinamide (dose titrated from 0.8 g/day to 1.5 g/day) was started. The TB treatment was completed 6 months later based on clinical improvement , although T-SPOT.TB was still positive. During the period when ADA was discontinued, the patient received adjunctive therapy with betamethasone eye drops and sub-Tenon's injection of triamcinolone acetonide to manage the condition. However, the efficacy of these treatments approach was limited to control ME , resulting in decreased BCVA in the left eye (10/20) and gradual elevation of intraocular pressure due to topical administration of steroid. Therefore, a decision was made to restart TNF inhibitor. Although miliary TB treatment had been completed, the patient still tested positive for T-SPOT.TB, necessitating initiation of infliximab (IFX) in combination with isoniazid (300 mg/day) to address the condition. Following the initiation of IFX, subsequent fluorescein angiography demonstrated more severe vascular leakage compared to the initial examination. However, improvements of ME, vitreous opacity and BCVA in the left eye (24/20) were observed. Furthermore, there was no TB relapse during the course of treatment after starting IFX for 3 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2592_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2592_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..676903e71ccbc05eeac2fc4725d29b4b71ed974b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2592_en.txt
@@ -0,0 +1,8 @@
+An 8-year-old boy (height, 122 cm; body weight 26.9 kg; ASA physical status class I) with Perthes’ disease was scheduled for osteotomy. He had no significant medical history other than amblyopia. He had no family history of metabolic diseases and none of his family members had received general anesthesia. His blood pressure in the ward was approximately 100/60 mmHg.
+Anesthesia was induced using a propofol bolus of 2 mg/kg, followed by rocuronium 0.8 mg/kg and fentanyl 0.2 μg/kg. After intubation, a radial artery catheter was placed to monitor blood pressure and hemoglobin (Hb). The patient was placed in the right-lateral recumbent position. Anesthesia was maintained with 40% oxygen and 2% sevoflurane in combination with the continuous infusion of 0.2–0.4 μg/kg/min of remifentanil. The intravenous fluids administered included Ringer’s solution with acetate, bicarbonate Ringer’s solution, and a colloidal solution; lactated Ringer’s solution was not used. Blood loss was recorded as 150 mL, and 200 mL of autologous blood was used intraoperatively. Blood gas parameters including pH, partial pressure of carbon dioxide (pCO2), bicarbonate (HCO3), Hb, and lactate levels were closely monitored. Throughout anesthesia, there was a progressive increase in lactate levels, indicative of high anion gap metabolic acidosis . The duration of surgery was 5.5 h, and the duration of anesthesia was 8 h. No intraoperative tourniquet was used, and the systolic blood pressure remained at 80–100 mmHg. There was no increase in partial pressure of exhaled carbon dioxide and no muscle rigidity, and the patient’s temperature remained around 37.5 °C. The lactate dehydrogenase level measured intraoperatively was 116 U/L. The intraoperative fluid balance was + 2050 mL, and the urine output was maintained at 1.8 mL/kg/h (400 mL).
+The postoperative arousal was uneventful, and the patient was extubated without complications. His laboratory data showed lactate levels within reference limits, with pH 7.4 and lactate 0.94 mmol/L the day after the surgery.
+The patient was referred to the pediatric department for a thorough examination of his metabolic disease. Blood samples were collected on postoperative day 49. Laboratory analyses included fasting blood glucose, lactate/pyruvate (L/P) ratio, ketone and amino acid fractions, urinary lactate, and vitamin B1 levels. None of the differences were significant. Laboratory data suggested that the patient was unlikely to have congenital metabolic abnormalities and that it could be drug-induced or as a result of surgical invasion. We suggested muscle biopsy and genetic testing for a close examination of malignant hyperthermia and mitochondrial disease, which remained differential diagnoses; however, his parents did not wish to do so.
+The patient was scheduled for nail extraction 6 months after the initial surgery. Hyperlactatemia due to hypoperfusion could not be completely ruled out; however, because it could be drug-related, an anesthesia plan was discussed in our department.
+Hyperlactatemia, an initial symptom of malignant hyperthermia and PRIS, is rare, but can be fatal. Therefore, we decided not to use propofol or inhalational anesthesia. Midazolam could be a choice, but its long half-life can cause delayed emergence and respiratory depression . To avoid its disadvantages and avoid the use of propofol and inhaled anesthesia, induction and maintenance of anesthesia with remimazolam were planned.
+The appropriate dosage of remimazolam in pediatric patients is yet to be established, and dosages differ in each report [, ]. Based on these reports, we determined the dosage based on the per-body weight dosage for adults indicated in the package insert.
+Remimazolam 12 mg/kg/h until sleep onset, remifentanil, and rocuronium were administered to induce general anesthesia. After intubation, the patient was placed in the right-lateral recumbent position. Anesthesia was maintained using remimazolam 1 mg/kg/h and remifentanil 0.2–0.5 μg/kg/min. Intraoperative infusions included Ringer’s acetate and bicarbonate Ringer’s solutions; no lactate Ringer’s solution was used. The duration of surgery was 82 min and the duration of anesthesia was 153 min. The intraoperative fluid balance was + 740 mL, and the urine output was 4.22 mL/kg/h (230 mL). Although the operative time was shorter than that of the initial surgery, increased lactate levels were observed . The day after surgery, the patient’s lactate level was within the reference limits, and he was discharged from the hospital without any postoperative problems.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2594_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2594_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..57e528630d3f5b359f914b16e68ee3e91805c104
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2594_en.txt
@@ -0,0 +1,13 @@
+In July 2011 a 63 year old man with a total laryngectomy was admitted to the Department of Otolaryngology Head and Neck Surgery at Vittorio Veneto Hospital for suspected aspiration of tracheoesophageal prosthesis.
+The patient underwent total laryngectomy for advanced squamous cell carcinoma of the larynx eighteen months before this admission.
+He was an engineer, smoked 60 pack/years, and usually drank half litre of wine daily.
+The disease had been diagnosed two years before and the patient had been treated in the first place with radiotherapy exclusively. Seven months after the end of the treatment, in January 2010, he underwent emergency tracheostomy for acute dyspnea due to recurrence of larynx carcinoma: then he underwent total laryngectomy with primary insertion of tracheoesophageal prosthesis.
+During his hospital stay he started voice rehabilitation with speech therapist for about four days.
+When the patient arrived at our department in July 2011 he referred that the TEP had torn away during daily cleaning procedure, so he tried to replace the device but the attempt was unsuccessful.
+The lost TEP was a classic 10 mm Blom Singer Indwelling prosthesis, changed 2 months earlier (s ).
+At the admission he was asymptomatic, in particular he had no dyspnea, stridor, fever or cough.
+Anyway, at the examination the prosthesis was absent and he underwent immediately standard 2 view chest radiography, which demonstrated a ring-shaped opacity placed in the right lower lobe, suspicious for the aspirated TEP .
+Thus it was planned to remove the foreign body with fiberoptic flexible bronchoscopy and to place another voice prosthesis, under general anesthesia, at the same time.
+The flexible bronchoscope (Olympus BF 1 T 180) was inserted through the tracheal stoma. The TEP was present in the bronchus intermedius, just distal to its origin and it was retrieved without difficulty by grasping it with biopsy forceps , then withdrawing the whole bronchoscopy out of the tracheal stoma.
+After removing the TEP copious issue secretions filling the bronchus intermedius were suctioned and sent for culture.
+The patient was discharged the day after with prescription of antibiotic treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2595_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2595_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cc0fda3d3295f274948b94363e0f7f18f38dd339
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2595_en.txt
@@ -0,0 +1,5 @@
+A 48-year-old Chinese woman was administered a blood-activating and stasis-eliminating compound by a local physician for ankle pain. A “blood-activating and stasis-eliminating compound” is a type of traditional medicine that can be used as an analgesic and antipyretic. The ingredients of this blood-activating and stasis-eliminating compound include safflower, dog ridge (made), mistletoe, herba lycopi leaf, spatholobi, caulis trachelospermi, cocklebur, Cyperus rotundus, Periploca sepium Bge, and natural copper (calcined). It does not cause an autoimmune response, such as rash or vasculitis. Edema and skin rashes in both lower limbs appeared 3 days after this treatment. She was further treated for edema with furosemide and spironolactone at the same local hospital, and she was transferred to our hospital in September 2019. She did not have diabetes, nor did she have any relevant family, life, or allergy history. At admission, her vital signs on physical examination were as follows: body temperature, 36.5 °C; blood pressure, 127/90 mmHg; pulse, 71 beats/min; and respiratory rate, 20 breaths/min. Several round areas of the skin rash of varying sizes were seen on the arms, legs, and trunk. Pitting edema was observed in both lower limbs. Abdominal and cardiac exams showed no abnormalities.
+The laboratory test results were as follows: urinary protein, 2+; blood protein, 3+; urinary protein excretion, 5.02 g/24 h; and creatinine, 385 μmol/L . Further assessment revealed that the patient was positive for ANCAs by indirect immunofluorescence (a titer of 1:10), positive for p-ANCAs (a titer of 3.1 as the antibody index) by enzyme-linked immunosorbent assay (ELISA), and negative for both anti-GBM and anti-proteinase 3 (c-ANCA) antibodies after three repeated assays . Computerized tomography (CT) revealed scattered areas of inflammation in both lungs, with a small amount of pericardial effusion and bilateral pleural effusion. Half a month later, CT showed no inflammation in either lung, and the pleural effusion had disappeared . Renal ultrasonography showed normal-sized kidneys with elevated echogenicity.
+Light microscopy on a Nikon ECLIPSE E-200 microscope (Nikon, Tokyo, Japan) revealed a total of 13 glomeruli, with three globally sclerotic glomeruli. Ten glomeruli had cellular crescents, and three had fibrocellular crescents, which suggested crescentic glomerulonephritis. The obliteration of Bowman’s capsules and segmental sclerotic lesions were noted in 5 glomeruli. In addition, tubular atrophy (30%) was accompanied by interstitial fibrosis (30%), with the interstitial infiltration of lymphocytes, monocytes, and plasmocytes . Immunofluorescence was observed under Olympus BX41microscope (Olympus, Tokyo, Japan) to assess five glomeruli, which showed IgG linearly deposited alongside the GBM . Electron microscopy (EM) performed with a transmission electron microscope (JEOL Ltd., Tokyo, Japan) showed the collapse and rupture of the GBM in the presence of foot process fusion. The absence of electron-dense deposits was another EM hallmark of the disease . Therefore, a diagnosis of anti-GBM disease with positivity for p-ANCA and another atypical ANCA was established, despite repeated negative serum anti-GBM antibody test results.
+After the diagnosis of anti-GBM disease was established based on the clinical features and biopsy findings in our patient, treatment with methylprednisolone and plasmapheresis was initiated immediately. The treatment was initiated with 500 mg of intravenous high-dose methylprednisolone, which was administered three times, followed by oral prednisone at 50 mg per day. A hemodialysis catheter was implanted in the right femoral vein to enable plasmapheresis every 2 days (ten sessions in all). Interestingly, positivity for p-ANCA disappeared, but the patient was still positive for total ANCAs after the fourth session of plasmapheresis; the patient was negative for both c-ANCA and anti-GBM antibodies at admission. However, no signals for total ANCA or anti-GBM antibodies were observed after ten sessions of plasmapheresis.
+The patient had good tolerance of all drugs and procedures and was successfully discharged after medical care. She was followed up via outpatient visits to continue treatment with prednisolone and cyclophosphamide. Additionally, her kidney function and lung disease were regularly monitored in specialized departments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2619_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2619_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..501f49a5a40abfb12c480b139df856ec53d98a68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2619_en.txt
@@ -0,0 +1,3 @@
+A 22-year-old woman who was 5 months postpartum presented with a left-sided breast lump of 3 months duration. The lump was associated with pain and tenderness. For the last 15 days, she had also developed retraction of nipple along with thick nipple discharge. This was her first pregnancy and she could not feed her child on this side. There was no history of fever or trauma to the breast. On examination, her left breast was grossly enlarged with red and inflamed overlying skin. The nipple-areola complex was markedly enlarged with hyperpigmentation of areola but there was no excoriation. Thick discharge was seen on the nipple. On palpation, a large, multinodular, tender lump of about 6.0 × 5.0 × 2.4 cm was felt in the upper and outer quadrant. The lump was firm to hard in consistency. It was free from the chest wall and the overlying skin. The opposite breast was normal. A clinical possibility of inflammatory carcinoma was suspected and the patient was sent for fine needle aspiration cytology (FNAC). This confirmed a benign inflammatory lesion. A course of 2 weeks of antibiotics was given. However, the lump persisted following which it was excised and sent for histopathology. The postoperative period was uneventful. At present, both mother and baby are healthy and the baby is feeding from the right breast.
+Grossly, the specimen was received in the form of multiple irregular tissue pieces measuring 0.8 × 08 × 1.0 cm to 4.0 × 2.5 × 1.5 cm in size. The outer surface was lobulated and the cut surface showed multiple yellowish, soft nodules ranging from 0.3 to 1.0 cm in diameter. The margins of each nodule were circumscribed and well demarcated from the surrounding stroma. The adjacent areas were whitish and translucent .
+Microscopic examination revealed two types of lobules separated by an extensively hyalinized stroma . Some of these lobules showed classical lactational changes comprising many hyperplastic and dilated acini filled up with pink, eosinophilic secretions. These acini were lined with round to oval cells with fine chromatin and conspicuous nucleoli. Many of these cells had granular eosinophilic cytoplasm. Others had abundant, clear vacuolated cytoplasm with the nucleus pushed to the periphery . The ducts were also dilated and filled up with milk . The second type of lobules depicted ongoing involutional changes in the form of sheets of macrophages replacing and destroying the acini . In places, the phagocytic cells showed prominent admixture with lymphocytes some of which were also found infiltrating into the acinar epithelium. A few lymphoid aggregates were also noted around the individual ducts and acini . Based on all these findings, a diagnosis of lactating breast with delayed involution was offered.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2643_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2643_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6251a9bc082e033e7e1b592b05c6f68690963ff5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2643_en.txt
@@ -0,0 +1 @@
+A 12-year-old boy presented with a chief complaint of pain and swelling in the lower jaw on the right side. He reported a gradual increase in the size of the swelling which had persisted for 4 months. On examination, a diffuse swelling was noted extending anteroposteriorly from 34 to 36 tooth region on the left side and 44 to 46 region on the right side and superoinferiorly from the gingival margin to the lower border of the mandible . The swellings measured approximately 2 × 3 cm in size and were of the same color as the surrounding mucosa. On palpation, both swellings were soft in consistency, with smooth margins and were nontender. Panoramic radiographs showed unilocular, well-circumscribed radiolucent areas extending from 34 to 37 on the left side and 44 to 47 on the right side of the mandible and involving retained mandibular second premolars on both sides . Cone-beam computed tomography (CBCT) was used to obtain a three-dimensional image, enabling the exact location and extent of the lesions. Cone-beam computed tomography examination of the left mandibular region showed well-defined, well-corticated expansile osteolytic radiolucency measuring approximately 36.1 × 23.6 × 16.0 mm in its greatest anteroposterior, superoinferior, and transverse dimensions (A). The radiolucency on the right side was approximately 38.0 × 28.7 × 19.4 mm encroaching the inferior border of the mandible (B). Furthermore, the systemic evaluation of the patient for syndromic features, such as malocclusion, condylar defects, gingival hyperplasia, and maxillary micrognathia, was confirmed negative. Hence, based on the clinical and radiographic findings, a provisional diagnosis of a nonsyndromic benign odontogenic cyst was established for both lesions. The biopsy specimen consisted of four soft tissue bits with the largest one measuring approximately 2.5 × 2 × 1 cm and smallest measuring 0.5 × 0.5 × 0.4 cm in size, brown in color, and soft in consistency. Histopathological examination of the cystic lesion on the left side revealed a 4 to 5 cell layered nonkeratinized epithelium overlying an inflamed connective tissue capsule (A arrowhead). A proliferative hyperplastic epithelium in an arcading pattern was noted in many areas under the influence of an intense juxtaepithelial inflammatory infiltrate (A arrows and B). The lesion on the right side demonstrated a thin nonkeratinized stratified squamous epithelium with many hyperplastic areas and a connective tissue with chronic inflammatory cell infiltrate (C). The findings were suggestive of inflammatory follicular cyst on either side.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2650_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2650_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..15d7ed73b19a462fcfccab8c29979204532c5b70
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2650_en.txt
@@ -0,0 +1,8 @@
+A 14-year-old White Italian boy came to our Emergency Unit with a headache that had worsened over 20 days together with blurred vision and diplopia over the previous 10 days. His past history was negative for significant morbidities. He reported a recent episode of fever associated with cough, which coincided with the onset of headache. For this respiratory infection he had started taking levofloxacin 500 mg once a day one week before coming to our attention but had stopped taking it after three days due to worsening headache. This headache was initially associated with daytime somnolence, myalgia and arthralgia. The somnolence and arthralgia underwent rapid and spontaneous regression, with subsequent appearance of blurred vision.
+The physical examination revealed an alert adolescent with weight of 66 kg (75th -90th percentile) , height of 169 cm (50th–75th percentile) and body mass (BMI) of 23.1 kg/m2 (85th–95th percentile) . The general examination was normal. The neurological examination was normal except for a right eye abduction deficit. Eye examination showed a normal visual acuity (10/10) in both eyes with normal colour vision and pupillary light responses, but a fundus examination revealed severe bilateral papilloedema with elevated disc, hyperaemia, blurred margins and vessel tortuosity in both eyes . Lancaster red-green test confirmed a right abducens nerve palsy, and campimetry showed a restricted visual field with external right muscle deficiency on the right side. Cranial neuroimaging (CT and MRI) showed a normal brain parenchyma with no evidence of hydrocephalus, mass, structural lesion, or abnormal meningeal enhancement. MRI neuroimaging showed oedema of both optic nerves with a tapered appearance of the right optic nerve. Venography was not performed, but an angio-MRI of the cerebral circulation was normal. Visual evoked cortical potentials were normal. A 24-h Ambulatory Blood Pressure Monitoring was negative.
+Blood tests showed high M. pneumoniae IgM (15.00 AU/ml, normal range 0–9) and normal M. pneumoniae IgG levels (3.89 AU/ml, normal range 0–9) suggesting a recent infection, with normal white blood cell indices and negative C-reactive protein. Clarithromycin was then prescribed for 14 days without any adverse effects.
+Serological screening for Coxsackie, Parvovirus, ECHO virus, Adenovirus, Cytomegalovirus (CMV), Epstein-Barr Virus (EBV), Herpes Simplex Virus 1 (HSV1), and Herpes Simplex Virus 2 (HSV2) excluded recent infections. Thyroid function was normal. Antinuclear antibodies (ANA), anti-double stranded DNA (dsDNA), ENA screening and rheumatoid factor were negative.
+During hospitalisation we observed a complete and spontaneous regression of headache and an initial spontaneous reduction in diplopia within a few days. Oral prednisone 50 mg/day (0.75 mg/kg/day) was administered for a week and ocular fundus was monitored.
+Since severe bilateral papilloedema persisted one week after the first assessment, lumbar puncture was performed with the patient sedated and relaxed in lateral recumbent position. Opening cerebrospinal fluid (CSF) pressure measured with a standard manometer was 20 cm H2O and closing pressure was 19 cm H2O. These CSF pressure values have traditionally been considered borderline, but are within normal range according to a recent study in children .
+CSF biochemical tests and cultures were negative. HSV1, HSV2, VZV, HHV6, CMV, Neisseria, Haemophilus, Streptococcus pneumoniae, Streptococcus B group, Escherichia coli, Listeria and Cryptococcus neoformans, Parvovirus, Adenovirus, EBV DNA and Enterovirus and Parechovirus RNA PCR were negative. CSF oligoclonal bands were absent on CSF and blood tests.
+Oral acetazolamide (1 g divided twice daily) was introduced to accelerate recovery. A gradual further improvement in diplopia was seen during hospitalisation . Ophthalmological, neurological and neurosurgical follow up was continued after discharge. The patient gradually improved, with complete resolution of the right abducens nerve palsy in one month and resolution of papilloedema in three months . For this reason, acetazolamide was gradually reduced and stopped on resolution of the papilloedema (see Additional file ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2662_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2662_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5d520a12f92221688624b2a904292735b320dd95
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2662_en.txt
@@ -0,0 +1,2 @@
+A healthy 23-year-old Asian man presented with sudden onset of diplopia followed by left-sided facial asymmetry for 3 days. On examination, he appeared well orientated without impaired cognition. Visual acuity and color vision was normal. Bilateral pupils were 3 mm equal and reactive to light with an absent relative afferent pupillary defect. Assessment of extraocular movement revealed a complete left conjugate horizontal gaze palsy. Upon right gaze, there was limited left eye adduction and horizontal nystagmus of the right eye upon abduction . The impaired extraocular movement was not corrected by oculocephalic reflex. Prism cover test (PCT) revealed left esotropia of 30 prism diopters (PD). There was no ptosis and convergence was normal. Fundus examination was unremarkable. Cranial nerve examination showed left lower motor neuron facial nerve palsy, as demonstrated by the inability to wrinkle left frontalis, left lagophthalmos, and shallow nasolabial folds . Other neurological examinations were normal.
+Brain magnetic resonance imaging (MRI) was done and showed multifocal T2 fluid attenuated inversion recovery (FLAIR) hyperintense lesions without restricted diffusion, involving bilateral periventricular, juxtacortical, and infratentorial regions, which includes left pontine tegmentum . A focal gadolinium-enhanced lesion with an open ring sign was seen at left frontal juxtacortical. A diagnosis of MS was made on our patient’s first presentation based on his MRI brain findings, which fulfilled the latest McDonald criteria (2017). Cerebrospinal fluid (CSF) investigation revealed positive oligoclonal bands, which further confirmed our diagnosis. Pulsed steroid therapy was commenced, and his symptoms completely resolved after 1 month. He was subsequently placed on maintenance therapy with interferon beta-1a and followed up by our neuro-medical team.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2670_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2670_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d1fe69c8b0bd81f744d2ce7261d0d65426101ffb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2670_en.txt
@@ -0,0 +1,4 @@
+A 55-year-old male patient with a medical history of systemic arterial hypertension was admitted to the neuroemergency department, after being transferred from another service, with a report of sudden, intense thunderstorm headache, associated with the left eyelid ptosis and diplopia. During the neurological examination, the patient was awake, lucid, and oriented. He had complete palsy of the left oculomotor nerve, with no other focal neurological deficits. Neck stiffness was present.
+Cranial CT performed on the day following the headache showed no SAH, but showed an expansive process in the sella turcica associated with sellar enlargement . SAH was then confirmed by lumbar puncture (Fisher I). A cranial angio-CT was made and revealed an intradural saccular aneurysm in the cavernous segment of the left internal carotid artery (ICA) .
+The patient underwent cranial microsurgery for cerebral aneurysm clipping that confirmed the intradural location of the aneurysm, arising from a tortuous cavernous ICA .
+He underwent control cerebral angiography on the 2nd postoperative day that demonstrated complete aneurysm occlusion , with no residual neck and no vasospasm and complemented the study with magnetic resonance imaging (MRI) of the sella turcica that was consistent of pituitary macroadenoma with apoplexy . He was discharged on the 21st day after the hemorrhage, maintaining complete left oculomotor nerve dysfunction, but with no other complaints and no neurological deficits.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_269_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_269_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8468d5df3d5880f9b9eb94c3c60f88d93cd08fa2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_269_en.txt
@@ -0,0 +1 @@
+A 53-year-old female was admitted to our institute with a sudden severe headache, accompanied by nausea and vomiting with a slight left hemiparesis. There was no history of traumatic events, infectious or inflammatory diseases, hypertension, or other cardiovascular disorders. The results of the routine hematologic tests showed indices within normal limits. The computed tomography (CT) scan of the head showed subarachnoid hemorrhage (SAH) in the left sylvian fissure and intracerebral hemorrhage (ICH), measured 22 mm × 26 mm, in the left posterior parietal area . The CT angiography (CTA) reconstructed with 3D imaging software showed a small saccular aneurysm in the M4 segment in proximity of the angular area . No digital subtraction angiography (DSA) was performed. Due to a sudden decreased level of consciousness, the emergency surgery was necessary. A left parieto-temporal craniotomy was performed. Through the use of neuronavigation it was possible to locate the ICH and the aneurysm. Under microscopic vision, a small corticotomy was made and the ICH was gently evacuated. A small saccular aneurysm was found. Before clipping, the indocyanine green videoangiography (ICGV) was used to identify the perforating arteries close to the aneurysm sac, and to detect the neck. The aneurysm neck was clipped with a mini-clip and the aneurysm sac was coagulated with a bipolar forceps. After clipping, the ICGV showed the patency of all efferent and afferent arteries to the aneurysm and confirmed the aneurysm exclusion. The postoperative CTA showed neither residual aneurysm nor occlusion of the parent vessel . The motor deficit was progressively recovered and the patient was discharged on the 20th postoperative day without complications. At 3-month follow-up examination, the patient was asymptomatic and feeling well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2701_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2701_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d3ff7ee9775984a7bcdf2932a9647ba88884f807
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2701_en.txt
@@ -0,0 +1,13 @@
+Routine ultrasound found a left hepatic mass with multiple hepatic cysts.
+A 56-year-old female was admitted to our hospital after a mass in the liver was detected by routine ultrasonographic examination a month prior, with a chief complaint of occasional abdominal distension.
+The patient was diagnosed with hypertension at 51 years old and reported no history of hepatitis, tuberculosis, or AIDS.
+The patient reported no family history of liver malignancy or hepatitis.
+The patient exhibited stable vital signs, and no issues were detected following a physical examination.
+Tumor marker tests used can be seen in Table .
+An abdominal CT scan showed a slightly low-density mass at the junction of the left and right lobes of the liver, existing behind multiple scattered, hypoattenuating, and round lesions with clear boundaries. Portal venous phase CT showed the lesion with progressive heterogeneous enhancement . An abdominal MRI identified a hypo-vascular mass at the junction of the left and right lobes of the liver with multiple hepatic cysts of various sizes, which could not be ruled out as malignant . Imaging diagnoses of hemangioma, angiomyolipoma, hemangiosarcoma, and hepatocellular adenoma were considered but dismissed. Moreover, computer tomography (CT) also showed multiple enlarged lymph nodes in the mediastinum, who presented in uniform density without the signs of calcification and necrosis.
+The primary diagnoses are primary hepatic neoplasm and simple hepatic cysts.
+The patient underwent a left hemihepatectomy to remove the tumorous lesion in segment 4 of the liver, without any other unique perioperative treatments.
+The hepatic specimen from the resection was 17 cm × 12.5 cm × 7 cm in size and contained a tumorous lesion of the size of 5.5 cm × 5 cm × 4.7 cm. The cut surface of the specimen showed a hard gray-reddish tumorous lesion within the soft gray-yellowish hepatic tissues. Additionally, numerous cystic cavities were observed in the liver, with the largest one being 2 cm × 1.8 cm × 1.5 cm in size with clear fluid inside.
+Routine pathological examination of H&E tissue staining showed that the hepatic tumor cells were oval and spindle and were distributed around the hepatic blood vessels in concentric circles, without degenerative stromal changes, such as fibrosis, hyalinization, or myxoid changes; mitotic figures; tumor necrosis; or vascular invasion being observed . The blood vessels were branched, just like those in hemangiopericytoma. Meanwhile, a plurality of cystic cavities lined with single cuboidal epithelium could be seen below the liver capsule . Immunohistochemical staining showed that the spindle cells expressed SMA and H-caldesmon but did not detect the expressions of Bcl-2, CD34, S-100, Desmin, HHV-8, CD117, Dog-1, CD21, CD23, CD1a, CgA, Syn, HMB45, and MelenA. The Ki-67 index was low (about 1%). EBER in situ hybridization was performed, and the spindle tumor cells were negative.
+Gene + OncoFusion tumor gene-fusion RNA examination with 555 gene fusions revealed the presence of PDGFRB mutations but not of SRF-RELA gene fusions. Overall, the gene fusion RNA examination did not unveil any common gene mutations or arrangements on the genes, including common mutations in genes related to malignancy or myopericytoma, such as PRKCSH, SEC63, LRP5, ALG8, and SEC61, or common germline mutations associated with autosomal dominant polycystic liver disease (ADPLD) .
+No recurrence or metastasis was observed, and the enlarged mediastinal lymph node remained unchanged within the subsequent 29 months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_270_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_270_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4625f6f0f886ffdb7ee838a8fb2ea5e858d0b70e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_270_en.txt
@@ -0,0 +1,8 @@
+A 58-year-old Caucasian male presented to the emergency department with worsening exertional dyspnoea for 1 year and generalized body swelling for 4 months. The swelling started from lower extremities and slowly became anasarca. The review of systems was pertinent for fatigue, weakness, orthopnea, and paroxysmal nocturnal dyspnoea and negative for chest pain, cough, sputum, or syncope.
+The previous history was negative for any co-morbidities or home medications. The social history was negative for nicotine or substance use disorders and positive for alcohol use disorder with eight beers a day for 30 years. The patient was living alone and working at a construction company, however, denied exposure to particles like asbestos etc.
+Upon presentation, the vital signs revealed blood pressure of 123/76 mmHg, heart rate of 94 beats per minute, respiratory rate of 24 per minute, and oxygen saturation of 90% while the patient was breathing ambient air. The physical examination showed raised jugular venous pressure (JVP), normal S1 and S2, and generalized anasarca. The pulmonary examination revealed decreased breath sounds and bilateral crackles. The focused exam for CTD including lymphadenopathy, rash, ulcers, hair loss, joint swelling, etc. was negative.
+In a patient with new-onset congestive heart failure (HF), the differential diagnosis of the acute coronary syndrome, cardiomyopathies including but not limited to alcoholic, constrictive vs. restrictive, thyrotoxicosis, hypertension, and valvular heart disease should be considered.
+The laboratory data were within normal limits except for elevated brain natriuretic peptide levels of 274 pg/mL (reference range <100 pg/mL). The electrocardiogram was unremarkable while the chest radiography (CXR) revealed increased cardiac silhouette, pulmonary vascular congestion, and bilateral pleural effusions. The CXR also showed a bright layer surrounding the heart, suggestive of calcified pericardium . The computerized tomography confirmed the presence of calcified pericardium with thickness up to 23 mm .
+The patient was started on oxygen supplementation and diuretic therapy with partial improvement of the symptoms. Further investigation with a transthoracic echocardiogram (TTE) revealed classical features of CP. The ejection fraction was normal along with bi-atrial enlargement (see , ). The parasternal long-axis M-mode revealed rapid expansion and sudden diastolic flattening of the inferolateral wall due to thickened pericardium outside and septal bounce secondary to interventricular dependence (IVD) . There was increased respiratory atrioventricular valve inflow variation due to intracardiac and intrathoracic pressure dissociations and IVD . The inferior vena cava was dilated along with diastolic expiratory hepatic Doppler flow reversal due to the right sided septal bounce (see , ).
+Upon tissue Doppler, the septal e’ was more than 8 cm/s and more than the lateral e’ consistent with annulus reversus . On invasive evaluation with right heart catheterization, the right atrial pressure tracing showed Friedrich’s sign with a prominent ‘y’ descent due to rapid diastolic emptying along with rapid ‘x’ descent . Simultaneous left and right ventricular pressure tracings revealed the ‘Dip and plateau’ or ‘square root’ sign characteristic for rapid early diastolic dip and equalization of diastolic pressures, along with IVD . A thick shell of calcified pericardium with restricted heart motion was evident on fluoroscopy (see , ).
+The case was discussed with cardiothoracic surgery and the plan was made to proceed with pericardiectomy. The patient underwent successful procedure with removal of the calcified pericardium which allowed a significant distensibility of the heart (see , ). The patient had an uneventful recovery and significant improvement in the symptoms. The patient was discharged home on furosemide with close follow-up. The patient’s symptoms were significantly improved at one month follow-up visit.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2721_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2721_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..216908e823d78e0f843f6bc70c3ef4c610c56dd0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2721_en.txt
@@ -0,0 +1 @@
+A 59-year-old lady with a BMI of 27 kg/m2 and no comorbid underwent an open appendicectomy via a Lanz incision for perforated appendicitis. There was a superficial surgical site infection which was treated by dressing followed by secondary suturing. Three years later, she presented to us with an incarcerated incisional hernia. We performed a laparoscopic intraperitoneal onlay mesh (IPOM) repair for her. Intraoperatively, standard port placement was done, followed by adhesiolysis of small bowel segments from the hernia sac. The fascial defect measures 6 cm in the largest dimension . Prior to the mesh fixation, primary fascial closure was done using non-absorbable sutures (Prolene® 0) passed extra-corporeally with the help of an intravenous cannula BD Angiocath™ (14 gauge) instead of a transfascial suture passer. The rest of the procedural steps were the same as a standard laparoscopic IPOM repair. Post-operative recovery was uneventful, and during her follow-up six months later, she has no hernia recurrence or chronic pain.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_273_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_273_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2bbf9b2b98d5ba8bd8fc707e3a06e9c2499a7073
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_273_en.txt
@@ -0,0 +1,4 @@
+An 80-year-old woman was brought to our hospital complaining of fever and difficulty with body movement. Her medical and surgical histories were unremarkable. She had a body temperature of 37.7 °C, blood pressure 147/113 mmHg, heart rate 124 beats/min, and respiration rate 17/min. On physical examination, subcutaneous emphysema was found from the left lower abdomen to the left femoral region. Muscular defense was not found. Blood tests revealed an elevated white blood cell (WBC) count and C-reactive protein (CRP) level, and decreased hemoglobin (Hb) and platelet count. The examination also revealed acute kidney injury. Blood glucose was 137 mg/dL, and HbA1c was 6.4% . On the first day, the sequential organ failure assessment (SOFA) score was 1, and the Quick SOFA score was 0.
+Enhanced computed tomography (CT) showed a thickened wall of the descending colon and retroperitoneal abscess formation in this area. From these findings, penetrating descending colon cancer was suspected . Emphysema was present from the retroperitoneal abscess around the descending colon to the left thigh through the left femoral ring . Lymph node metastasis and distant metastasis were not detected.
+The patient was suspected to have NF due to penetration of descending colon cancer. Left hemicolectomy and open drainage of the left femoral region were performed . A microbiological culture of the abscess revealed the presence of group C β-Streptococcus, Escherichia coli, Prevotella species, and Corynebacterium species. Histopathological findings showed a tumor with a histological type of well-differentiated adenocarcinoma. The tumor had grown through the serosa (T4a), but there was no metastasis to lymph nodes (N0).
+After surgery, the patient received intensive care for sepsis and underwent lavage of the open drainage site. Drainage was insufficient, and so additional open drainage was performed on postoperative day (POD) 1 . After additional drainage, control of focal infection was successful and sepsis was gradually controlled. Follow-up CT on POD 11 showed no residual abscess, and so negative pressure wound therapy was tried. Closure of the drainage site was performed on POD 22, and the patient was transferred to a different hospital on POD 26. She has now achieved 6-month relapse-free survival.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2752_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2752_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5dd50015dca7bf539f04078de208fb7f5f97ac7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2752_en.txt
@@ -0,0 +1,5 @@
+A 59-year-old male with no history of smoking exhibited a slightly increased carcinoembryonic antigen level (5.6 ng/mL) during a health check. Chest computed tomography (CT) revealed a tumor (maximum diameter: 13 mm) in the left lower pulmonary lobe . He was referred to our hospital with suspected left lower lobe lung cancer (cT1bN0M0 stage1A2). CT and three-dimensional CT (3D-CT), which was performed using the Fujifilm Synapse Vincent system (Fujifilm Corporation, Tokyo, Japan), revealed the following anatomical anomalies in the left lung: 1) a displaced B1 + 2 running behind the main pulmonary artery, 2) an anomalous V1 + 2 joining the left inferior pulmonary vein , and 3) hyperlobulation between S1 + 2 and S3 with a completely fused interlobar fissure between S1 + 2 and S6 . 3D-CT also indicated that the interlobar plane between S1 + 2 and S6 ran perpendicular to the cranio-caudal direction because the volume of S1 + 2 was relatively large . Bronchoscopy revealed that three bronchi branched from the left main bronchus .
+We planned VATS for surgical diagnosis and treatment. Hyperlobulation between S1 + 2 and S3 and a fused fissure between S1 + 2 and S6 were observed . At first, we performed non-anatomical wedge resection of the lesion to achieve a rapid pathological diagnosis. The patient was diagnosed with adenocarcinoma, and left lower lobectomy and systematic nodal dissection were performed.
+The major pitfalls that we had to pay attention to during this surgery were as follows: 1) to avoid injuring the displaced B1 + 2 running behind the main pulmonary artery and 2) to avoid cutting the anomalous V1 + 2.
+The inferior pulmonary vein was identified on the posterior side of the hilum, and the anomalous V1 + 2 joined it . To prevent B1 + 2 from being mistaken for B6, we distinguished B1 + 2 from the distal section of B6 on the posterior side . The distal branch of A8 was identified using the interlobar fissure. After A8 was divided, we peeled away the pulmonary artery in the proximal direction to identify A6 and V1 + 2, which ran near A,6 and a branch of V1 + 2, which ran between S1 + 2 and S6 . This branch was used as a landmark when we divided the fissure between S1 + 2 and the inferior lobe. Forceps were passed from the anterior to posterior side between a branch of V1 + 2 and A,6 and the largely fused fissure between S1 + 2 and the inferior lobe was divided using a stapler. After dividing the fissure, A6 and A9 + 10 were identified and divided. The inferior bronchus branched from the left main bronchus at the level of the branches of B3 + B4 + 5 and the displaced B1 + 2, which was located at a more proximal site than normal; therefore, we needed to peel away the bronchus while holding down the pulmonary artery and identified the station 11 lymph nodes. Forceps were passed from the anterior to the posterior side along the station 11 lymph nodes, and the incomplete fissure between S5 and inferior lobe was divided using the stapler. After dividing the fissure, the inferior bronchus was divided, which completed the lobectomy ND2a-2 procedure.
+The operation time was 185 min, and 30 mL intraoperative blood loss occurred. Pathologically, the tumor was diagnosed as an invasive mucinous adenocarcinoma with a maximal diameter of 15 mm, and the pathological stage was p-T1aN0M0 stage I A1. The patient’s postoperative course was uneventful, and he was discharged from hospital 6 days after the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2809_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2809_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1910fda7cd0b5ae76be76621e4724b738a4f20ca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2809_en.txt
@@ -0,0 +1,4 @@
+A 31-year-old woman was sent to the emergency department of a tertiary referral center due to an unknown diagnosis. The patient was feeling nauseous and complained of intensifying pain in the upper left abdominal quadrant.
+The woman was hemodynamically stable. During physical examination, abdominal muscle tension was observed, and there was no rebound tenderness. Ultrasound revealed a mass in the upper left side of the abdomen and a small amount of unclear fluid around the intestines. In the blood test, only leukocytosis of 17.3 × 109/L was abnormal.
+Three weeks earlier, in a regional hospital, she was diagnosed with ectopic pregnancy (7 weeks of gestation) in her left fallopian tube. Left laparoscopic salpingostomy was planned, although salpingectomy was performed due to heavy bleeding. Data on ultrasound findings before surgery was not available. The serum human chorionic gonadotropin (hCG) concentration was not tested. Histological reports showed no chorionic villus, and only several trophoblasts were seen in the surgically removed material. In the past, the woman had had two normal deliveries, pelvic inflammatory disease and one more ectopic pregnancy in her right fallopian tube. Therefore, she underwent laparoscopic right salpingectomy.
+A computed tomography (CT) scan was performed to differentiate the mass found on ultrasound. Abdominal and pelvic CT showed a 68 × 60 × 87 mm heterogenic mass, likely a hematoma, which was below the spleen. Pelvis was filled with hemorrhagic fluid, and the uterus was enlarged. Arterial extravasation was spotted from the lower spleen pole. Conventional angiography of the splenic artery was performed, and extravasation was identified in the region below the spleen. The vessel was embolized (A–E). Due to the unknown origin of the hematoma and the recent history of surgery for ectopic pregnancy, and gynecologist consultation was sought. The gynecologist ordered a urine pregnancy test, which was positive. The serum human chorionic gonadotropin (hCG) concentration was 3363.6 U/L. The clinical case was considered a rare pathology of extratubal secondary trophoblastic tissue reimplantation. As the bleeding was stopped with embolization, a conservative two-dose methotrexate (MTX) treatment protocol with MTX 50 mg per square meter of body surface area intramuscularly (mg/m2 BSA i/m) on day 1 and day 4 was administered. Abdominal pain did not intensify; subjectively, the woman started feeling better. The decrease in serum hCG concentration between days 4 and 7 was 24.1% (i.e., more than 15%); thus, hCG testing was repeated weekly . Menstruation renewed 29 days after the first dose of MTX. Seven months later, the CT scan showed that the size of the heterogenic mass below the spleen decreased to 18 × 14 × 16 mm (F).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2821_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2821_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..191e899e2d7f8c31320f47e8b7d76deb5d9398cb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2821_en.txt
@@ -0,0 +1,5 @@
+Our 54-year-old male Caucasian patient had had a severe car accident at the age of 38. He suffered multiple fractures of the central face. His right eye had to be enucleated and replaced by a prosthesis. The patient underwent multiple surgeries and stayed in the intensive care unit for more than two weeks, and then for several weeks in the hospital. He noticed a complete loss of his sense of smell, which was confirmed in subsequent litigation. The patient reported that he was not able to smell smoke or gas and he could not detect flavor in food and beverages. Consequently, the patient's quality-of-life significantly decreased.
+Approximately nine years after the accident, he reported his first olfactory impression. It was the smell of hay which was perceived during a walk. The ability to smell continually improved over three years, and has stayed constant since then. No specific therapies regarding smell function were given to the patient. Today, he has no problems with his sense of smell and has normal flavor perception during eating and drinking.
+Computed tomography showed patent olfactory clefts, both after the accident, when the patient was anosmic, and 10 years later, when he had regained his olfactory abilities. These images ruled out the presence of obstructions due to sinunasal disease as possible causes of smell dysfunction.
+After complete ear-nose-throat examination including nasal endoscopy, smell function was tested 16 years after the accident using the 'Sniffin' Sticks' test battery . This test has been extensively validated and comprises three subtests: a test of olfactory threshold, an odor discrimination task, and an odor identification test. The patient yielded 28.5 points, which represents a score within the lower normal range .
+In order to confirm the absence of anosmia, evoked-response olfactometry was applied to the patient using an olfactometer (Burghart Instruments, Wedel, Germany). Following stimulation with selective olfactory stimuli (50% v/v phenylethanol), event-related potentials were clearly detectable .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2823_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2823_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..442bea6c225c6f0c96aba7bad0aafbabd0520b44
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2823_en.txt
@@ -0,0 +1,4 @@
+A 7-year-old boy was admitted to the emergency department with a punctured nail in the left mastoid area after he fell off from a tree . The patient was fully conscious with stable vital signs and no neurologic deficit. The patient exhibited a Glasgow Coma Scale (GCS) score of 4-5-6, demonstrating isocoric and reactive pupils with a diameter of 3 mm/3 mm. There was no medical history indicating fainting, vomiting, nausea, or seizure activity.
+A head CT scan reveals a PBI by a foreign nail object in the left mastoid region . The lesion, ±6.5 mm caliber, and ±7 cm length penetrates from the left mastoid, traverses the left cerebellum, and terminates in the right cerebellum . The metal artifact caused blurring in the visualization of critical structures such as the pons, cerebellum, ventricle IV, cisternal systems, and cerebellopontine angle. The lesion, with a depth of approximately ±5.5 cm, entered through the left temporal bone’s mastoid part, traversing the left cerebellum and terminating in the right cerebellum. Furthermore, there was a hyperdense lesion filling the bilateral posterior horns of the lateral ventricles. There was no apparent soft-tissue swelling. The internal carotid arteries and the vertebrobasilar arteries are challenging to assess due to metal artifacts. The visualized CTA of the head appears within normal limits, with no evidence of thrombus, aneurysm, or vascular malformation. The patient received an anti-tetanus and antibiotic. A multidisciplinary team comprising neurosurgeons, otolaryngologists, vascular surgeons, and anesthesiologists performed immediate surgical procedures, including mastoidectomy and retro sigmoid craniotomy. Surgical neurotreatment through craniotomy remains considered the safest approach. A crucial aspect of this procedure involved achieving hemostasis to reduce active bleeding and securely closing the dura to prevent CSF leakage.
+During the surgical procedure, the patient was positioned in the park bench position to enhance access to the surgical site. The incision employed was a Lazy S-shaped postauricular incision, precisely aligned with the entry point of the foreign object. Initial management of the sizable wooden block necessitated meticulous handling, with its gradual removal in segments adhering to stringent sterilization protocols. Preceding patient positioning, electrical sawing was conducted to ensure sterility maintenance. Subsequent to the incision, a layered approach was adopted for mastoidectomy, systematically removing bone until visualization of the foreign object was achieved. Following nail localization, dural closure was effectuated utilizing primary closure techniques.
+The absence of damage to adjacent intracranial tissues underscores the success of this surgical approach. The patient received broad-spectrum anti-tetanus and antibiotic treatment for three months. Following the operation, the patient’s recovery progressed positively, with full restoration of consciousness and no apparent neurological issues.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2827_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2827_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..982129da5708c91cac49ce989718b689c23f68a4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2827_en.txt
@@ -0,0 +1,7 @@
+A 53-year-old caucasian G1P1 otherwise healthy female patient was known for a long history of diffuse right and left colonic diverticular disease, with repeated episodes of abdominal pain due to recurrent diverticulitis.
+She presented to the emergency department at our institution with severe left-lower-quadrant abdominal pain, cramping and anorexia. Physical examination revealed a soft abdomen, with localized left lower quadrant sharp tenderness, guarding and moderate rebound on examination. Abdominal Computed Tomography (CT) scan showed bowel wall thickening and contrast-enhancement along a 45 mm portion of the medium-to-distal sigmoid colon. A marked increase in soft tissue density was also observed within the pericolonic fat, with evidence of a 23 mm paramedian fluid collection in the pre-sacral area. The patient was admitted to the surgical ward and antibiotic coverage was started together with analgesics. Symptoms resolved quickly, she was discharged home a week later with a diagnosis of self-limited diverticular microperforation, and an outpatient follow-up was scheduled for elective surgical planning.
+Four months later, she underwent a laparoscopic sigmoidectomy with a double-stapled colo-rectal transanal anastomosis. Surgery was successful, but on post-operative day 2, the patient developed signs of peritonitis, with pain, fever, and elevated markers of inflammation. After close clinical observation, and careful re-evaluation of the case, on post-operative day-6 a second exploratory laparoscopy was performed. The procedure ruled out an anastomotic leak, as well as no abnormalities were observed at any level within the abdominal cavity. Patient improved post-operatively and was discharged home a week later.
+Nine days after hospital discharge, she presented to the outpatient clinic for a scheduled follow up. A control abdominal plain X-ray was obtained, confirming the stability of her condition. However, looking at the X-ray, the staff surgeon noted a filiform metallic object projected around the midline at the upper abdominal quadrant level (T11-T12). Considering patient’s history, a retained surgical item was strongly suspected, with the wire-like image being potentially consistent with the radiopaque marker of a surgical sponge. In order to clearly establish the nature of this foreign body, at first the surgical dressing was removed, but no superficial radio-opaque material was present. The patient’s medical record was then carefully reviewed. According to her chart, no epidural were ever placed at our institution. Preoperative available x-rays were also analyzed. Focusing on the area where the metallic image was expected, we surprisingly discovered it was visible in every exam including the interested region . At further questioning, the patient recalled an epidural catheter being placed twelve years before, at an outside hospital, during the last trimester of pregnancy. Apparently, at the time, the device was placed to provide analgesia for a painful-rib-syndrome . Particularly, she was experiencing excruciating pain in the upper abdomen-lower chest region, both anteriorly and posteriorly. As the patient’s pain was unresponsive to oral analgesics, the epidural catheter was placed (hence the low-thoracic location), and several cycles of analgesia were provided for about a month prior to labor through an elastomeric pump. The patient described the intervention as beneficial. Interestingly, she also recalled the catheter to be subcutaneously tunneled. After delivery, the pain immediately disappeared, thereby suggesting an association with pregnancy-related changes of the musculoskeletal structure. The epidural was removed in the immediate postpartum.
+After discussion of the case between the anesthesia and surgical teams, including neurosurgical consultation, and considering the will of the patient, the patient was scheduled for urgent surgical removal of the fragment.
+In the operating room, inspecting the skin of the right paravertebral region, a small scar could be observed, with a fibrotic reaction attributable to a foreign body lying just underneath. A looped radio-opaque object with its tip at the T12 level was then seen on intraoperative fluoroscopy. Examining lateral projections, showing most of the catheter to be superficially located, the attending neurosurgeon excluded the need for laminectomy. Under sterile conditions and with the patient in the prone position, local anesthesia was administered and incision of the skin and fascia was performed at the level of the scar. The proximal end of the catheter fragment was isolated about 1 cm below the incision and then carefully removed by slow constant traction.
+A 15 cm fragment of a Flextip Plus 19G wire-reinforced epidural catheter (Arrow-Teleflex, Limerick, PA) was retrieved, with a large uncoiled portion close to its proximal end . The operator verified the black terminal marker indicating tip integrity was present. Surgery was performed without any complication. A fluoroscopic control showed the absence of any metallic residual foreign body, and direct visualization during dissection of the skin confirmed that no portion of the uncoiled portion was left behind.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2839_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2839_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..63e0c4f5d0ead27a35fd9694f0f2b41a78a2d986
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2839_en.txt
@@ -0,0 +1,3 @@
+A 60-year-old female had progressive HV and bunion deformities for many years. Despite increasing pain in the bunion area initially and then the crossover deformity between first and second toes, she could still manage for several years by wearing increasingly more accommodating shoes with wider forefoot region and roomy toe box made of soft materials. Due to her daily required walking activities, she developed thick and painful metatarsal calluses despite wearing mostly thick-soled shoes only. She could hardly tolerate the metatarsalgia of her feet in walking due to the constant feeling of walking on a pebble in her shoes. She found that walking was becoming an exhausting chore to avoid. She felt losing balance easily on uneven ground and walking down stairs. She had fallen several times already. Her mother had also HV deformity but not as severe and she got by without surgery. Physical examination revealed bilateral HV deformity that could only be partially corrected. The passive range of motion of her right foot first MPJ was 45° in both extension and flexion and 60° and 45°, respectively, of her left foot first MPJ. Her right second toe had severe varus deformity that was crossing over the hallux but without any remarkable clawing deformity. Her left second toe varus deformity was not as severe. The second toe varus deformity of her left foot could be manually realigned completely but not her right foot second toe. Both second MPJs were moderately tender and had reduced passive flexion movement due to pain. First metatarsals were hyper mobile in both sagittal and frontal planes. There were large and thick calluses under the forefoot region of both feet . Dorsoplantar standing x-rays of her feet revealed a right foot first intermetatarsal angle (IMA) of 17.5° and metatarsophalangeal angle (MPA) of 33.7° and 16.8° and 27.9°, respectively, of her left foot. IMA and MPA are usually considered normal within their upper limits of 9° and 15°, respectively. All first and second MPJs were incongruent and the right second MPJ subluxated in dorsomedial direction. Both tibial and fibula sesamoids were dissociated from their first metatarsals. Pre-operative walking plantar pressure study by F-Scan (Tekscan, USA) revealed poor weight bearing and reactive force under the first ray and obvious lateral shift of functional area of her forefeet to the second and third metatarsal heads where she had large and thick metatarsal calluses. This patient agreed to undergo a simultaneous bilateral syndesmosis procedure [, ], a non-osteotomy soft tissue technique, for her HV deformity correction and possible additional surgery and pinning if necessary for the varus deformity correction of her second toes.
+An initial one-inch incision was made along the distal dorsal medial border of the second metatarsal. After blunt dissection, the interosseous muscle was retracted laterally and partially resected to help expose the lateral soft tissue structures for the release of the lateral collateral and metatarsosesamoid ligaments. The adductor hallucis tendon was preserved and the fibular sesamoid was not resected. The distal third of the first and second metatarsals was then exposed subperiosteally and roughened in a fish-scale fashion with an osteotome. Three drill holes of 2 mm diameter were made in dorsoplantar direction in the distal half of first metatarsal shaft about 5 mm apart. Double-strand number-onepolydioxanone dissolvable sutures (ETHICON, Johnson & Johnson, USA) were then passed through the drill holes and around the second metatarsal, binding the two together. Intraoperative anteroposterior (AP) view X-ray was then taken to assess the MPV deformity correction and first metatarsal alignment with a needle holder temporarily locking the intermetatarsal cerclage suture before it was tied later. However, to our surprise that, not only the HV and MPV deformities were corrected but also the severe right second toe varus deformity was also mostly corrected spontaneously without any surgical intervention to it yet. The same phenomenon also was happened to her left second toe but with complete spontaneous correction. The residual varus deformity of right foot second toe was then further corrected by capsulorrhaphy and collateral ligaments release of its MPJ. A medial horizontal elliptical incision was then made to remove redundant skin, bursa, capsular tissues, and exostoses. The combined single ligament tendon capsular layer was then approximated with interrupted 2-0 Vicryl sutures (Ethicon, Johnson & Johnson, USA) without plication.
+The patient worea forefoot cast for protected walking for 3months. She was allowed only to return to unrestricted activities and shoes about 6months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2845_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2845_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..055716dbd01e356a56595bba7d7d812838343c7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2845_en.txt
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+Our case is a 4 years and 8-month-old Syrian Arabic girl with a birth weight of 4 kg, who is the sixth of seven siblings born to healthy consanguineous parents. She followed normal psychomotor development and experienced no remarkable illness until the age of 4 years and 2 months when her parents noticed a rapid weight gain (about 1 kg every 10 to 15 days) due to excessive eating (she required six to seven big meals/day). Later, they observed her to have alterations in body secretion (decreased tears when crying, decreased nasal discharge, unfavorable body odor, and decreased sweating) in addition to blue cold extremities, diarrhea alternated with constipation, polyuria, and polydipsia. Two months after the onset of obesity she had urinary incontinence during night sleep. Then, significant behavioral changes developed including: mood alteration, anxiety episodes, rage attacks, nervousness, and aggressive behavior, in addition to recurrent fatigue, social withdrawal, prolonged periods of sleep (12 hours continuously), and difficulty staying awake during the day. These complaints grew to be a serious concern to the family so she was admitted to Damascus Children Hospital, endocrinal department, at the age of 4.5 years, for further investigations.
+For three generations, the family history was negative for similar presentations, obesity, or psychiatric disorders. It was noteworthy that an older sister of our patient had died at the age of 12 years with a diagnosis of acute myeloid leukemia (AML). Her sister’s malignancy was not accompanied by any of the signs or symptoms our patient had.
+On physical examination, general obesity was noticed without striae or altered skin pigmentation. No dysmorphic features were observed, neither were there any minor or major congenital malformations. Her weight was 25 kg (above 97% percentile) while her length and head circumference measured 110 cm (at 90% percentile) and 52 cm respectively. Her body mass index (BMI) was equal to 20.1 .
+An ophthalmic examination revealed left exotropia with normal fundus and normal papillary response. The performed laboratory analyses did not indicate any significant abnormality. Her complete blood count (CBC), blood glucose, sodium (Na), chlorine (Cl), potassium (K), calcium (Ca), alanine aminotransferase (ALT), aspartate aminotransferase (AST), triglycerides (TG), cholesterol, urine density, creatinine, and urea were all within normal limits. Her thyroid-stimulating hormone (TSH), free thyroxine (T4), morning cortisol, adrenocorticotropic hormone (ACTH), prolactin, growth hormone (GH), insulin-like growth factor-1 (IGF1), follicle-stimulating hormone (FSH), and luteinizing hormone (LH) were also within normal limits.
+Her abdominal and pelvic ultrasound was normal. Her bone age was slightly advanced and it fitted 5 to 5.5 years old. Brain magnetic resonance imaging (MRI) was normal; it showed no cortical atrophy. A homogenous mild enlargement of her pituitary gland was observed on both T1-weighted and T2-weighted images with normal hyperintense posterior lobe on T1-weighted images .
+Since the endocrine function tests were normal, her symptoms had been explained on the basis of psychotropic origin, and she was discharged with antipsychotic medication (risperidone 1 mg orally per day) and the recommendation to follow up at the out-patient psychiatric clinic after 3 months of prescribed treatment. After 3 months of discharge, when she was 4 years and 8 months old, she developed dyspnea that worsened with exertion and during sleep, continuous snoring, and recurrent chest pain. The respiratory symptoms lasted for 5 days after which she had two episodes of cyanosis and obstructive apnea which lasted for 10 minutes with improvement via oxygen mask. As a result of progressive respiratory distress (respiratory rate 35/min, expiratory grunting, flaring of nostrils, wheezing with prolonged expiration, and remarkably loud snoring) she was readmitted to Damascus Children Hospital, intensive care unit (ICU). Investigations showed hypoxemia, hypercapnia, and respiratory acidosis accompanied by radiological evidence of a big round opacity in her right lung .
+She was intubated 24 hours after admission and attached to a mechanical ventilator because of severe respiratory distress with altered consciousness: blood gases were pH 7.27, partial pressure of carbon dioxide (PaCO2) 79 mmHg, partial pressure of oxygen (PaO2) 38 mmHg, and oxygen saturation 79%. Her laboratory results were within normal limits except for elevated values of Na (up to 162) and C-reactive protein (77 mg/L). During this admission, her weight was recorded as 40 kg (>97th percentile).
+A chest computed tomography (CT) scan demonstrated a 6 cm round mass filling most of her right lung and pushing her heart and mediastinum to the left with infiltration and consolidation of the right lower lobe of her right lung .
+Subsequently, when her health stabilized, a complete resection was performed of a 10×10 cm solid round mass from the posterior wall of her chest. It was a mature ganglioneuroma .
+Her unexplained rapid gain of weight and the presence of chest ganglioneuroma brought attention to ROHAAD syndrome as a diagnosis of her situation and helped to exclude other illnesses that could be considered in the differential diagnosis. Familial obesity and Prader–Willi syndrome were both excluded since her family history did not support the first, and with the absence of mental retardation and congenital abnormalities there was no indication to investigate the latter.
+A good improvement in consciousness was achieved by stopping sedative drugs, so she was able to speak, move her limbs, and interact with others. Nevertheless, she required prolonged ventilation because of respiratory instability and she had myoclonic seizures. Three attempts at extubation failed without a clear reason. A brain MRI was ordered which revealed a generalized cortical atrophy of her brain with the same mild pituitary gland enlargement observed in a previous MRI .
+A month after her admission to the ICU, a tracheostomy was performed because of lack of spontaneous breathing. One week later, she had cardiorespiratory arrest and died. A timeline of her signs and symptoms is shown in Fig. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_285_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_285_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f2b3aa3b4daa7b13c758f44798bc2d2b2ce5e631
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_285_en.txt
@@ -0,0 +1,7 @@
+A 26-year-old Asian man was transported to the emergency department via ambulance due to bilateral lower limb weakness. He had no relevant medical history except for a diagnosis of aseptic meningitis more than 10 years ago without sequelae. The patient was a construction worker who performed heavy labor. He stated that he had suffered from intermittent muscle cramping over the right shoulder radiating to back for a week, and he visited a local traditional medicine practitioner a day before the emergency department visit. Non-steroidal anti-inflammatory drugs and another unknown agent were injected. The muscle cramping improved before he slept. However, acute limb weakness occurred after the patient woke up in the morning. He had difficulty standing and fell, resulting in upper limb contusions.
+Upon arrival at our emergency department, the tympanic membrane temperature was 38.1°C, with normotension and no other abnormalities in vital signs. In addition, a review of the system showed no loss of consciousness, limb or trunk pain, upper respiratory symptoms, vomiting, diarrhea, or heavy sweating. He had no regular consumption of alcohol or smoking habits, and his family history included only hypertension and diabetes mellitus of his grandparents, without diseases related to hypokalemia or muscle weakness.
+The patient was oriented with a good mental health status and appeared to be well nourished. Physical examination showed decreased muscle power of the bilateral lower limbs, mainly proximal, and both scored 2/5, which progressed to 1/5. The deep tendon reflex of the bilateral knees and sensation of the lower limbs were intact, and the muscle power of the upper limbs was not affected. There was also no Babinski sign elicited on either side. Blood tests, including complete cell count, blood sugar, and a biochemical panel, were normal, except for white blood cells (10,800/μL), potassium (1.7 mEq/L), and creatine phosphokinase (178 U/L). Urinalysis was normal. However, electrocardiogram showed a flattened T wave and exhibited U waves in the precordial leads V1–V3.
+Oral and intravenous potassium supplements with 40 mEq was administered, and the serum potassium level result was still 2.0 mEq/L the following morning. We then administered another 60 mEq of potassium, and upon assessment, the muscle power of the patient’s bilateral lower limbs improved in the afternoon (4/5). He was admitted to the ward and was administered an additional 20 mEq of intravenous potassium (a total of 120 mEq since the emergency department); hypokalemia resolved (serum potassium 4.0 mEq/L), and the patient could walk steadily. Because his paralysis improved rapidly after hypokalemia correction and myopathies were less likely, electromyography was not done during admission.
+The urinary potassium excretion of the patient was low (urine potassium/creatinine ratio is 1.5 mmol/mmol) and there was no evidence of potassium loss from gastrointestinal tract. He also denied potassium-shifting or potassium-wasting medication use, such as insulin, beta-agonists, thyroxine, or diuretics. The levels of serum aldosterone (109.5 pg/mL), renin (34.98 pg/mL), and free T4 (1.14 ng/dL) were borderline normal; however, elevated levels of serum thyroid stimulating hormone (TSH) (5.91 uIU/mL) were noted. Arterial blood gas analysis was normal. Hypokalemic periodic paralysis was considered as the clinical impression because of rapid normalization of potassium levels and improvement of weakness. However, the patient did not receive further genetic tests due to personal reasons.
+Furthermore, the patient denied having much carbohydrate-rich food intake or strenuous exercise before the attack. His family contacted the local clinic which disclosed that it had administered 5 mg dexamethasone through intramuscular injection. His serum cortisol level was <1.00 μg/dL and 4.39 μg/dL at 2 and 4 days after the injection, respectively. The final diagnosis was HPP of the non-familial type, suspected to be induced by dexamethasone injection. Finally, he was discharged without further sequela.
+One year later, he came back to our emergency department due to hypokalemia-induced paralysis after eating a big carbohydrate-rich meal. We advised him to avoid using corticosteroids and eating carbohydrate-rich food.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2862_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2862_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f13f681d3c8b6a03c7f961fa1263ecaa576b6297
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2862_en.txt
@@ -0,0 +1,11 @@
+The patient is a 17 year old boy with a history of a congenital vesicoureteral reflux and other congenital abnormalities of kidney and urinary tract (CAKUT) which gradually caused nephrosclerosis, secondary hypertension and chronic kidney disease (CKD). In April, 2019 he started peritoneal dialysis (PD) because of CKD stage 5. In June, 2019 he received a deceased donor kidney transplant (from a 58 year old female, cause of death – intracerebral hemorrhage. CMV +, EBV +, hepatitis markers – negative, CMV donor + /recipient –). Before KTx induction therapy consisted of Basiliximab – interleukin 2 receptor antibody (IL2Ra) 20 mg IV, mycophenolate mofetil (MMF) 750 mg PO and tacrolimus 3 mg PO. Intraoperatively methylprednisolone 500 mg IV was administered. After KTx patient underwent maintenance therapy with tacrolimus 3 mg PO once daily (o.d.), MMF 750 mg PO twice daily, methylprednisolone 48 mg PO Prophylaxis for Cytomegalovirus (CMV) with valganciclovir 450 mg PO for 6 months as high risk and prophylaxis for Pneumocystis jirovecii TMPSMX 80/400 mg PO was given for 3 months (up to September, 2019). Additionally, patient received treatment with antihypertensives and anticoagulants.
+The post-transplant period was mostly uncomplicated with good diuresis, patient had no rejection episodes. Tacrolimus, other immunosuppressant and antihypertensive treatment was tailored a few times in order to achieve either required drug serum concentrations or clinical efficacy, graft function was relatively stable, eGFR ranging from 44,1 to 51,4 mL/min/1.73m². Darbopoetin alfa 20 μg once every two weeks s/c and folic acid was started due to secondary anemia and continued for 6 months. In July, 2019 the first graft biopsy was performed due to proteinuria and poorly controlled hypertension. Results showed focal mesangioproliferative changes without immunoreactant deposition. Immunosuppresive treatment with tacrolimus and antihypertensive treatment was intensified
+In September, 2019 the patient was hospitalised due to leukopenia, neutropenia, diarrhea, loss of apetite. His blood tests showed elevated CMV viremia (up to 8811 copies/ml, while on previous outpatient visits no viremia was detected). MMF was discontinued and valgancivlovir dose was increased up to 450 mg twice daily, for 2 weeks until viral load became undetectable. Patient had fungal toenail infection, topical terbinafine and naftifine were prescribed. Valganciclocvir was discontinued in December, 2019, after completion of 6 months of post-KTx prophylaxis. The last outpatient visit was 12 days before the case of PCP. During the visit the patient had no complaints, his physical examination was unremarkable, graft function was stable with eGFR of 41,4 mL/min/1.73m² and low CMV viremia of 25 copies/ml (which was below the significant threshold). His immunosuppressive regimen consisted of tacrolimus 6 mg PO o.d., methylprednisolone 8 mg PO o.d. and MMF 500 mg PO twice daily and were not tailored recently.
+At the end of June, 2020 patient was admitted to the hospital due to the subfebrile temperature, dry cough, shortness of breath for about 1 week and general fatigue for more than 3 weeks during physical activity. Important to note that additional information about earlier onset of patient’s complaints was explicated only after the patient was hospitalized, because at last outpatient visit they did not inform about complaints of fatigue. Patient also lost 4 kg down to 46 kg of weight in the last month. On physical examination the patient was tachycardic (HR – 128 bpm), oxygen saturation (SpO2) was 89% and a subfebrile temperature of 37.2oC. Patient required 2–3 L/min of oxygen to maintain oxygen saturation above 92%. Blood pressure (BP) was 124/80mmHg. There was a reddish, dry maculopapular rash on the upper side of the trunk and around the neck and signs of toenail fungus were seen. Lung auscultation was normal. PCR tests for SARS-CoV-2 from nasopharyngeal swabs were negative twice. No other remarkable findings.
+Initial laboratory tests showed decreasing eGFR down to 32 mL/min/1.73m². C-reactive protein (CRP) was elevated – 79.2 mg/l, tacrolimus concentration – 5.7 ng/ml. Complete blood count, albumin, liver enzymes and electrolytes were normal (laboratory tests are presented in ). Tuberculosis was excluded with both negative Tuberculin skin test (TST) and Interferon-gamma release assay. Atypical bacterial infections were excluded with negative serological testing and negative nasopharyngeal swab PCR. Blood culture was taken. Both EBV and CMV blood tests for PGR were taken and CMV viremia was present at 51 copies/ml.
+Chest radiograph revealed fine bilateral interstitial infiltrates with interstitial edema.
+Immunosupressive and antihypertensive treatment was initially unchanged. Topical antifungal treatment was prescribed for suspected fungal etiology of toenail and skin lesions while microbiological tests were ongoing. O2 flow through face mask of 2 l/min was continued.
+Chest CT scan showed bilateral ground glass opacities, pneumatoceles in basal segments and diffuse varying in size centrilobular and peribronchovascular consolidation foci.
+On the second day of hospitalisation, while the workup was still in process and bronchoscopy for acquisition of BALF was in line, patient’s condition deteriorated, resulting in increased breathing rate, dyspnea and supplemental oxygen demand of up to 12 l/min in order to keep SpO2 ≥92%. It was followed by a decrease of kidney function down to eGFR of 27,1 mL/min/1.73m². Patient was empirically started on TMP-SMX 320 mg IV o.d., Fluconasole 100 mg IV o.d., Sol. Ganciclovir 115mg IV o.d. MMF dose was reduced to 250 mg twice daily, which was later temporarily discontinued. A bronchoscopy was performed and a BALF sample tested positive for P. jirovecii. CMV (3575 copies/ml) and EBV (70000 copies/ml) were detected too. In addition, immunoglobulin G (IgG) was found to be significantly lower – 2,16 g/l, so an IV infusion of 20g IgG was administered.
+Over the next days the patient’s condition improved, with a reduction of O2 therapy and a gradual resolution of symptoms – patient reported no fatigue, better general well-being and only occasional coughing. Slight improvement in kidney function was observed with eGFR of 30,9 mL/min/1.73m² and patient was discharged 2 and a half weeks later after he received IV TMP-SMX for 18 days, and IV ganciclovir for 1 week. Later valganciclovir PO was continued for a total of 1 month and TMP-SMX at a lower dose of 480 mg PO was continued for 3 months in total.
+At follow-up his condition has progressively improved, with no signs of infection or respiratory distress, with a markedly improved kidney function and normal inflammation markers as seen in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2884_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2884_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bcd0ae835d8d2f0aeb21debdcab49a786cd1bf64
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2884_en.txt
@@ -0,0 +1,4 @@
+A 26-year-old woman had bilateral sensorineural deafness since birth and tonic-clonic seizure 1 month after birth. Her laboratory examination showed severe hypocalcemia and hyperphosphatemia, and serum iPTH levels were undetectable. She was diagnosed with congenital hypoparathyroidism, following which oral vitamin D supplementation was initiated. In, 20XX-5, calcification in bilateral kidneys was detected on abdominal ultrasonography, indicating renal dysfunction (serum creatinine level, 0.8–1.1 mg/dL).
+Subsequently, she consulted our institute in October 20XX; the laboratory examination revealed her urine calcium/creatinine (Ca/Cr) ratio was 0.25 and serum iPTH level was 0.2 pg/mL. Abdominal CT revealed severe nephrocalcinosis . Arterial blood gas analysis was unremarkable and tubular acidosis was not indicated. The urine calcium level was adjusted; her urine Ca/Cr ratio was controlled between 0.2 and 0.3. However, her renal calcification persisted. Thereafter, her renal dysfunction rapidly progressed and she was started on dialysis in February 2013, and LDKT was simultaneously planned. In June 20XX + 1, GATA3 mutation was confirmed by genetic analysis, and she was diagnosed with HDR syndrome.
+In January 20XX + 7, ABO-incompatible LDKT was performed. The donor was her mother, who did not have GATA3 mutation. She received double filtration plasmapheresis, plasma exchange, and immunosuppressive regimen, including cyclosporine, mycophenolate mofetil, prednisone, and basiliximab. Rituximab was also administered twice on the day and two weeks before LDKT.
+After LDKT, her serum creatinine level continued to decrease . Her serum and urine calcium level was maintained at a normal range (urine Ca/Cr ratio ≤0.1). Her graft function was fine (serum creatinine 0.9–1.0 mg/dL), and graft calcification was not observed 1 year after LDKT .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2895_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2895_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..12259abc32c7af3093670fe4dedaf1301a2265c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2895_en.txt
@@ -0,0 +1,6 @@
+A 49-year-old female with a body mass index of 17 kg/m2 presented for pathological fracture of right femoral bone head with metastatic adenocarcinoma and was scheduled to undergo bone tumor resection and artificial bone replacement. She was diagnosed with Osler-Weber-Rendu syndrome at the age of 30 and accompanied with multiple pulmonary arteriovenous malformations (AVMs) and pheochromocytoma. She had a history of brain abscess, takotsubo cardiomyopathy and preoperative coil embolization of the AVMs. She did not have any history of recurrent epistaxis or gastrointestinal bleeding.
+A preoperative physical examination did not reveal any special finding on her body surface. Blood pressure was 105/64 mmHg, with doxazosin at a dose of 3 mg per day, and heart rate was 97 bpm. Peripheral oxygen saturation (SpO2) was 86% in room air, possibly due to the remaining pulmonary AVMs, but the Hugh-Jones classification was class I. Blood tests were remarkable only for hemoglobin level of 11.2 g/dL. Urinary adrenaline, noradrenaline and dopamine levels were 14.2 mcg/day, 965.8 mcg/day and 807.3 mcg/day, respectively. An electrocardiogram (ECG) showed negative T-waves on V3-5 and a transthoracic echocardiogram showed a peripheral left ventricle hypertrophy with an ejection fraction of 67%. Preoperative image examination revealed bilateral pulmonary AVMs , but no AVM in the brain or in the spinal cord, and a pancreas tail tumor, which was considered to be the origin of the metastatic bone tumor.
+Preoperative estimation of the operation duration was 5 h, and estimated intraoperative blood loss was 500 mL. She was in anxiety and wished to have sedation during the procedure.
+Combined spinal and epidural anesthesia was planned in order to reduce the risk of rupture of the pulmonary AVMs due to inadequate pain control and positive pressure mechanical ventilation. We planned to add sedation by general anesthesia with a supraglottic airway device (SGA) to maintain spontaneous ventilation because of the estimated long duration of surgery, her mental status and large amount of blood loss.
+After entering the operating room, a peripheral venous line was secured, and a pericapsular nerve group block was performed using 20 mL of 1% lidocaine in order to relieve the pain of transferring between beds in the operating room and of positioning for spinal and epidural anesthesia . Then the patient was positioned laterally on the left side, an epidural catheter was inserted at the L2-3 lumbar intervertebral space, and spinal anesthesia was performed at the L3-4 lumbar intervertebral space using 3.3 mL of 0.5% isobaric bupivacaine. After changing to the supine position and confirming Th10 or lower levels of the block, SGA device (Air-Q®, Cookgas LLC, USA) was inserted with 50 mg propofol and 75 mcg fentanyl, and spontaneous breathing was maintained with concentrations of 1.0–1.5% sevoflurane. Under sedation, a central venous line and an arterial line were secured, and processed regional cerebral oxygen saturation (rSO2) was monitored in addition to standard monitoring including 5-lead ECG, pulse oximetry and capnography. Although no major blood pressure changes were observed during induction of anesthesia, her systolic blood pressure fluctuated in the range of 70 to 220 mmHg during the operation, necessitating frequent boluses of phentolamine and nicardipine. Her SpO2 and rSO2 were stable in the range of 89–92% and 55–60%, respectively, under a fraction of inspired oxygen of 0.3. Neither positive end-expiratory pressure nor pressure support was applied, and respiratory rate of spontaneous breathing was 20–30 per minute with expired carbon dioxide concentration of 30–38 mmHg during the procedure. There was no difficulty or trouble in managing her airway with an SGA device in the lateral position. No epidural local anesthetic agent was required, and the total amounts of fentanyl used during the procedure was 300 mcg. The surgery was competed in 170 min and the total amount of hemorrhage was 630 mL. A total of 1953 mL of Ringer’s solution and 4 units of red blood cells were administered during the procedure with 630 mL of urine output. After confirming emergence from anesthesia without a new neurological abnormality, the SGA device was removed in the operating room.
+After the operation, she was transferred to the intensive care unit (ICU) as planned. Her pain was well controlled with patient-controlled epidural analgesia. Her postoperative course was uneventful, and she was discharged from the ICU on postoperative day 1.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2903_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2903_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5bd2a742ee7b4010b8e338a9218c8451c80cb9cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2903_en.txt
@@ -0,0 +1 @@
+A 71-year-old Japanese man came to our hospital with a chief complaint of hematuria. Diagnosis of muscle invasive bladder cancer without distant metastases was confirmed after imaging tests and transurethral resection of bladder tumor (TURBT). He underwent radical cystectomy and pelvic lymph node dissection; an ileal conduit was also constructed. Microscopically, the tumor exhibited solid growth of spindle-shaped cells with atypia. Immunohistochemically, the cells were positive for CD56, a neural cell adhesion molecule expressed on the cell membrane of neurons, and synaptophysin, a synaptic vesicle glycoprotein that is present in neuroendocrine cells . In contrast, they were negative for CK20, which is a marker of urothelial carcinoma. The cells showed strong intranuclear positivity to ki-67 antibodies (> 70%) . Invasion beyond the bladder wall and metastasis of one of the thirteen regional lymph nodes that were excised were observed. Diagnosis of SCBC (pT3bN1M0) was confirmed. No component of urothelial carcinoma was found. Additionally, pathological re-examination of TURBT specimen exhibited similar features to the cystectomy specimen, which was pure SCBC. The patient received four cycles of adjuvant chemotherapy with gemcitabine (1000 mg/m2, administered intravenously) and cisplatin (70 mg/m2, administered intravenously); 6 months after cystectomy, he complained of right arm edema and hoarseness. Left tracheal deviation was observed on a chest radiograph ; Computed tomography (CT) scan revealed superior vena cava syndrome due to a 70 mm right-sided infraclavicular lymph node metastasis . Additionally, a 28 mm abdominal wall tumor and a 68 mm pelvic tumor were found. At that time, the serum neuron-specific enolase (NSE) level was 227 ng/ml. The 21-day cycle regimen (including carboplatin, etoposide, and atezolizumab) was administered intravenously, according to the clinical practice guidelines for extensive-disease SCLC . We administered carboplatin (area under the curve, 5 mg min/mL) on the first day, etoposide (100 mg/m2) from the first through the third day, and atezolizumab (1200 mg) on the first day. Considering the risk of nausea and loss of appetite, we intravenously administered palonosetron (0.75 mg) on the first day and dexamethasone (6.6 mg) from the first through the third day and orally administered aprepitant (125 mg) once daily on the first day, aprepitant (80 mg) once daily on the second and third day, and metoclopramide (5 mg) three times daily from the third through the seventh day. On the third day of the first cycle, right arm edema and hoarseness had improved. Additionally, tracheal deviation disappeared from the radiograph . While the patient experienced grade II neutropenia from days 8–10 of each cycle, it abated spontaneously without administration of the granulocyte colony-stimulating factor. He did not develop anemia or thrombocytopenia. Moreover, owing to the preventive therapy, he did not experience nausea or loss of appetite. After four cycles, all recurrent tumors completely disappeared from the CT scan. The serum NSE level decreased to 8.0 ng/ml. The patient continued to receive maintenance atezolizumab therapy (1200 mg, administered intravenously) every 21 days, without any evidence of recurrence over the 12 month follow up. Retrospectively, programmed death ligand 1 (PD-L1) staining was performed using a cystectomy specimen. The immune cells infiltrating the tumor were positive for PD-L1, whereas the tumor cells were negative for PD-L1 . The proportion of tumor-infiltrating immune cells expressing PD-L1 in the tumor area was more than 1% and less than 5%. Additionally, the proportion of tumor cells expressing PD-L1 in all tumor cells was less than 1%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_290_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_290_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18a19a8c2ee12b8b3c51ed39fdaf6a3cd867de51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_290_en.txt
@@ -0,0 +1 @@
+A 68-year-old man was referred to our institution with a diagnosis of rectosigmoid colon cancer. Colonoscopy revealed a type 2 tumor at the rectosigmoid colon . Right hemiparesis was present as a result of two cerebral infarctions that had occurred during the 2 months prior to his first admission. After consultation with a neurologist, we considered that it was necessary to wait several months before performing a major operation due to the risk of inducing another cerebral infarction. However, advanced cancer would be expected to grow during the waiting period. We therefore considered that it was necessary to administer systemic chemotherapy to suppress tumor growth. We initially administered five courses of preoperative chemotherapy (mFOLFOX6). No cerebral events or severe adverse events occurred during the chemotherapy. Stable disease, according to the RESIST criteria, was achieved with the preoperative chemotherapy. A laparoscopic Hartmann’s operation with D3 lymph node dissection was performed at 4 weeks after the last course of chemotherapy. The patient’s postoperative course was good without any complications. The final diagnosis of the rectal cancer was Dukes B with well-differentiated tubular adenocarcinoma and rectal tumor invasion to the subserosa (T3) without lymphatic or venous invasion . The resected specimen was free from cancer cells. The patient had complained of a perianal abscess for 5 years before his first admission. However, we gave priority to treating the rectal cancer. Although his anal symptoms did not worsen during chemotherapy, at 1 month after the Hartmann’s operation for rectal cancer, his perianal abscess worsened and induration with two secondary open lesions was detected on physical examination . The pathological examination of the biopsied perianal tissue revealed adenocarcinoma. Because the perianal tumor was localized without invasion of the neighboring tissue on magnetic resonance imaging findings , and considering his physical states, we performed local excision under spinal anesthesia for curative resection. The final pathological diagnosis of the resected specimen was metastatic adenocarcinoma to an anal fistula originating from rectal cancer, and the resected margin was free from cancer cells . Immunohistochemistry revealed that both the rectal tumor and anal tumor were cytokeratin 7 (CK7) − and cytokeratin 20 (CK20) + . Based on the pathology of the primary tumor and the absence of lymphatic or venous invasion, metastasis was considered to have occurred due to the implantation of exfoliated cancer cells. Seven courses of postoperative adjuvant chemotherapy with the same regimen have been administered. No recurrence of the tumor has been seen for 31 months after the operation. If a locally recurrent tumor had been found near the rectum and anus without distant metastasis during follow-up, laparoscopic resection of the tumor with the residual rectum and anus would have been attempted after considering the patient’s performance status.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2918_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2918_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c04ef67ae8cd34573c501c7738c5fce6e9133af
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2918_en.txt
@@ -0,0 +1,6 @@
+A 78-year-old Greek (Caucasian) male, a smoker with a BMI of 25.7 kg/m2 who was classified as an American Society of Anesthesiologists (ASA) physical status grade III patient and therefore had a medium risk of anesthesia, was diagnosed with osteoarthritis of the left hip and thus was scheduled for an elective total hip replacement. His cardiac history included hypertension and dyslipidemia, with a normal pre-operative echocardiography examination (ejection fraction: 60%, with no abnormalities) and no history of pulmonary disease. He was also a type II diabetic, managed by oral medication (metformin) and had undergone a total knee replacement in the past without complications. His preoperative laboratory examination was within normal parameters and he was hemodynamically stable (pre-anesthesia assessment vitals: blood pressure: 137/67 mmHg, heart rate: 77 bpm, SpO2: 99%). The anesthesia plan included the use of a combined lumbar epidural and spinal anesthesia and analgesia.
+Upon arrival in the operating room (OR) standard monitoring including continuous electrocardiography (ECG), oxygen saturation (SpO2) and non-invasive blood pressure measuring was commenced. An oxygen mask administering 6 lt/min was used throughout the procedure. The neuraxial spinal technique was performed aseptically, by a second year anesthesia trainee who had previously performed more than 40 procedures, supervised by a senior consultant anesthetist, with the patient in a sitting position at the level of the L4-L5 intervertebral space using a midline approach. After local anesthesia with 5 ml of 2% lidocaine, an 18-Gauge Tuohy needle attached to a syringe filled with approximately 8 ml of air was used. Intermittent pressure was applied to locate the epidural space using the loss of resistance to air technique.
+The epidural space was located relatively easily after a single redirection of the needle. A needle-through-needle approach with an adjustable locking mechanism was used to locate the subarachnoid space. Cerebrospinal fluid (CSF) flowed freely through the spinal needle without the presence of blood. A mixture of 1,9 ml of ropivacaine 0.75% wit 0,2 ml (10 mcg) of fentanyl for a total volume of 2,1 ml was introduced into the subarachnoid space. The spinal needle was carefully removed, and the epidural catheter (Portex Epidural Minipack System 1, Smith’s Medical) was then placed in the epidural space. The spinal block was confirmed using the temperature differentiation method and both sensory and motor block were present. An arterial continuous blood pressure monitoring catheter was inserted in the patient’s radial artery prior to the commencement of the procedure. The patient exhibited stable baseline hemodynamics with a mean arterial pressure of 90 mmHg and a heart rate of 70–80 beats/min.
+For surgery the patient was subsequently placed on the right lateral side with his left hip facing upwards. He received no intravenous anesthetic or analgesic medication throughout the procedure. Approximately 2 h after the spinal blockand and the initiation of the procedure the patients’ blood pressure suddenly dropped from 163/84 mmHg to 82/45mmHg and his heart rate decreased to 45 bpm. He was alert and responsive but stated that he felt dizziness. Sinus bradycardia was apparent on the ECG. The anesthesiologist in charge administered promptly 5 mg of ephedrine and a total of 1 mg of phenylephrine in consecutive boluses over a period of 30 s. Simultaneously O2 administration via a face mask was increased to 15 lt/min and intravenous fluid administration was increased. There was no improvement in the patient’s hemodynamic state and his blood pressure dropped further to 55/35 mmHg and the patient then became unresponsive. Fearing imminent patient arrest, the anesthetic incident alert was raised for additional help and 1mg of adrenaline was given intravenously by the consultant anesthetist. This produced an immediate rise in the blood pressure (up to a peak of 183/88 mmHg which required the administration of small 0.05 mg/ml boluses of nitroglycerin to prevent extreme hypertension) and the patient’s mental status promptly returned to normal. An immediate cardiology assessment was requested. A point of care echocardiogram demonstrated no new cardiac abnormalities or changes compared to the patients’ preoperative assessment echo. During the episode, there was a small drop in the patient’s SpO2 from 97% from 100% but his arterial blood gasses were normal. No dyspnea or chest pain was recorded during or after the episode.
+After the end of the procedure, the patient was admitted to the post-anesthetic care unit (PACU), where continuous monitoring of his vital signs was performed. No additional epidural medication was administered and his epidural catheter was removed. A computed tomography pulmonary arteriogram (CTPA) was performed, which was negative for a pulmonary embolism. A chest and abdomen CT was also performed, which demonstrated air in the subcutaneous tissue, the intermuscular space, the spinal canal around the spinal cord (pneumorrachis), at the left side of the L4 and L5 vertebral bodies and inside the mediastinum para-aortically .
+Post operatively, the patient underwent a complete and thorough cardiovascular assessment including a clinical examination by a cardiologist, cardiac echocardiography, cardiac enzymes and a carotid triplex ultrasound with no abnormal findings. He was put on bed rest under continuous cardiac monitoring (blood pressure, heart rate and ECG) with no other such episodes of hemodynamic instability or hypotension been recorded. He was discharged home on the fifteenth postoperative day and was followed up as per routine clinical practice by his orthopedic surgeon.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2919_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2919_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5a32972e53ceec2e1cac54c7bc95a8186a72d48
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2919_en.txt
@@ -0,0 +1,9 @@
+A 68-year-old female presented to the emergency department with melena.
+The melena started a day before she consulted us. She had no past history of chronic abdominal symptoms suggesting the presence of celiac disease.
+The patient had a history of hypertension and hyperlipidemia.
+She had no significant personal and family history.
+Her body temperature was 36.4 ºC, blood pressure was 128/85 mmHg, and heart rate was 98 bpm with sinus rhythm. She had mild abdominal tenderness, but there was no obvious hepatosplenomegaly or lymphadenopathy. Digital rectal examination revealed melena.
+Laboratory tests indicated a hemoglobin level of 11.3 g/dL, blood urea nitrogen level of 26.0 mg/dL, and creatinine level of 1.64 mg/dL. Her serum lactate dehydrogenase level was 232 U/L (106- 211 U/L) and soluble interleukin-2 receptor level was 213 U/mL (145- 519 U/mL) .
+Urgent esophagogastroduodenoscopy (EGD) showed an ulcerative lesion with fresh blood clots in the transverse part of the duodenum . Based on the location and shape of the lesion, we suspected not only a peptic ulcer, but also an ulcer caused by vascular malformation or malignancy. Therefore, we decided to interrupt the endoscopy and perform contrast-enhanced computed tomography (CT) scan, which showed slight localized contrast enhancement on the wall of the transverse part of the duodenum in the early phase of contrast injection . No vascular lesions were observed, and there was no extravasation of contrast agent in the delayed phase. EGD was immediately resumed again for further observation of the lesion. When we removed the blood clots, a protruding vessel was seen at the base of the ulcer, which was coagulated using hemostatic forceps (Coagrasper; Olympus Corp., Tokyo, Japan) .
+Following this hemostatic treatment, the patient was discharged from the hospital without re-bleeding. The lesion that caused the bleeding was suspected to be a malignant tumor of the duodenum based on its location. EGDs, including forceps biopsies from the ulcerative lesion, were performed three times after the initial hemostatic treatment. While the first and second biopsies revealed no malignancy, the third biopsy showed findings suggestive of malignant lymphoma. On pathological evaluation, diffuse proliferation of atypical medium-sized lymphoid cells was seen in the entire mucosa, along with a few intraepithelial lesions . No necrosis was observed. Immunohistochemical analysis revealed that the cells were positive for CD3 and CD56, and negative for CD4, CD5, CD8, CD20 and EBER .
+At this point, MEITL was suspected, and examinations for systemic lesions were subsequently performed. No abnormal lymphocytes were found on iliac bone marrow examination. 18Fluorodeoxyglucose (18FDG) positron emission tomography/CT (18FDG-PET/CT) showed nodular FDG accumulation in the wall of the transverse part of the duodenum, consistent with the findings of contrast-enhanced CT . There was no abnormal FDG accumulation in the systemic lymph nodes or other parts of the gastrointestinal tract. The results of total colonoscopy and random biopsies of the gastrointestinal tract were unremarkable.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2931_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2931_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..045825fa11a21a6dd808fb9540ea08cdf84b9f90
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2931_en.txt
@@ -0,0 +1,7 @@
+A 56-year-old male with a past medical history of alcohol substance abuse with seizures, hypertension, and tobacco abuse presented to our urban Level I trauma center after falling from a ladder. He presented with left shoulder, elbow, and chest pain. Radiographs demonstrated displaced 3-part proximal humerus fracture ( and ). In addition, the patient was found to have a non-displaced ipsilateral radial neck fracture and ipsilateral non-displaced 4th–9th rib fractures.
+Operative management of the injury occurred the following day. An anterolateral deltoid splitting approach was used, and the fracture was identified and reduced. A fibular strut allograft (LifeNet Health, Virginia Beach, VA.) was inserted into the humeral canal to augment the fixation. Fracture fixation was performed with a DePuy Synthes (West Chester, PA) 3.5 mm locking compression plate (LCP) proximal humerus plate ( and ). The greater and lesser tuberosities and associated rotator cuff muscles were sutured down to the plate using large non-absorbable suture. Total operative time was 75 min, and the estimated blood loss was minimal. The patient was then transferred to the post anesthesia care unit (PACU). There were no perioperative complications.
+The patient was immobilized with a sling and instructed to be non-weight bearing. The patient was able to be range of motion as tolerated to his left upper extremity. The additional injuries were treated nonoperatively. The patient was discharged on post-operative day 5.
+On post-operative day 11, the patient presented again to our trauma center after a fall down multiple stairs while intoxicated. The patient presented with the left shoulder pain, back pain, and left chest wall pain. The previous surgical incision showed routine healing. Radiographs demonstrated a displaced peri-implant proximal humerus fracture just distal to his original fracture fixation ( and ). In addition, the patient was found to have multiple vertebral superior endplate fractures.
+Operative management of the injury occurred the following day. The same anterolateral deltoid splitting approach was used and extended into the anterolateral approach to the humerus. The peri-implant humeral shaft fracture was first reduced and provisionally held together with two separate lag screws. Then, the distal two screws from the proximal humerus plate were removed. A DePuy synthes (West Chester, PA) 10 hole 3.5 mm LCP metaphyseal plate with a thin proximal flare was placed so that the two most proximal screws were overlapped to link the two constructs (-). The greater tuberosity fragment had displaced from the fall and was fixed with an independent lag screw and an additional heavy gauge non-absorbable suture. Two proximal screws that were loosened from the fall were also replaced ( and ). Total operative time was 72 min, and the estimated blood loss was minimal. The patient was then transferred to the PACU. There were no perioperative complications.
+The patient was immobilized with a sling and instructed to be non-weight-bearing. The patient was able to be range of motion as tolerated to his left upper extremity. The additional injuries were treated nonoperatively. The patient was discharged on post-operative day 1.
+The patient followed up at 2 weeks postoperatively with a well healing incision and no complications. The patient had full passive range of motion, decreased active range of motion secondary to pain, and was otherwise neurovascularly intact. The patient was then lost to follow-up until 13 months postoperatively when he presented for repeat clinical evaluation. Clinically, the patient had no complications with full strength and range of motion. The patient reported very minimal pain and was not using pain medication. Radiographs at this final visit demonstrated stacked plate fixation with appropriate positioning, evidence of bony union, and no signs of displacement or hardware loosening. The patient was able to return to his previous level of activity.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_293_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_293_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..55567b000053fd41f549b826c0cdbe51df726ade
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_293_en.txt
@@ -0,0 +1 @@
+A 56-year-old woman with no history of smoking was admitted to the respiratory department of our hospital on April 24, 2022, with a history of cough and dyspnea over the past six months. Chest computed tomography revealed a massive right hydrothorax. The patient underwent thoracocentesis, and pleural fluid tumor markers, including carcinoembryonic antigen (CEA), cytokeratin 21-1 fragment, and carbohydrate antigen 19-9 (CA199) were significantly elevated. A reexamination of chest CT after pleural effusion drainage demonstrated a hilar mass accompanied multiple nodules in both lungs. Subsequently, tracheoscopy was performed, which unveiled neoplasm in the medial segment of the middle lobe of the right lung . The pathological diagnosis was adenocarcinoma, and immunohistochemical analysis showed that the tumor cells were positive for CK7, NapsinA, ALK, and TTF-1 . The following next-generation sequencing (NGS) analysis (Yunying Medical Inspection Institute) confirmed that the intergenic region (chr2: 30,193,816)-ALK fusion (with an abundance of 8.10%) was positive , suggesting may be benefit from the treatment of Alectinib or Crizotinib. We prescribed Alectinib for the patient, and the dose was 600 mg two times per day. Reexamination after three months showed an obvious decrease of the hilar mass and other nodules, no recurrence of pleural effusion . The patient had no apparent side effect after therapy but a slight abnormal liver function in first two weeks.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2969_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2969_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c8f92e24d3544b9daadfc763c60a8d7c5834ca57
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2969_en.txt
@@ -0,0 +1,6 @@
+A 26-year-old female, gravida-3 para-1, at 30 1/7 weeks of gestation presented to the Emergency Department with symptoms of lower back and sacroiliac joint pain, along with abdominal distension. Her medical history revealed that she had been admitted to a county hospital during the second month of her pregnancy due to hyperemesis gravidarum. After one week of supportive therapy, her symptoms mostly subsided. During the fourth month of her pregnancy, fetal movement was observed, and she had regular antenatal care with normal NT (Nuchal Translucency), low-risk Down’s screening, and normal OGTT (Oral Glucose Tolerance Test) results. Four-dimensional ultrasonography suggested an intrauterine pregnancy with a single alive fetus in the breech position and strong light spots in the left ventricle of the fetal heart. Approximately four weeks before admission to our hospital, she experienced progressively worsening low back pain, for which a local doctor recommended observation and rest considering her enlarged pregnancy abdomen.
+The patient presented with abdominal distension, lower limb dyskinesia, and severe ache, which appeared one day before admission. A pelvic examination conducted in the county hospital revealed the presence of a large fungating gray mass that encompassed the entire cervix, with cervical contact bleeding testing positive. The patient exhibited symptoms such as a pale face, poor spirit and appetite, normal sleep, dry stool occurring once every three days, normal urination, and a weight loss of 10 kg compared to before her pregnancy, since the onset of the disease.
+The patient received multiple blood transfusions due to severe anemia. Ultrasound examination revealed the presence of a diffuse echo-change approximately 13.6 cm by 11.5 cm in size in the liver, which appeared to be a solid-cystic mass that could potentially be a metastatic tumor. To confirm the diagnosis, cervical cancer screening and biopsy were conducted . Immunohistochemical analysis was performed and the results revealed positive expression of AE1/AE3, CK8/18, CAM5.2, P16, PAX-8, Syn, CD56, and CgA. Additionally, the tumor showed high proliferation index with over 90% of cells staining positively for Ki-67.
+The magnetic resonance imaging (MRI) results indicated the presence of a significant cervical mass measuring 5.3 × 6.6 × 7.2 cm. In addition, abnormal signals were detected in multiple other locations, including the right scapula, clavicle, multiple ribs, thoracic vertebrae, lung, lumbar vertebrae, right femoral lesser trochanter, bilateral iliac crest, right ischium, acetabulum, and surrounding soft tissue. Multiple cystic solid masses were also detected in the liver, with the largest mass measuring approximately 13.5 × 13.7 × 14.8 cm, which may suggest metastasis .
+A multidisciplinary team consisting of specialists in gynecology, oncology, maternal-fetal medicine, neonatology, interventional medicine, palliative care, and pain management was convened to discuss the case. It was unanimously agreed that a biopsy was warranted, which subsequently revealed poorly differentiated cervical carcinoma exhibiting high-grade neuroendocrine features that were consistent with a diagnosis of large cell neuroendocrine carcinoma. The collective diagnostic results confirmed that the patient was suffering from a rare form of cervical cancer, specifically cervical neuroendocrine carcinoma (CNECC) with HPV18(+) and stage IVB. Considering the gestational age of the fetus and the patient’s deteriorating pain and desire to terminate the pregnancy, she declined neo-adjuvant chemotherapy (NACT) and elected to undergo cesarean section delivery at 31 4/7 weeks gestation after receiving fetal lung maturation therapy. The placenta was unremarkable and no tumors were found . The neonate had Apgar scores of 10 and 10 at 1 and 5 min, respectively, weighed 1700 g, and was subsequently transferred to the neonatal intensive care unit under the care of a neonatologist.
+Following surgery, the patient was treated with three cycles of carboplatin and etoposide chemotherapy, followed by an additional five cycles of paclitaxel, nedaplatin, and bevacizumab chemotherapy, with each course administered at 3-week intervals. Unfortunately, she succumbed to multiple tumor metastases six months post-treatment, leading to cardiopulmonary failure, infection, and cachexia. Despite this tragic outcome, the infant was discharged in a healthy condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2981_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2981_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4f1c3027bca9051d9cad8d293e4268e8be0fb7af
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2981_en.txt
@@ -0,0 +1,6 @@
+A 73-year-old right-handed Taiwanese man was admitted to our hospital after suffering syncope. On the day of admission, he had been well until 7:00 in the morning, when he was playing tennis. Specifically, he suddenly lost consciousness and fell to the ground. The patient promptly regained consciousness, but his verbal output was limited to saying the word “hao” (meaning “yes” in English). His friends took him to our emergency department at 8:39 am.
+On arrival, the patient was E2VaM4. On examination, he was alert. He had impairments in speech fluency, comprehension and repetition. His only verbal output was the sound “hao” or “hum”. Gait, extraocular motion, motor, and sensory functions were all normal. He showed no eye ptosis nor facial palsy. Blood parameters, including homocysteine levels, lipid profile, diabetes, oncology and endocrine measures, were unremarkable. Brain CT with contrast revealed no apparent intracranial haemorrhage or mass. However, CT perfusion indicated poor perfusion over the left middle cerebral territory .
+Tracing back his medical history, the patient was normostenic (body mass index was 18). He had hypertension for more than twenty years. He also suffered from hyperlipidaemia and coronary artery disease, and 7 months previously, he had received one drug-eluting stent. His daily medications included amlodipine 5 mg, aspirin 100 mg and rosuvastatin 5 mg. He played tennis twice a day and never smoked or drank alcohol. His highest education was senior high school and was fluent in Chinese, Taiwanese and Japanese. He used to work at an international trading company but had been retired for two years.
+Under the impression of acute cerebral infarction with global aphasia, he then received a recombinant tissue plasminogen activator (rtPA) injection at 9:26 am and was switched to our intensive care unit for further management. Brain non-contrast magnetic resonance imaging (MRI; Fig. ) was conducted on day 5, disclosing an acute infarction in the territory of the left middle cerebral artery (MCA), just in the perisylvian gyri, the classic areas of Wernicke and Broca. After 12 days of inpatient treatment, the patient was later discharged under stable conditions with global aphasia status and no focal neurologic signs. He was able to resume playing tennis on a daily basis soon after discharge.
+The patient then received speech rehabilitation, including verbal production, auditory comprehension training, augmentative communication training, phonetic placement and high-level cognitive function training at our hospital and another hospital. His language expression gradually recovered. The CCAT was then performed 14 months after the initial stroke. His average CCAT score was 5.6, indicating moderate to severe aphasia . Detailed analyses of his spoken language characteristics showed subnormal performances for both sentence intonation and sentence length , indicating he had fluent aphasia.
+We subsequently checked is cerebral blood flow using regional brain single photon emission computed tomography (SPECT; Fig. ). No radioactivity was found in the left frontal and left parietotemporal regions, and instead, a relatively high level of radioactivity uptake was noted over the right thalamus, frontal and occipital lobes.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3011_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3011_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..04cf16a75da454176230573da03cb2c36e1d1ed7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3011_en.txt
@@ -0,0 +1,11 @@
+Our patient is a 64-year-old man who presented to the hematology clinic for evaluation of persistent anemia, weight loss, and fatigue. The patient reported fever, cough, and a significant weight loss of up to 40 kg over 10 months. He was also diagnosed with episcleritis of the left eye and chondritis of the left ear. He reported erythematous circumferential papules on his arms and legs that waxed and waned along with recurrent pain and edema in his right face. He was treated with a course of antibiotic for possible streptococcus infection with no significant improvement of his symptoms.
+
+Initial blood work was significant for macrocytic anemia, with elevated alkaline phosphate. Owing to ongoing low-grade fevers, weight loss, myalgias, and cough, the patient underwent QuantiFERON gold testing. Results were indeterminant, so the patient was referred for computed tomography (CT) scans of the chest, which revealed numerous cavitary nodules. The CT-guided biopsy of pulmonary nodules demonstrated caseating granulomas with cryptococcal organisms. Acid-fast bacillus cultures were negative; patient cryptococcal antigen levels were elevated of 1:2560. The patient was treated with a 12-month course of voriconazole without significant improvement in his symptoms. Detailed serologic evaluation for systemic autoimmune diseases was unremarkable besides a positive anti-double-stranded DNA antibody (anti-dsDNA) and positive rheumatoid factor.
+
+Further workup was warranted, whole body CTs demonstrated no signs of solid tumors, and the hemoglobin electrophoresis results were normal. A bone marrow biopsy revealed hypercellular marrow with significant myeloid hyperplasia and well-demarcated small vacuoles in the cytoplasm of a few myeloid and erythroid precursors. Increased stainable storage iron with rare ring sideroblasts was also noted. Concurrent flow cytometry showed no immunophenotypic evidence of a lymphoproliferative disorder or an abnormal blast population. Owing to a declining hemoglobin level down to 8.7 g/dL, the patient was referred for an endoscopic ultrasound and CT enterography, both of which were unremarkable.
+
+The patient presented again to the clinic for a raised, erythematous, non-blanching rash which relapses and remits every 2 weeks. A physical exam showed a rash on his bilateral upper and lower extremities, with occasional upper extremity vesicles that revealed no specific pathology when biopsied. One month later, the patient was admitted due to persistent failure to thrive despite decreasing cryptococcus titers (ratio of 1:10), increased caloric intake, and iron supplementation for anemia. Laboratory evaluation via enzyme-linked immunosorbent assay (ELISA) revealed positive double-stranded DNA antibodies (dsDNA) and positive antinuclear (ANA) antibodies, and rheumatology was consulted. Subsequent testing with gold standard immunofluorescence was negative for dsDNA and ANA antibodies. At this time, the patient was taken to Cleveland Clinic for immunology evaluation.
+
+The patient was diagnosed with VEXAS syndrome based on a mutation of ubiquitin-like modifier activating enzyme 1 p.Met41Val (UBA1 p.M41V) detected by Sanger sequencing. He was prescribed prednisone 40 mg daily with a tapering protocol as well as 1 Bactrim 800 to 160 mg tablet 3 days a week.
+
+Rapid improvement of his myalgias, chondritis, and rash was seen. The patient experienced profound hyperglycemia secondary to his steroids and was started on insulin. Currently, the patient is taking prednisone daily and ruxolitinib 10 mg daily.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3024_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3024_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf83e6d239625950e809258d568cbb61f5392c36
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3024_en.txt
@@ -0,0 +1,19 @@
+We present the case of a 51-year-old woman with a history of fibromyalgia and anorexia-bulimia of more than 30 years of evolution, without toxic habits. She comes to the emergency room presenting a picture of expectoration of a yellowish appearance, with scarse cough and without fever, of five months of evolution.
+
+The blood test did not detect significant alterations. However, the chest X-ray showed extensive consolidation predominantly affecting the middle lobe and the upper left lobe, so the patient was admitted for study.
+
+Microbiological and serological determinations were negative (human immunodeficiency virus and SARS-CoV-2), except for the isolation of Serratia marcescens in moderate growth in the sputum.
+
+A chest computed tomography (CT) scan was performed, which reported confluent opacities including areas of ground glass opacities and consolidation, bilateral and diffuse distribution, and greater extent in the upper left lobe, the lingula, the middle lobe and the lower left lobe. Empirical antibiotic treatment (ceftriaxone 2 g/24 h and azithromycin 500 mg/24 h) and corticosteroid (methylprednisolone 40 mg/12 h) were initiated for seven days.
+
+A flexible fibrobronchoscopy was performed in which no alterations were observed in the tracheobronchial tree. A bronchoalveolar lavage was performed in the middle lobe from which a turbid and yellowish liquid was obtained. Shortly after its obtaining, the liquid obtained was separated into two phases, leaving a supernatant of a foamy, yellowish appearance in the upper part, which was sent to the services of Pathological Anatomy and Microbiology. During the bronchoscopy, biopsy with clamp was performed in the mucosa of the bronchus of the lower left lobe.
+
+The cytology of the bronchoalveolar lavage was negative for malignancy with a differential count of 90% macrophages, 7% lymphocytes and 3% polymorphonuclear cells. As for the microbiological study, no bacterial or fungal growth was observed, no acid-fast bacilli were observed, the mycobacterial culture was negative after 42 days of incubation, and no Legionella spp. was isolated.
+
+Biopsies reported lung parenchyma with preserved architecture, no specific lesions or evidence of deposits, with occasional macrophages with microvacuolated cytoplasm.
+
+Pulmonary function tests were performed with no significant abnormalities.
+
+Due to the absence of clinical changes, and the patient remaining in good general condition at all times, it was decided to proceed with hospital discharge, pending a pulmonary cryobiopsy. This biopsy was performed two months later in the lower left lobe. According to the anatomopathological report, the samples obtained showed areas of occupation of the air spaces by abundant macrophages with intracytoplasmic vacuoles of varying sizes, characteristic of exogenous lipoid pneumonia. Also, large extracellular vacuoles were recognized, surrounded by macrophages with occasional multinucleated elements.
+
+The presence of macrophages with intracytoplasmic vacuoles is characteristic of exogenous lipoid pneumonia. In light of these findings, the final diagnosis was exogenous lipoid pneumonia in probable relation to the patient's purgative behavior, who is currently in the process of recovery and changing habits, without cough or expectoration.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3031_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3031_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b68f3739f2ce8daf0922b6125af503bec6c83bbe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3031_en.txt
@@ -0,0 +1,30 @@
+A 18-year-old previously healthy female (165 cm, 65 kg, body mass index (BMI) 23.9), without pre-existing comorbidities or a family history for cardiac pathologies, was admitted to the cardiac care unit (CCU) at nine o’clock with cold-like symptoms and progressive dyspnea after five days of cold-like symptoms (fever, cough and expectoration). She had shortness of breath, palpitation (Heart rate: 156 beats per minute), and hypotension [Blood pressure (BP): 98/58 mmHg without vasoactive drugs usage]. Upon examination at an external hospital, a pulmonary computerized tomography (CT) revealed indications of cardiogenic pulmonary edema and moderate pulmonary inflammation. The patient presented upon admission in an alert and coherent state, but with a diminished overall condition, exhibiting sinus tachycardia at a rate of 150–160 beats per minute and experiencing oxygenation impairment. Due to hypoxia, the patient necessitated supplemental oxygen administration through both nasal cannula (at a flow rate of 3 L per minute) and mask inhalation (at a flow rate of 6 L per minute) to maintain a transcutaneous pulse oxygen saturation (SPO2) level of approximately 93%. The arterial blood gas analysis revealed a pH value of 7.44, a partial pressure of oxygen of 93 mmHg, and a partial pressure of carbon dioxide of 32 mmHg following the administration of oxygen.
+
+The patient reported no history of smoking or alcohol consumption. Additionally, there was no evidence of illicit drug use, immune-checkpoint inhibitor usage, or anti-tuberculosis medication intake. The patient received two doses of the Coronavirus Disease 2019 (COVID-19) vaccine on July 26th and August 17th, 2021, respectively. The patient contracted COVID-19 infection three months prior as a result of the implementation of a “herd immunity” policy.
+
+Laboratory results on admission showed an increased aspartic transaminase (AST) level of 56 IU/L, creatine kinase (CK) level of 373 IU/L, creatine kinase-MB (CK-MB) level of 36.5 IU/L, troponin I (TnI) level of 4.1 ng/mL (reference range: < 0.02 pg/mL), N-terminal pro brain natriuretic peptide (NT-proBNP) levels of 14,100 pg/mL, and serum creatinine levels of 119 umol/L. The lactate value was 1.7 mmol/L. The D-dimer was in the normal range (1.590mg/L). In addition, the inflammatory markers of white blood cell count, absolute neutrophil count, serum C-reactive protein (CRP), serum procalcitonin, amyloid A and interleukin 6 were 8.27×10^9/L, 6.26×10^9/L, 124.05 mg/L, 0.768ng/mL, 1114.5mg/L and 6235.0pg/mL, respectively. Thyroid function test suggested that hypersensitive thyrotropin (TSH) was decreasing (0.39 mIU/L), but triiodothyronine (T3) and tetraiodothyronine (T4) were normal.
+
+Twelve lead electrocardiogram (ECG) admitted to hospitalization (April 13th, 2023) demonstrated sinus tachycardia. ECG showed QS complex only in V1-V3 leads and 1–2 mm ST-segment depression in II, III, aVF, V4-V6 leads. Chest radiograph showed bilateral pulmonary scattered inflammatory changes and possible pulmonary oedema after IABP implantation. After a period of treatment, the ECG findings on April 18th revealed flat or inverted T waves in leads V1-V6. On April 19th, chest radiograph showed no signs of pulmonary congestion or inflammation.
+
+The transthoracic echocardiography (TTE) revealed a severely impaired left ventricular ejection fraction (LVEF ~35.7%), a moderately reduced right ventricular function [tricuspid annular plane systolic excursion (TAPSE) =12 mm)], moderate to severe regurgitation of the mitral valve and tricuspid valve (the estimated pulmonary artery systolic blood pressure was 49 mmHg). The inferior vena cava was widened and its’ respiratory collapse rate was less than 50%. The patient was admitted with a diagnosis of fulminant myocarditis: acute heart failure, cardiac function Grade III (New York Heart Association classification system); pulmonary infection; upper respiratory tract infection.
+
+Due to the patient’s hemodynamic instability caused by acute heart failure, a continuous intravenous treatment regimen was administered. This included furosemide (4.1 ug/kg/min), dopamine (2.5 ug/kg/min), and metaraminol bitartrate injection (0.2 ug/kg/min) using microinjection pumps. Additionally, methylprednisolone sodium succinate (320 mg daily) was intravenously administered for five consecutive days to inhibit myocardial inflammation, while being protected by intravenous human immunoglobulin (PH4, 20 mg daily). Pulmonary infection was managed through transvenous administration of cefuroxime sodium every eight hours.
+
+Drug and Instrumental Treatment
+Three hours after admission, the patient exhibited a gradual progression into cardiogenic shock, specifically reaching the classic stage as defined by the cardiogenic shock staging of the American Society for Angiocardiography and Intervention. This was characterized by hypotension (blood pressure: 97/50 mmHg with the use of vasoactive drugs) and severely impaired oxygen saturation (SPO2 80%) at twelve o’clock. The patient’s heart rate was measured at 148 beats per minute, and the lactate value was recorded as 2.9 mmol/L at that time. Despite the administration of dopamine and metaraminol bitartrate to stabilize the patient’s vital signs, the cardiogenic shock remained uncorrected.
+
+Thus, an IABP was initially used for cardiogenic shock management in cardiac catheterization room in hospital day one. An IABP device (Impella cardiac power, IAB-06840-U; Teleflex®, Arrow International LLC, USA) was placed to decrease afterload and improved diastolic BP in order to increase pulsatility and improve coronary perfusion. Because of reduced vigilance and ongoing hemodynamic instability, the patient was intubated and ventilated. Subsequently, on the first day of hospitalization in the evening, femoro-femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) was administered using the Cardiohelp device (Getinge AB, Göteborg, Sweden). Following initiation, there was a partial reduction in aortic valve opening, leading to the discontinuation of metaraminol bitartrate. Additionally, a daily administration of human blood albumin (10 g) was implemented to enhance colloid osmotic pressure. Furthermore, fresh frozen plasma was administered to improve coagulation function and minimize the risk of bleeding associated with the instrumentation.
+
+On the first day following the initiation of IABP (Counterpulsation pressure: 110 mmHg) and VA-ECMO (Rotation speed: 3495 RPM/min; Flow: 2.62 L/min), TTE still indicated a decrease in myocardial contractility, with an LVEF of 36.6%. High dose of dopamine combined with furosemide were continued as treatment, while the invasive radial arterial BP was measured at 95/56 mmHg. By the third day after instrument implantation, there was an improvement in myocardial contractility and hemodynamic stabilization was achieved, resulting in a gradual reduction in vasopressor levels to 1.5 ug/kg/min. Thus, extracorporeal membrane oxygenation (ECMO) was discontinued on the fourth day after implantation, resulting in arterial blood pressure (BP) of 112/72 mmHg without the use of dopamine. Due to the patient’s hemodynamic stability, the intra-aortic balloon pump (IABP) was removed on the fifth day after implantation, resulting in arterial BP of 114/74 mmHg. The patient experienced a rapid recovery, as mechanical ventilation was discontinued the following day and arterial BP remained at 112/72 mmHg.
+
+Eight days after she was admitted, TTE revealed that the patient had a normalized cardiac function with no sign of persisting heart failure (left ventricular end diastolic diameter (LVEDD), 42.5 mm; interventricular septum thickness (IVS), 10.5 mm; LVEF, 50.8%). We stopped using diuretics because of almost normal cardiac function.
+
+Etiology
+Coronary angiography revealed no artery stenosis in hospital day one. Fulminant myocarditis may be caused by a variety of factors, including viral, bacterial, toxic, and autoreactive. In this patient, legionella pneumophila A IgM antibody, mycoplasma and chlamydia IgM antibody, adenovirus IgM antibody, respiratory syncytial virus IgM antibody, influenza virus A and B IgM antibody, and parainfluenza virus antibody were negative. The laboratory test of toxoplasmosis, cytomegalovirus, rubivirus, herpes simplex virus type 1 and 2, parvovirus B19 IgM antibody showed negative but IgG antibody revealed positive. In addition, SARS-CoV-2 RNA was negative through the throat swab test.
+
+The antinuclear antibody (ANA) was weakly positive (Spotty type 1:100), anti-mitochondrial antibody M2 was positive, anti-Ro-52 antibody and anti-SS-A antibodies were strongly positive. Both myeloperoxidase-ANCA (MPO-ANCA) and proteinase 3-ANCA (PR3-ANCA) were negative. Anti-double-stranded DNA and other autoimmunity anti-body were negative. We considered the patient might suffer from with Sjogren’s syndrome but the labial gland biopsy data were lacking.
+
+Fever and Depressive State
+On hospital day 8, the patient developed fever, with body temperature fluctuating between 38 and 39 degrees. In addition, the inflammatory markers of white blood cell count, absolute neutrophil count, serum CRP and procalcitonin were 23.91×10^9/L, 20.69×10^9/L, 11.04 mg/L and 0.62 ng/mL, respectively. Serological tests for tuberculosis (T-SPOT, TB test), Widal reaction and blood cultures were negative. On the eighth day of hospitalization, a lung CT scan exhibited dispersed streaks in the lower right lung, prompting a modification in the antibiotic regimen to piperacillin sulbactam (4.5g intravenous every eight hours). Nevertheless, by the tenth day of hospitalization, the patient’s temperature did not show any signs of reduction, raising doubts regarding the association between the fever and the progression of pneumonia. Subsequently, on the eleventh day of hospitalization, a comprehensive abdominal CT scan revealed colorectal dilatation, necessitating heightened awareness for the possibility of paralytic intestinal obstruction. Following the administration of warm saline retention enema, the patient’s body temperature rapidly declined the following day.
+
+Moreover, the patient exhibited notable levels of anxiety, depression, and suicidal inclinations on the ninth day of hospitalization. To address these concerns, psychological counseling therapy and the administration of sertraline hydrochloride tablets were implemented. Over time, the patient experienced a gradual recovery, leading to their transfer to the intermediate care unit on the thirteenth day and eventual discharge on the fourteenth day. Follow-up for seven month after discharge showed the patient had no chest tightness and shortness of breath after activity and the cardiac function was maintained at grade I (New York Heart Association classification system).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3051_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3051_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5c1fd427c33db5def4a40f3fc41f158b564b859d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3051_en.txt
@@ -0,0 +1,10 @@
+Clinical finding
+A 28-year-old male presented with right preauricular, painless swelling for 9 months. The swelling was gradually increasing in size. On examination, superficial swelling was found, which measured 4.8 cm × 4.0 cm in size, firm in consistency, mobile, smooth surface, regular border, and nontender. There was no sign of facial nerve deficit. He did not have any family history of cancer or history of radiation exposure.
+
+Management
+The patient was advised for head-and-neck ultrasound and FNAC of the preauricular swelling. USG showed a heterogeneous, hypoechoic mass with well-defined border on the right side of the superficial lobe of the parotid gland. These radiological findings suggest the diagnosis of a benign tumor in the parotid gland.
+
+A FNAC was performed in the preauricular or parotid swelling. According to the Milan system for reporting salivary gland cytology, the FNAC of the parotid gland was categorized as IV – neoplasm. After that, a superficial parotidectomy with facial nerve preservation was performed under general anesthesia. Then, the parotidectomy specimen was sent to the pathology department for histopathological examination.
+
+Histopathology
+A parotidectomy specimen was received grossly as a multiple nodular mass measuring 6.2 cm × 4.3 cm × 2.0 cm. It cuts firm. The cut surface showed multiple small nodular solid yellowish-to-whitish areas. Microscopic examination of hematoxylin and eosin stained section showed malignant tumor islands that composed of an admixture of different types of malignant tumor cells, including malignant acinar cells, clear/vacuolated cells, intercalated duct-like cells, and nonspecific glandular cells. These tumor cells are arranged in solid and microcystic patterns that infiltrate into the sclerotic stroma. Malignant acinar cells are large polygonal cells with abundant basophilic granular cytoplasm and eccentrically placed small hyperchromatic nuclei. Intercalated duct-like cells are cuboidal cells with amphophilic cytoplasm with centrally placed dark nuclei. Nonspecific glandular cells have vesicular nuclei with eosinophilic cytoplasm. Sheets of malignant tumor cells are also traversed by very delicate blood vessels. There is no evidence of necrosis. The morphological diagnosis was hence, as the differential diagnosis of ACC and secretory carcinoma (SC). After that, we performed a special stain PAS-D, which showed abundant PAS-positive diastase-resistant cytoplasmic granules in the malignant acinar cells. On further IHC, DOG-1 was positive with cytoplasmic expression in tumor cells, while mammaglobin was not expressed in tumor cells. This special stain and IHC almost confirmed the diagnosis of ACC in the parotid gland. Currently, the patient has remained disease-free with no signs of recurrence.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3055_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3055_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06dba1bd3ac651b82ad42bc4c9380b35030ec5e6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3055_en.txt
@@ -0,0 +1,11 @@
+On February 20, 2021, a 40-year-old man presented to the emergency department with a fever and headache with no clear infectious focus. His personal history included no known drug allergies, no toxic habits, and no cardiovascular risk factors, with a history of a bacterial meningitis in childhood without sequelae and a protein S deficiency that was not being treated at that time. During the first contact in the emergency department, he was diagnosed with a urinary tract infection and was treated with cefuroxima. Two days later, he was brought back to the emergency department with a confusional state and tonic-clonic seizures, and despite treatment with midazolam, he had recurrent tonic-clonic seizures, which required sedation and orotracheal intubation in the intensive care unit due to refractory status epilepticus. As a recent event, 21 days before the beginning of the clinic, the first dose of vaccination with ChAdOx1 nCoV-19 was described.
+
+The physical examination, once sedated and intubated, showed a tendency to cervical hyperextension, with ocular deviation upwards and to the right, frequent clonic and synchronous myoclonic reactions in all four limbs, clonoid hyperreflexia in all four limbs with bilateral positive Hoffman reflexes and bilateral flexor cutaneous-plantar reflexes. There were no meningeal signs, and the rest of the neurological examination was affected by the sedation and intubation of the patient. In the initial complementary tests, which included a complete blood count, polymerase chain reaction for SARS-CoV-2, serology of the most common neurotrophic viruses, analysis of the cerebrospinal fluid (biochemistry, serology, polymerase chain reaction multiplex, cytology and autoimmunity), abdominal ultrasound, head computed tomography without contrast and head magnetic resonance with contrast, only a discrete thickening and oedema in the FLAIR and DWI sequences in both frontal cortices, with a right predominance, was observed. The rest of the tests showed findings within the normal range, except for an increase in D dimers, creatine kinase and leukocytosis with neutrophilia.
+
+The patient was diagnosed with refractory status epilepticus with possible frontal focal origin, with no history of epilepsy. To cover the possible infectious etiology, aciclovir, ampicillin and ceftriaxone were started empirically, without a favorable clinical response being described. During his stay in the intensive care unit, a neuroimaging study was performed with computed tomography and computed angiotomography to rule out venous thrombosis of the sinuses, which showed no pathological findings. However, in a new cranial magnetic resonance, performed 18 days after admission, a diffuse and bilateral alteration of the hemispheric cortex and the right thalamic pulvinar was observed. After treatment with immunomodulators, and 6 days after the previous magnetic resonance, a new magnetic resonance control was performed with a notable improvement in terms of the lesions found in the initial magnetic resonance.
+
+Regarding the electrophysiological study of our patient, multifocal seizures, generalized state pattern and suppression-seizures were found in the successive electroencephalograms performed on day 16 and 18 after admission, depending on the anaesthesia and the therapeutic window.
+
+Regarding the analytical and radiological study of the case, we note that, in the analytical profiles, the autoimmunity (antinuclear antibodies, anti-neutrophil cytoplasm antibodies and anti-neuronal antibodies), the polymerase chain reaction for SARS-CoV-2 in the nasopharyngeal exudate, the serology, the microbiology, the tumour markers, the computed tomography of the body, the transthoracic echocardiography and the testicular ultrasound were all negative. In the control lumbar puncture at 72 hours, a discrete mononuclear pleocytosis (27 cells; 95%, mononuclear) was observed without glucose consumption and with minimal hyperproteinorraquia. The anti-DPPX, anti-NMDA, anti-CASPR2, anti-LGI1, anti-GABA and anti-AMPA antibodies in the cerebrospinal fluid were negative.
+
+Our patient remained in the intensive care unit for 86 days suffering multiple systemic complications, including pulmonary thromboembolism, basilic vein venous thrombosis, hyponatraemia and hypothyroidism with negative autoimmunity, and several nosocomial infections resolved during admission. In the face of refractoriness to treatment, he was diagnosed with cryptogenic NOSRSE. Sequentially, or in combination, up to seven antiepileptic drugs (benzodiazepines, valproic acid, carbamazepine, lacosamide, levetiracetam, phenobarbital, phenytoin, perampanel and topiramate) were administered, a succession or combination of anaesthetic drugs in parenteral infusion (pentothal, propofol, midazolam and/or ketamine), a ketogenic diet and immunotherapy (plasmaferesis and rituximab), and he progressed favourably, with remission of both clinical and electrical crises on day 77 after admission. After 93 days of admission he was discharged with partial reduction of antiepileptic drugs (levetiracetam, topiramate, lacosamide, perampanel and clobazam) and without severe cognitive defects, although maintaining moderate flaccid tetraparesis as a neurological deficit secondary to polyneuropathy of the critical patient.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3084_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3084_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..15e056f212278cfc8672aa1970550cdeba93857b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3084_en.txt
@@ -0,0 +1,2 @@
+A 66-year-old asymptotic male with hypertension, hyperlipidaemia, and a history of syncope was admitted to the hospital after ambulatory 24 h Holter electrocardiography monitoring, which revealed non-sustained ventricular tachycardia. His physical examination was unremarkable. Electrocardiogram revealed sinus rhythm without any ST-segment changes. 2D echocardiography showed preserved left ventricular ejection fraction of 65%. Non-invasive coronary computed tomography angiography (CCTA) showed 60% stenosis of the LMCA bifurcation with the minimal lumen area of 5 mm2, 40% stenosis in the proximal LAD, and 60% stenosis in the proximal LCx. Invasive coronary angiography confirmed stenosis of the LMCA bifurcation as well as revealed two obstructive stenoses of the second diagonal branch (DB) and the distal LCx. The SYNTAX score was 26, which indicates moderate complexity of coronary artery disease and require careful consideration between PCI and CABG. After the heart team’s (cardiologists, interventional cardiologists, cardiac surgeon) decision and patient’s consent, the complex PCI using DK crush bifurcation stenting technique was planned. Firstly, using the right radial approach, successful PCIs of the distal LCx and the second DB were performed. Secondly, LMCA LAD/LCx procedure was carried out. A 7F (French size) EBU (Extra Back Up, a guiding catheter used to provide maximal support and control during PCI) 3.75 mm guiding catheter was used and two Sion Blue ES (Sion Blue Extra Stiff, a guiding catheter used for high torque control and support) guidewires were placed in the distal segments of LCx and LAD. Then, an Ultimaster Nagomi 3.5/18 mm stent was implanted into the LMCA towards the LCx and partially crushed by a 3.0/15 mm semi-compliant balloon. Subsequently, after rewiring, balloon kissing was performed with a 3.0/15 mm semi-compliant balloon in LCx and a 3.5/15 mm semi-compliant balloon in LAD. Ultimaster Nagomi 4.0/15 mm stent was implanted into the LMCA towards the LAD. Proximal optimization technique (a technique involving inflating a balloon in the proximal part of the larger branch to optimize the opening and ensure better stent apposition and expansion before further stenting of the smaller branch) was performed with a 4.0/8 mm non-compliant balloon and, after rewiring the LCx, re-kissing was performed with a 3.0/15 mm balloon in LCx and a 3.5/15 mm balloon in LAD. Finally, an adequate apposition of LMCA/LCx and LAD stents was confirmed by the intravascular ultrasound monitoring. The final angiography revealed an excellent angiographic result, with optimal stent expansion, lesions covered, and TIMI 3 flow in all coronary arteries. The 1-month follow-up of the patient was uneventful.
+
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3094_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3094_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..196f4df0edc62b74f82a8954c69b5c84b40da7c8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3094_en.txt
@@ -0,0 +1,11 @@
+Our patient was a girl who was 40 weeks in utero and born through natural vaginal delivery as the first child of a Japanese couple. Her birth weight, height, and head circumference were 3244 g (+0.67 standard deviation [SD]), 46.8 cm (−0.77 SD), and normal, respectively. Neonatal asphyxia was not observed at birth. Her family history lacked evidence regarding consanguineous marriage, epilepsy, or neuromuscular disease. At 15 days old, she presented with bilateral tonic–clonic seizures that lasted for a few minutes, which started in the left or right upper extremity. The seizure frequency increased to approximately 10 per day; the patient was admitted to the hospital by her previous doctor. Interictal electroencephalography (EEG) revealed multifocal spontaneous spikes. The EEG showed isolated spike waves in the right frontal, central, and occipital regions that did not spread widely. It was not a suppression-burst or hypsarrhythmia pattern. General blood tests, plasma amino acid analysis, general spinal fluid tests, spinal fluid virus isolation, and urinary organic acid analysis revealed no abnormalities. Brain magnetic resonance imaging (MRI) revealed no obvious epilepsy-inducing structural abnormalities. She was started on phenobarbital for neonatal-onset epilepsy of unknown classification; however, she showed no improvement. She was referred to our hospital at the age of 75 days.
+
+Physical examination and general neurological findings revealed no obvious facial abnormalities or deformities. Eye-tracking and smiling when someone touched or held her were appropriate for infant age. Interictal EEG revealed normal sleep waves; however, there were frequent localized spike waves and spike–slow wave complexes. A tentative diagnosis of symptomatic localization-related epilepsy was made, and treatment was initiated. She continued to experience seizures approximately 10 times a day; therefore, phenobarbital was discontinued and carbamazepine was started at 78 days old. However, it was discontinued after a few days due to an increase in seizure frequency. Oral sodium valproate and zonisamide were initiated at 81 and 88 days old, respectively. Vitamin B6 was administered; however, it was discontinued after having no effect. After starting sodium valproate and zonisamide, there was a gradual decrease in the seizure frequency; however, even at the maximum dose, seizures were still observed 3–4 times a day. Initially, the seizures were generalized tonic convulsions starting from the left upper extremity. However, around the age of 88 days, she displayed a series of nodding spasms. After adjustment of medications, oral intake was decreased, and tube feeding was initiated. At 108 days old, the patient underwent examination for primary disease according to the Department of Child Neurology, National Center of Neurology and Psychiatry. Long-term EEG monitoring revealed frequent irregular high-amplitude spikes and slow waves without left-right synchrony during sleep and wakefulness, which indicated a hypsarrhythmia. Ictal EEG revealed a fast-wave rhythm and positive slow waves preceding the spasm. Eye tracking and chuckling during the early disease stage were no longer observed. Further, she was considered to be developmentally regressing and was diagnosed with West syndrome. Brain MRI revealed no structural abnormalities presenting as obvious epileptic foci, including focal cortical dysplasia. The patient was started on adrenocorticotropic hormone (ACTH) therapy at 114 days old, which was administered daily for two weeks.
+
+The seizures disappeared the day after starting ACTH therapy. Recurrent spasms were observed 8 days after initiating ACTH therapy. Subsequently, sodium valproate and zonisamide were continued; however, there was no change in seizure frequency. Nitrazepam was started at the age of 4 months, which decreased the seizure frequency to 1–2 per day. EEG revealed multifocal spikes; however, the typical hypsarrhythmia disappeared and there was improved background activity. Cerebral cortical atrophy occurred as a side effect of ACTH therapy. Development remained regressive, without evidence of head control, eye tracking, or chuckling. Due to aspiration pneumonia, nutrition was maintained by tube feeding. The patient was discharged from the hospital at 6 months old. After 7 months old, the patient lacked obvious clinical seizures. At 10 months old, genetic testing for West syndrome was performed. Subsequently, she was hospitalized for a urinary tract infection and pneumonia at 10 months and 1.3 years old, respectively.
+
+At approximately 1.2 years old, she began experiencing a series of seizures involving the twitching of her right leg during sleep for 2–3 min at a time. Ictal EEG revealed series-forming myoclonus seizures. Interictal EEG showed multifocal spikes and slow waves at sleep onset without hypsarrhythmia. Moreover, background activity during wakefulness revealed continuous slow waves. Brain MRI showed diffuse cerebral atrophy and corpus callosum thinning; however, there were no obvious abnormal structures. Despite the observation of a new seizure type, three antiepileptic drugs were administered at extreme doses and no indication for active surgery was indicated.
+
+At 1.5 years old, she underwent further genetic testing. Target capture sequencing was performed to screen 114 epilepsy-related genes in the proband of the Department of Pediatrics at Fukuoka. We identified a missense variant (RefSeq accession number NM_003165: c.875G > A [p.Arg292His] available at https://www.ncbi.nlm.nih.gov/refseq/ (accessed on 27 July 2022)) in the STXBP1 gene. Sanger sequencing confirmed the variant in the proband. A search for this variant in her parents through Sanger sequencing revealed that the variant was de novo. Finally, she was diagnosed with developmental and epileptic encephalopathies exhibiting clinical characteristics of West syndrome due to STXBP1 gene mutation (c.875G > A [p.Arg292His], previously reported in ClinVar [rs796053361] as a pathogenic variant). Other unidentified variants in addition to STXBP1-p.Arg292His may have contributed to her clinical phenotype; since she did not undergo whole genome or whole exome sequencing, we continue to investigate this possibility.
+
+The patient is currently 2.1 years old. Although the frequency of epileptic seizures has decreased, her development remains regressive, and she has a severe intellectual disability. At the time of writing, apart from the neurological phenotype, the patient had no other symptoms, such as metabolic disease, primary immunodeficiency, or hyperinflammatory condition. She continues to receive medical treatment. Should the seizures worsen in the future, we will review the choice of drug according to the seizure type and consider palliative epilepsy surgical treatment to reduce seizure frequency.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_311_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_311_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..13474bb61cc7400655cec48c930e9ef4a3ef124f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_311_en.txt
@@ -0,0 +1,6 @@
+This case study was approved by the Institutional Review Board of the ethical committee of Fudan University Shanghai Cancer Center.
+A 48-year-old woman presented with epigastric discomfort for several weeks, and the levels of serum tumor markers were normal. Computed tomography (CT) of the abdomen showed a mass (diameter 21.7 mm) confined to the neck of the pancreas with low density and two enlarged lymph nodes approximately 8 mm in size around the pancreas . Subsequently, she underwent positron emission tomography/computed tomography (PET/CT). A lytic bony lesion in the caput femoris was found besides the pancreatic mass , while there were no signs of metastasis in the axillary and supraclavicular lymph nodes, liver or lung. After consideration of imaging manifestations of malignancy, the patient underwent distal pancreatosplenectomy.
+Microscopic analysis revealed that the tumor was composed of pleomorphic cells infiltrating the lobules of the pancreas . The malignant cells were arranged in the form of solid sheets and nests and as single files, with high nuclear to cytoplasmic ratio and loss of cohesion . The cell contours were round to polygonal. The cytoplasm of the cells was abundant and eosinophilic, with nuclei of increased size, frequent mitotic figures, and nucleolar prominence . There were no metastases in any of the ten lymph nodes removed around the pancreas.
+Immunohistochemical staining revealed that the tumor cells were positive for p120 (cytoplasmic) and GATA3 and negative for estrogen receptor (ER), progesterone receptor (PR), human epidermal growth factor receptor 2 (HER2), E-cadherin, gross cystic disease fluid protein 15 (GCDFP-15) and mammaglobin.
+Past medical history of this patient was significant for a modified radical mastectomy. Two years ago, a lump was found in her right breast without swelling or pain, and she chose to follow up. The patient presented to our outpatient clinic because of dragging pain in her right breast 10 months later. Physical examination revealed a breast mass (approximately 4 × 4 cm) in the internal inferior quadrant, and invasive carcinoma was confirmed by core needle biopsy. Ultrasonography showed no other metastases in the left breast, supraclavicular lymph nodes or abdomen. The patient was diagnosed with invasive PLC (4.5 × 3.5 × 2.0 cm in size) after modified radical mastectomy , with the absence of metastases in all 17 lymph nodes removed (pT2 N0 M0, stage IIA). By immunohistochemistry, the tumor showed a triple-negative breast cancer (TNBC) phenotype (ER−/PR−/HER2-), negative for E-cadherin , positive for GATA-3 , and the Ki-67 index was approximately 40%. After mastectomy, she received adjuvant chemotherapy with paclitaxel for 6 courses and then underwent regular follow up.
+The profile of this case is in accordance with the diagnosis of metastatic pleomorphic lobular breast cancer in the pancreas. The patient was then treated with capecitabine, an orally administered chemotherapeutic agent used in the treatment of numerous cancers, including metastatic breast cancer.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3130_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3130_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6c4eaf4087aa3ebedaf5c6420204ef2031df77bb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3130_en.txt
@@ -0,0 +1,41 @@
+A 63-old man presented to our Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto, complaining of low visual acuity in both eyes and ocular discomfort for about two years.
+
+His ophthalmic history was unremarkable. His uncorrected distance visual acuity (UDVA) measured with Snellen charts was 20/100 in the right eye (RE) and 20/200 in the left eye (LE), while his best corrected visual acuity (BCVA) was 20/50 in the RE and 20/100 in the LE. A history of amblyopia in his left eye was reported.
+
+Slit-lamp examination revealed a horizontal gray-whitish band across the central cornea in both eyes, sparing the peripheral cornea and the limbus. No other pathological findings were observed.
+
+He was diagnosed with CBK secondary to occupational exposure to mercury vapors, since he was a worker of steel industry.
+
+Fundus examination was not possible. The anterior segment OCT (AS-OCT) showed a thickness corneal opacity of 150 um in both eyes.
+
+This study adhered to the Declaration of Helsinki and was approved by the Ethics Committee of the Ophthalmology Unit of “SS. Annunziata” Hospital Review Board. The patient provided informed consent for all procedures and their possible complications were explained. The patient gave informed consent for the publication of any case details and accompanying images. The IRB of the Ophthalmology Unit of “SS. Annunziata” Hospital, Taranto gave the approval for the publication of this case report.
+
+The tomographic maps (Precisio2®, iVIS Technologies, Taranto, Italy) showed in both eyes an irregular corneal morphology due to the presence of the opacity.
+
+Our first attempt was performing EDTA chelation procedure which removed the superficial calcium plaques. Two months after the procedure, the UDVA had improved to 20/80 in RE and to 20/100 in the LE, but the cornea was not completely clear, with residual stromal haze. The EDTA chelation procedure had no effect on the deeper calcium deposits and the tomographic maps showed irregular corneal surface. For this reason, a combined treatment with PRK and PTK was scheduled in both eyes in order to recover visual acuity and minimize surgical invasiveness.The customized treatment was determined by taking into account the following parameters: spherical error, some biometric data including anterior chamber depth, axial length; corneal morphological irregularity index (CMI) measured by tomographer (Precisio2®, iVIS Technologies, Taranto, Italy); pupillometry (pMetrics®, iVIS Technologies, Taranto, Italy).
+
+CMI, measured in μm, is a parameter which indicates the aberrations above the second order of the anterior and posterior corneal surface. It is strongly correlated to the quality of vision of the patient: the more the CMI, the worse the quality of vision.
+
+The customized ablation is achieved using a ray tracing-based software. Ray tracing is based on the Snell law of refraction and allows the evaluation of the pathway of light rays after their passage through the eye from the anterior corneal surface to the retina. In this way, it is possible to know the exact refractive contribution of each surface and fully customize excimer laser ablation. This is achieved by not performing a full regularization of the anterior corneal surface; instead, a small amount of aberration on the anterior corneal surface is left to compensate for the posterior surface aberrations which are of opposite sign. In fact, the posterior corneal shape introduces posterior corneal morphological irregularities, which partially compensate for the anterior ones.
+
+In this way, the ray tracing algorithm optimizes the quality of vision and at the same time minimizes the consumption of stromal tissue.
+
+We decided to perform the surgery first on the right eye and then after 20 days on the left eye. The surgery was performed using topical anesthesia (oxybuprocaine eye drops, Benoxinato Cloridrato, Alfa Intes S.r.l). We decided to use a no-touch approach in order to have less postoperative pain and faster re-epithelialization. The surgery was executed with the iRes™ excimer laser, working with flying-spot of 650µm at 1000Hz (iVis Technologies S.r.l).
+
+The customized ablation profile obtained had a refractive zone of 5.60 mm in RE and 5.50 mm in LE, and a connecting zone of 8.90 mm in RE and 9.60 mm in LE. The cumulative ablation stromal depth was 34 μm in both eyes.
+
+Following surface ablation, PTK with a frequency of 10% was carried out with masking agents (1% hydroxymethylcellulose) to smooth the ablated surface, with a depth of 80 μm.
+
+To avoid any kind of corneal haze, 0.02% Mitomycin C (MMC, 0.2 mg/mL, diluted in BSS®) was applied over the ablated area for 20 seconds. At the end of the procedure, a soft therapeutic contact lens was placed. The therapeutical postoperative regimen consisted in topical dexamethasone and amikacin eye drops given four times a day for a week. The patient was then put on 0.1% fluorometholone eye drops and artificial tears eye drops for 12 weeks, which were tapered gradually. The patient was examined the day following surgery, and additional follow-up visits were carried out at one week, two weeks, one, three, and six months, respectively.
+
+At the 1-week follow-up visit the contact lens was removed, with a complete epithelial healing. On slit lamp examination the clarity of the ablated area was notably improved.
+
+AS-OCT scans and topography were performed at 1 week, 1, 3 and 6 months after treatment.
+
+At the 1-month follow-up the final uncorrected visual acuity (UCVA) improved from 20/200 to 20/20 in right eye and to 20/63 in the left eye.
+
+CMI decreased from 15 μm to 3 μm in RE and from 21 μm to 11 μm in LE, and minimum corneal thickness was reduced from 567 μm to 533 μm in RE, and from 574 μm to 540 μm in LE.
+
+The improved visual acuity was maintained at 3-month follow-up and 6-month follow-up, with the patient fully satisfied. The corneal clarity remained during the 6 months follow-up.
+
+The postoperative follow-up was uneventful. The ablation map and topographic changes of both eyes were reported.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3143_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3143_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7ecd7df502a5c80429e61b1ec016f9de18ba6f8c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3143_en.txt
@@ -0,0 +1,29 @@
+We report the case of an 11-year-old girl who had been presenting a severe asthenia for a month, orthostatic dizziness, headaches and abdominal pain. Patient familial history was remarkable due to the total absence of the pericardium associated with hypo-gammaglobulinemia and bronchiectasis in her 9-year-old sister [5]. Patient personal history was uneventful.
+
+A previous recent laboratory examination had revealed moderate inflammation (leucocyte count: 13,440/mm; CRP: 30 mg/L) but increased sedimentation rate (68 mm/h), and slightly increased fasting glycemia (106 mg/dL) with a normal insulin concentration. Urine analysis showed bacteriuria. On that basis, she received a treatment with sulfamethoxazol.
+
+Patient status did not improve, and thus, she was referred to our institution for endocrinological and cardiological advice. A physical examination confirmed recent weight loss (2.5 kg in 10 days), systemic arterial hypertension (147/104 mm Hg) in an upright position dropping in a supine position (80/60 mm Hg), a normal heart rate and normal transcutaneous oxygen saturation.
+
+The patient was pale with wet and cold extremities. Precordium was hyperactive, and cardiac and pulmonary auscultation was normal as was abdominal palpation.
+
+An electrocardiogram showed left ventricular hypertrophy according to Davignon’s criteria with non-specific repolarization anomalies and a prolonged QT interval corrected by the Bazzett’s formula (QTc: 470 ms).
+
+Echocardiography demonstrated global left ventricular hypertrophy with a dilated aortic root (Z-score calculated according to: 2.5) and grade I aortic insufficiency.
+
+Abdominal ultrasound showed the presence of a right-sided adrenal mass.
+
+The left-sided adrenal gland and all other intra-abdominal organs were normal.
+
+An oral glucose tolerance test showed moderate hyperglycemia associated with hyperinsulinemia. Cortisol- and thyroid hormone serum levels were normal. Noradrenaline and normetanephrine urine concentrations were strongly increased (>711 μg/24H and >9000 μg/24H, respectively). The right-sided adrenal mass was confirmed via magnetic resonance imaging, and iodine-123-metaiodobenzylguathdine ([123I]-mIBG) scintigraphy confirmed isolated tracer fixation on the right adrenal gland.
+
+The patient was scheduled for surgery and stabilized until then using a combination of a β-blocker and calcium channel antagonist, allowing for blood pressure control. She underwent total adrenalectomy via laparoscopy. Anatomo-pathology confirmed the diagnosis of a typical pheochromocytoma without any signs of malignancy.
+
+Microscopic analysis showed a nest-shaped tumor architecture with large polygonal cells. The central part of the tumor presented some ischemic necrotic areas and vascular structures with recent thrombosis but no signs of vascular invasion. There was no mitotic activity.
+
+Immune-histological examination proved a high degree of positivity for the neural cell adhesion molecule CD56 and for the markers of neuroendocrine tumors chromogranine and synatophysine. The level of cell proliferation was estimated to be lower than 1%.
+
+A genetic evaluation was carried out. DNA sequence analysis allowed for the exclusion of pathogenic gene mutations implicated in hereditary paragangliomas and pheochromocytoma (SDHA, SDHB, SDHC, SDHD, SDHAF2, TMEM 127, MAX, VHL, FH, MDH2 and exons 10, 11, 13, 14 and 16 of the RET gene) but demonstrated a somatic mutation c.57C>T in exon 3 of the tumor suppressor gene von Hippel-Lindau.
+
+Cardiac examination, including echocardiography performed 2 weeks after right-sided adrenalectomy, showed residual left ventricular hypertrophy but normalization of the aortic root dimension (Z-score: 0.7) and QTc duration.
+
+Two years after the operation, the patient complained about dizziness, palpitations and chest pain. The clinical examination, including blood pressure, was normal. Concentrations of blood and urine catecholamines were in the normal range. Abdominal MRI showed a normal left-sided adrenal gland an empty right-sided adrenal lodge. Endocrinological and cardiological examinations, including echocardiography and abdominal MRI, were repeated and remain normal after a follow-up period of 5 years.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3204_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3204_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2fb3fc7ef556a27872599ec00782cf74ff988878
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3204_en.txt
@@ -0,0 +1,3 @@
+A 60-year-old man with a history of rheumatoid arthritis and hypothyroidism on levothyroxine therapy presents with a two-month history of sudden onset facial edema accompanied by asthenia, adynamic and macroglossia, which has led to nasal obstruction, oropharyngeal dysphagia to solids and liquids, and dysphonia. Due to the persistence of symptoms, a course of dexamethasone was administered and a tongue biopsy was performed, which showed amyloid deposits confirmed by mass spectroscopy, concluding that it was an AL amyloidosis. The serum level of lambda light chain was 145.6 mg/L; a bone marrow biopsy was performed, finding 30% of monoclonal plasma cells. The results of the complementary studies performed on the patient were a troponin of less than 6 ng/L, BNP (brain natriuretic peptide) of 18.6 pg/mL and an echocardiography without alterations, while the computed tomography showed hepatomegaly.
+
+Inpatient treatment was initiated with oral cyclophosphamide 500 mg/m2 and dexamethasone 20 mg/week, and a significant improvement was observed within the first 10 days of treatment.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_320_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_320_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cef0c37a77beea322eaea597a066fae4436145b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_320_en.txt
@@ -0,0 +1 @@
+A 35-year-old African American man with no significant past medical history was referred to our neuromuscular clinic for frequent falls and concern for neuropathy. He first noticed a bilateral foot drop causing an abnormal gait and frequent falls at the age of 25. He experienced slowly progressive muscle weakness with the involvement of the hands by the age of 33. He had no sensory complaints and no muscle cramping or stiffness. His 38-year-old brother also had a bilateral foot drop that started in his 30s and bilateral hand weakness. There was no history of a similar condition in any other family members, including parents and two paternal half-sisters. His neurologic examination revealed normal cognition and cranial nerve function without tongue weakness, atrophy, or fasciculation. Manual muscle testing revealed normal muscle strength in Medical Research Council grades except for finger extension 4/5, distal finger flexion 4/5, thumb abduction 3/5, hand interosseous muscles 4/5, hip flexion 5/5, ankle dorsiflexion 3/5, and ankle plantar flexion 4/5 bilaterally. He had muscle atrophy distally in all limbs with claw hands and pes cavus. Deep tendon reflexes were 2+ throughout except for absent Achilles tendon reflexes bilaterally. There was no percussion or handgrip myotonia, and the muscle tone was normal. Sensory examination was normal to pinprick, vibratory, and proprioceptive testing. He had a slow high steppage gait. He had bilateral contracture in the Achilles tendons with no gross spine deformity.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3224_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3224_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a1f63d139239429042693dea08082a423fadd981
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3224_en.txt
@@ -0,0 +1 @@
+A 69-year-old elderly woman presented to the Bazhong Traditional Chinese Medicine Hospital with symptoms of abdominal pain and vomiting. She was diagnosed with intestinal obstruction and underwent laparoscopic exploration, removal of foreign body in the ileum, lysis of adhesions, and resection and anastomosis of the affected intestinal segment. After surgery, the patient was instructed to abstain from oral intake, thus she was treated with a 250mL infusion of C14-24 fat emulsion containing 75g (manufactured by Sichuan Kelun Pharmaceutical Co., Ltd.) once a day via intravenous drip. The postoperative review revealed a triglyceride (TG) level of 19.71 mmol/L. On the third day after surgery, the patient experienced worsening abdominal pain and black stools, prompting them to seek medical attention at our hospital (Bazhong Central Hospital). Upon admission, a comprehensive physical examination was performed on the patient. Specifically, auscultation of the lungs revealed decreased breath sounds and the presence of crackles, indicating the presence of pulmonary inflammation. Abdominal examination revealed abdominal distension, generalized tenderness, and muscle guarding. Further, an abdominal CT scan was performed on the patient, revealing acute pancreatitis with pancreatic swelling and slightly decreased enhancement of the local density. The specific performance might be peripancreatic fluid collection, thickening of the peritoneum and omentum, homogeneous decrease in splenic density, and homogeneous increase in gallbladder density. Moreover, Extensive fluid accumulation was observed surrounding the abdominal aorta, splenic artery, and anterior renal fascia, with blurred fat planes in the abdominal cavity. The chest CT scan indicated inflammation in the bilateral lower lobes of the lungs, minimal pleural effusion, and atelectasis in the lower lobes of both lungs. Further analysis of the complete blood count revealed a white blood cell count (WBC) of 33.68×10^9/L, with 89.1% neutrophils (Neu), hemoglobin (Hb) level of 146g/L, platelet count (PLT) of 242×10^9/L, procalcitonin (PCT) level of 1.17 ng/mL, and C-reactive protein (CRP) level of 12.03mg/L. The fecal occult blood test was positive, suggesting gastrointestinal bleeding likely induced by postoperative and prolonged fasting. It is worth noting that due to the severe hypertriglyceridemia, it was not possible to evaluate the liver and kidney function, as well as the lipid profile. Overall, blood purification, plasma exchange, oral lipid-lowering medications, CT-guided precise puncture drainage and catheter placement in the necrotic area of the pancreas, along with antimicrobial therapy, fluid resuscitation, and supportive care, are all considered beneficial in aiding the patient’s recovery. On the first day of admission, the patient underwent plasma exchange, perfusion, antimicrobial therapy, antispasmodics, acid suppression, enzyme inhibition, and measures to stabilize electrolytes and provide nutritional support as symptomatic treatment. On the second day of admission, despite undergoing plasma exchange, the patient’s lipid levels remained elevated, and an electrocardiogram revealed atrial fibrillation (Table 1). To address this, amiodarone was added to the existing treatment plan for rhythm control therapy. Nevertheless, on the third day of admission, the patient exhibited poor mental status and drowsiness. Despite undergoing another round of plasma exchange, both lipid levels and inflammatory markers remained elevated. At this point, the patient developed multi-organ dysfunction involving the cardiovascular, respiratory, and coagulation systems, necessitating endotracheal intubation. Blood perfusion with HA380 and HA330 was initiated to support hemodynamic stability. Following perfusion therapy, a subsequent examination revealed a significant decrease in lipid levels compared to previous measurements. Therefore, plasma exchange was discontinued and the patient was switched to oral lipid-lowering medications for continued treatment. By the fourth day of admission, coagulation function indicators had essentially returned to normal. On the fifth day of admission, there was a significant decrease in the patient’s lipid levels compared to previous measurements. However, due to the patient’s rapid respiratory rate, diminished breath sounds in both lungs, and chest CT findings suggestive of atelectasis, blood purification was implemented as an adjunct to the existing treatment plan to alleviate fluid overload. On the eighth day of admission, the patient’s lipid levels showed significant improvement compared to previous measurements. Whereas, the patient developed recurrent fever, and after ruling out pulmonary infection, we considered acute necrotizing pancreatitis as the cause of fever. Hence, on the sixteenth day of admission, we performed CT-guided precise puncture drainage and catheter placement at the site of pancreatic necrosis, during which purulent fluid with a dark red color was obtained. Meanwhile, we continued with antimicrobial therapy and other treatments. On the twenty-fourth day of admission, approximately 5mL of purulent fluid was still draining from the catheter, but the color was lighter compared to previous drainage. A follow-up abdominal ultrasound showed normal pancreatic size and shape, clear contours, and uniform echo in the parenchyma, with no dilation of the main pancreatic duct. The results of the follow-up abdominal CT scan are consistent with the ultrasound findings. Further review of the chest CT reveals improved pneumonia bilaterally, with minimal pleural effusion in both lungs. Considering the significant improvement in the patient’s condition, the patient was discharged on the twenty-fourth day of admission. Moreover, we have conducted long-term follow-up of the patient. The prognosis is favorable, with repeated measurements indicating normal lipid levels.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3243_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3243_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd6224bc7c19863e6a7c9d20485ea0a283e86923
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3243_en.txt
@@ -0,0 +1,7 @@
+An 82-year-old man presented at our emergency department because of aggravated dyspnea classified as New York Heart Association functional class IV. He has been diagnosed with severe AS 1 year previously, at which time surgical aortic valve replacement was recommended. However, the patient refused open heart surgery at that time. His physical examination showed a blood pressure of 94/56 mmHg, pulse rate of 110 beats per minute, and drowsy mental status. Electrocardiography showed atrial fibrillation with occasional premature ventricular complex, and chest X-ray showed cardiomegaly with bilateral pulmonary edema. Laboratory examination revealed acute kidney injury, creatinine level of 3.8 mg/dL, and estimated glomerular filtration rate (eGFR) of 16 mL/min/1.73 m2. His N-type pro-brain natriuretic peptide level was elevated at 20,774 pg/mL. Transthoracic echocardiography (TTE) revealed low-flow, low-gradient tricuspid aortic valve stenosis (aortic valve area of 0.69 cm2 based on 2D planimetry, 0.86 cm2 based on the continuity equation, and mean systolic pressure gradient of 16.3 mmHg) with decreased left ventricular (LV) systolic function (LV ejection fraction, 34%). Annulus diameter measured by 2D-TTE was 20.6 mm.
+
+With the clinical diagnosis of acute decompensated severe AS accompanied by cardiorenal syndrome, surgical aortic valve replacement was indicated. However, the patient was considered very high-risk candidate for open heart surgery based on the Society of Thoracic Surgeons Predicted Risk of Mortality score (21.153%) [2]. Furthermore, his clinical status had not improved despite intravenous dobutamine infusion with furosemide infusion. Therefore, we ultimately decided to perform emergent TAVR.
+
+The TAVR procedure was performed under general anesthesia. In general, CT should be required to determine the procedure approach and prosthesis size, but it might be dangerous for a patient with decompensated heart failure accompanied by cardiorenal syndrome. Before the TAVR procedure, we attempted to obtain accurate information about annulus diameter by 3D-transesophageal echocardiography (TEE). The TEE annulus diameter measurement of 23.5 mm corresponded to that of the CoreValve transcatheter valve (26-mm; Evolute-R™, Medtronic, NY, USA). We punctured the left common femoral artery using the standard percutaneous access techniques, and peripheral angiogram was performed using Judkins Right 4.0 coronary catheter. Fortunately, peripheral angiography showed adequate size of the right iliofemoral artery for vascular access for the CoreValve delivery. Coronary angiography also showed no significant luminal narrowing. Then, we inserted a 26-mm self-expanding CoreValve through the right common femoral artery sheath and deployed it at the aortic valve under fluoroscopic guidance without rapid pacing. The immediate post-procedural aortogram and TEE showed mild paravalvular aortic regurgitation. The patient’s vital signs were stable during the procedure.
+
+The patient’s dyspnea was dramatically improved after the procedure, and chest X-ray showed marked improvement. The post-procedural TTE revealed improved LV systolic function (LV ejection fraction, 45%) with well-functioning CoreValve (aortic valve area of 2.15 cm2 based on the continuity equation and mean systolic pressure gradient of 3.22 mmHg). Urine output was also increased, creatinine level was decreased to 1.4 mg/dL, and eGFR increased to 52 mL/min/1.73 m2. He was discharged 7 days after the procedure, and his 3-month follow-up echocardiography showed no significant interval change from his immediate post-procedural findings.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3301_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3301_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a621cfcf1ce466e2e5bdfd134e12de03fa34b79a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3301_en.txt
@@ -0,0 +1 @@
+This case involves a 29-year-old mother who has given birth four times, currently in her second month postpartum, presenting to the emergency department with complaints of headaches and blurred vision persisting for three weeks. She also reported experiencing right-sided body weakness for one day. Despite being treated twice before for migraine headaches, a diagnosis of CVT was eventually made. There is no personal or family history of thromboembolism. Upon examination, her blood pressure was 100/60 mmHg, and all other vital signs were within normal limits. She was fully conscious, with a Glasgow Coma Scale (GCS) score of 15/15. Motor strength was 4/5 in the right upper extremity, 4+ in the right lower extremity, and 5/5 in the left upper and lower extremities. Meningeal signs were absent. Laboratory tests including complete blood count, random blood sugar, organ function tests, and viral markers were all normal. A contrast-enhanced head computed tomography (CT) scan revealed a filling defect along the superior sagittal sinus, resembling a delta sign, as well as a tubular filling defect along the posterior aspect of the superior sagittal sinus. Enoxaparin treatment was started, and the patient was admitted to the medical ward. On the admission day, the patient experienced a single episode of generalized tonic-clonic seizure and was subsequently moved to the intensive care unit, where phenytoin was initiated. Magnetic resonance imaging (MRI) with MRV conducted on the second day of admission revealed a focal filling defect in the right anastomotic vein and the posterior segment of the superior sagittal sinus. The patient underwent an ophthalmologic assessment, which revealed a diagnosis of papilledema. Treatment with acetazolamide was initiated accordingly. She remained in the intensive care unit for 5 days and subsequently spent 11 days in the medical ward. After a total of 16 days of hospitalization, the patient’s condition improved with the combination of phenytoin, acetazolamide, and warfarin. Considering the postpartum period as a temporary risk factor for CVT, oral anticoagulation and other medications were ceased after six months of treatment. The patient is presently in good health, indicating an absence of weakness, headaches, or any lingering symptoms previously experienced.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3309_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3309_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..586f5447eba5c73a1efd4311a293a7484ad2d0e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3309_en.txt
@@ -0,0 +1,20 @@
+Twin children aged 2 years and 8 months, born to a gravida 3, para 2 mother, presented to the Orthopedic department at CURE Children’s Hospital, Ethiopia. The presenting complaint was a bilateral decrease in size and poor thumb function in both children. The children were born at a local health center. The antenatal history was unremarkable, and the mother did not recall the birth weight. Apart from the decreased thumb size, they were born without any anomalies, and their parents had no consanguinity. There was no family history of twin pregnancies on either parent’s side.
+
+On physical examination, both children had bilaterally decreased size of their thumbs with other normal-appearing digits, the wrist in a neutral position, and no limb length discrepancy. They had well-formed skin creases and thenar folds. The children were observed to use their index and long fingers of both hands for pinching. During a passive range of motion, the first web space was tight with excessive adduction at the metacarpophalangeal (MCP) and carpometacarpal (CMC) joints of the thumb. The wrist, elbow, and shoulder ranges of motion were normal. On auscultation, heart sounds were well heard with clear bilateral air entry, no swelling, and no mass over the abdomen. No visible abnormalities were observed in their back or lower limbs.
+
+X-ray images were taken and showed a significantly decreased thumb size with abnormally developed basal metacarpal bone and deficient first CMC joint, and no radial deviation of the wrist joint. To rule out other associated anomalies, abdominal ultrasonography and echocardiography were performed in both patients, and the results were unremarkable. On complete blood cell count, twin A had hemoglobin of 12.5 g/dl and the platelet count was 356, whereas twin B’s hemoglobin and platelet count were 13.0 g/dl and 429, respectively. Based on the above findings, a diagnosis of type IIIB bilateral thumb hypoplasia was made for both twin children according to the modified Blauth classification,5 and pollicization was performed using the Buck-Gramcko technique, as described by Ezaki et al.
+
+Surgical Procedure
+After obtaining informed consent from the family, the infants were taken to the operating theater. General anesthesia was administered with endotracheal intubation and the skin prepared with povidone-iodine and draped. The limb was exsanguinated and an Esmarch’s tourniquet was applied.8 Similar skin incisions were utilized for all four hands, which were designed with a fish mouth appearance over the radial aspect of the index finger, and the palmar incision was more distal than dorsal so that the glabrous skin would be placed over the palmar aspect of the index finger, which in turn would improve the appearance of the index finger in the thumb position.
+
+
+The volar skin incision started from the radial aspect of the index finger and continued to the thumb, looking for a vessel within the hypoplastic digit to trace the radial neurovascular bundle of the index finger. After localizing the radial neurovascular bundle of the index finger, dissection proceeded further to the ulna to identify the proper digital artery on the ulnar side of the index finger and common digital arteries in the second web space. To allow tension-free index finger pollicization, the radial proper digital artery of the middle finger was ligated and labeled with a stay suture. The common digital nerve to the second web space was divided along the proper digital nerve to the ulnar side of the index finger and the radial side of the middle finger. No variation was observed during dissection.
+
+The intervolar plate ligament and fascia between the index and middle fingers were divided. The A1 and A2 pulleys of the index finger were opened to avoid flexor tendon buckling when the digit was shortened. The palmar digital arteries were protected with vessel loops, and dissection proceeded gently over the dorsal side. The dorsal flap was carefully raised to preserve the dorsal vein of the index finger. The extensor digitorum communis (EDC) and the extensor index proprius (EIP) were identified. The tendon of the EDC was severed at the level of the metacarpophalangeal joint for subsequent suturing to the base of the proximal phalanx. The suture was placed over the tendons of the palmar and dorsal interphalangeal muscles before dividing them for later transfer to the proximal interphalangeal joint extensor hood.
+
+About 2 cm of the index finger metacarpal was removed with a distal cut through the physis, where physeodesis was performed to prevent growth of the pollicized index finger. Hence, a 1.0 mm K-wire was inserted retrogradely from the metacarpal head to the proximal phalanx hyperextending into the MCP joint. Using the K-wire as a joystick, the digit was positioned at 35° palmar, 20° radial abduction, and 80° pronation and was secured with the same K-wire (1.0 m). The EDC tendon was sutured to the base of the new thumb to act as the new abductor pollicis longus. The tendons of the first dorsal and palmar interosseous muscles were transferred to the radial and ulnar aspects, respectively, to act as the abductor pollicis brevis and adductor pollicis, respectively. The extensor index proprius acts as the extensor pollicis longus. The tourniquet time was 2 hrs and the vascularity of the new thumb was checked. Any redundant skin was trimmed and the wound was closed in an interrupted fashion.
+
+After releasing the tourniquet, arterial circulation returned within a few seconds in three of the four pollicizations. However, in one case the arterial circulation was delayed beyond the expected time despite the application of warm saline-soaked gauze and release of some suture knots. Subsequently, we removed the K-wire from the proximal segment, after which the circulation returned immediately, which may be explained by inadvertent kinking of the arteries. The digit was then repositioned and fixed with the same K-wire and perfused well postoperatively. The skin was then closed with a 5.0 plain gut and covered with xeroform, fluffs of gauze and cotton, and a long-arm cast was applied.
+
+Follow-Up and Outcomes
+We removed the cast and K-wires after 6 weeks of immobilization and the pollicized index fingers were well-maintained in the thumbs position. The incisions healed adequately and no wound complications were observed. Hand physiotherapy was started to increase ranges-of-motion exercises, such as playing with different toys and encouraging them to hold a pencil. They were able to pinch at 12 weeks and grabbing at 6 months.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3315_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3315_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..58c9bd702c5808fb9d9f20c6604ea6a1af232901
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3315_en.txt
@@ -0,0 +1,9 @@
+A 29-year-old male patient was admitted to our department on December 29th, 2020 with complaints of moderate pain and chronic subcutaneous abscess with purulent flow from his old surgical scar on the lower back.
+
+Thirty-four months before admission, the patient underwent a traditional open bilateral L4 laminotomy without discectomy and intraspine device insertion for the treatment of L4-5 central lumbar spinal stenosis at another hospital. The patient was discharged 4 days after surgery without radiating pain, and the surgical wound was well healed. He gradually returned to his normal activity and work. However, he had moderate pain, redness and swelling of his old surgical scar approximately one month before coming to our hospital, but he did not receive any treatment. One month later, he had a mass at his old surgical scar site with purulent discharge, and he visited our hospital.
+
+A chronic subcutaneous abscess and normal neurological findings were found by physical examination. The erythrocyte sedimentation rate (ESR) was 2 mm/h, and the white blood cell (WBC) count was 6.550/mm3. Magnetic resonance imaging (MRI) of the lumbar spine was performed on the day of the visit and showed a chronic subcutaneous abscess connected to the artificial device. No evidence of lumbar discitis or epidural abscess was detected on MRI.
+
+Staphylococcus aureus was found in cultures of purulent flow from the chronic subcutaneous abscess, and cefoxitin 4 gr/day was initiated according to the sensitivity tests. The artificial implant was removed, debridement of the soft tissue and L4 and L5 spinous processes was performed, and closed drainage and wound closure were achieved. Pathological examination of the surgical material was consistent with chronic nonspecific infection, and Staphylococcus aureus was detected again in cultures.
+
+The wound healed satisfactorily, and the patient was discharged on the 10th postoperative day. He had no complaints more than 2 years later.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3323_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3323_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbfd449251e63295f1f879a788b9bef4b6275d76
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3323_en.txt
@@ -0,0 +1,7 @@
+The case report was approved by the Ethics Committee of the General Hospital of Veroia (decision No. 11, 10/12/2017). The patient’s family provided verbal informed consent. A 64-year-old man with a medical history of bipolar disorder and arterial hypertension was hospitalized for a delayed presentation ST-elevation myocardial infarction. He was admitted to our hospital 24 hours after symptom onset. Diagnostic coronary angiography revealed 95% stenosis at the distal third of the right coronary artery, and he underwent a primary percutaneous coronary intervention to the culprit lesion. Loading doses of aspirin and ticagrelor were given. During his hospitalization, he reported palpitations and shortness of breath. Clinical examination revealed normal heart sounds and a grade III systolic murmur at the cardiac apex. The patient’s blood pressure was 100/65 mmHg, pulse rate was 95 bpm, and respiratory rate was 14 breaths/minute. He had functional class II heart failure according to the New York Heart Association. Electrocardiography showed a sinus rhythm with Q-wave formation in the inferior wall leads (II, III, aVF), T-wave inversion in the same leads, and borderline QT prolongation (QTc of 490 ms). No ST elevation suggestive of left ventricular aneurysm formation was noticed. The P2Y12 inhibitor was switched from ticagrelor to prasugrel, and 24-hour ambulatory electrocardiography revealed frequent premature atrial and ventricular complexes. Transthoracic echocardiography showed a hypokinetic posteroinferior wall with a mildly reduced ejection fraction of 45% (Simpson’s method), moderate mitral regurgitation (vena contracta, 0.6 cm; proximal isovelocity surface area, 0.7 cm; effective regurgitant orifice area, 34 mm2), and mild pericardial effusion.
+
+Furosemide was added to lisinopril and metoprolol, but only mild to moderate improvement of the patient’s symptoms was noticed before he deteriorated. Furthermore, up-titration of these medications was difficult because of the borderline arterial pressure. The addition of ivabradine and the switch from ticagrelor to prasugrel did not change his clinical status. Ticagrelor may cause transient dyspnea in some patients, which reverses with discontinuation.3
+
+Forty days after the myocardial infarction, the patient was readmitted because of exertional dyspnea and worsening shortness of breath. New transthoracic echocardiography showed a dyskinetic cavity that was connected to the posteroinferior wall and communicated with the left ventricle, causing damage to the posterior mitral valve leaflet (P1 scallop) and resulting in severe mitral regurgitation. A color Doppler study confirmed passage of blood from the left ventricle into the cavity through an opening in the left ventricular wall. No thrombus formation was detected. The diagnosis of left ventricular pseudoaneurysm was made.
+
+Unfortunately, the patient died while waiting to transfer for surgical treatment.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3324_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3324_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..297ad6824a42a74d6c93ba31ee685f256b1ace5f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3324_en.txt
@@ -0,0 +1 @@
+An 18-year-old Caucasian British male patient presented to the emergency department complaining of sharp, central, pleuritic chest pain that radiated up to the throat and was worse when lying down. At presentation, he was alert, responsive, speaking in full sentences, and without airway compromise or respiratory distress. His respiratory rate was 18 breaths/minute, heart rate 62 beats/minute, blood pressure 133/62 mmHg, temperature 35.7 °C, and saturation of 97% on room air. He occasionally smokes tobacco and vapes. On examination, palpable surgical emphysema was noted on the neck and on chest X-ray. Baseline investigations, including arterial blood gas analysis and electrocardiogram, did not reveal any abnormalities. Troponin levels were within the normal range (3.9 ng/L). A computed tomography of the neck and thorax was then performed, which revealed extensive pneumomediastinum tracking along the cervical, axillary, presternal, and anterior pericardial regions; the lungs were reported as clear, with no lymphadenopathy and no aggressive bony lesions. Following the diagnosis of a pneumomediastinum, the patient was admitted and the search for the cause commenced. On retrospective history-taking, he reported taking five balloons of nitrous oxide in the afternoon, along with other recreational drugs (cocaine and “ecstasy”). Then 6 hours later, he presented with this chest pain. After discussion with a tertiary center, a water-soluble contrast study was performed, which showed no evidence of esophageal perforation. He remained hemodynamically stable throughout his stay in the hospital. Despite awaiting further studies and ongoing medical care, the patient discharged himself against medical advice and was lost to follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3333_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3333_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28d377af88401eca2ec53d1efe53dec67b124749
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3333_en.txt
@@ -0,0 +1,9 @@
+62-year-old male, ex-smoker, with a history of hypertension, diabetes mellitus, and a pulmonary lobectomy for a moderately differentiated squamous carcinoma, with a negative positron emission tomography (PET) scan for distant disease and postoperative N2 staging, on neoadjuvant treatment with carboplatin and docetaxel. He presented to the emergency department on day 9 of the first cycle of chemotherapy with sudden abdominal pain in the right flank and iliac fossa associated with two days of diarrhea and fever. On physical examination, he presented tachycardia (105 beats per min), generalized tremors, and fever (38°C axillary). The abdominal examination revealed distension, pain on palpation in the right hemi-abdomen, with defense and peritoneal reaction.
+
+Laboratory tests included a complete blood count with a hemoglobin of 9.1 g/dL and 600 leukocytes/mm3, with 93% lymphocytes and critical neutropenia. An abdominal ultrasound with a focused abdominal sonography for trauma (FAST) protocol showed a small amount of free fluid in the pelvis. After taking blood cultures, empirical antibacterial therapy with piperacillin/tazobactam and amikacin was initiated.
+
+An abdominal and pelvic CT scan with intravenous contrast was requested, which demonstrated a marked circumferential thickening of the walls of the cecum with an apparent break in continuity at the free edge and adjacent laminar fluid with air bubbles consistent with a contained intestinal perforation.
+
+He underwent an emergency exploratory laparotomy and a 2 x 2 cm ischemic area cecal perforation and secondary peritonitis were found. A right hemicolectomy and a terminal ileostomy were performed. The histopathological study of the colon biopsy revealed the presence of an adenocarcinoma of the ring-like cells (high grade) associated with ischemia.
+
+The patient died of sepsis progression 24 hours after surgery.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3343_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3343_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1c821e81ad2a2ac8a4d5d70da1e0cddc2b29503d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3343_en.txt
@@ -0,0 +1,13 @@
+A 17-year-old boy of Congolese origin, came to the hospital for tremors of the upper limbs occurring when the latter were solicited (eg, lifting a glass of water, bringing his hand to the mouth, and writing). The patient reported that the symptoms had been slowly progressing for approximately 6 months. In addition, the patient reported difficulty in seeing at a distance (decreased distance vision).
+
+The patient is the second of three siblings, the eldest of whom died of acute respiratory infections in early childhood. It should be noted that the patient was the product of a dizygotic full-term twin pregnancy and that his twin was in apparent good health at the time of consultation. No morbid history was reported in the neonatal period or in the first years of life. There was no history of abortion or miscarriage in the mother, who did not acknowledge any consanguinity with her partner (although the couple were monoethnic).
+
+Apart from the abovementioned complaints, the parents report a slowing of growth since the age of 10–11 years characterized by weight and stature stagnation (unlike his twin sister, who shows “normal” growth).
+
+The patient’s general condition was preserved with slight ptosis in both eyes on morphological examination. From an anthropometric point of view, the patient weighed 30 kg with a height of 143 centimeters and a head circumference of 52 centimeters (BMI for age = 14.6). It should be noted that secondary sexual characteristics (external genitalia, pubic hair, and axillary hair) were present and consistent with the declared age (see Tanner stage P5/G5). Ophthalmological examination reported poor visual acuity in both eyes (2 out of 10) and macular degeneration in the left eye (the right eye was normal on the fundus). Neurologically, the patient is oriented in time and space and does not show any tremor of the limbs at rest. However, we note the appearance of tremors of the upper limbs during action, essentially during the finger-nose maneuver, as well as during writing, resulting in significant dysgraphia. The walk is straight and balanced. No nystagmus was noted, and the various clinical neurological tests ruled out dysdiadochokinesia in our patient. A cerebellar syndrome with delayed growth was evoked in a 17-year-old adolescent with no previous neurological history.
+
+The helical CT scan of the brain without and after injection of iodinated contrast medium revealed bilateral striatopalidal calcifications. In addition, there are bilateral and symmetrical areas of hypodensity of the subcortical white matter opposite the occipital horns of the lateral ventricles, bridging the splenium of the corpus callosum and extending downward via the midbrain and the protuberance toward the two cerebellar hemispheres where they are more marked. In addition, there is an enlargement of the basal cisterns with an appearance of moderate bulboprotuberantial atrophy.
+
+The phosphocalcic balance was normal (calcemia 9.1 mg/100 mL [8.8–10.4]; inorganic phosphorus 4.8 mg/100 mL [2.5–5.0]) as well as negative for syphilis and toxoplasmosis serologies (VDRL negative, positive Toxoplasma IgG 2.2 and positive Toxoplasma IgM 0.5). The anti-nuclear antibody assay was weakly positive (anti-nuclear protein Ac 1/320, anti-nuclear DNA Ac 1/160). Thyroid hormones and cortisol were within normal limits (TSH = 0.98 mIU/L [0.15–5]; T3 = < 0.77 µmol/L; T4 = 114 nmol/L [80–140]; cortisol = 240 nmol/L [110–520]).
+
+In view of the failure to thrive (short stature and microcephaly) and the progressive cerebellar syndrome associated with intracerebral calcification, the diagnostic hypothesis of “Rajab-type cerebral calcification” could also be considered. Genetic testing is essential to confirm the diagnosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3386_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3386_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8052b8df05fc665686c79d40c332d9452db420a7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3386_en.txt
@@ -0,0 +1,17 @@
+A 54-year-old female patient was evaluated in the FOB Speech Pathology Clinic for complaints of sudden deafness. She had sought the doctor in 2014 for loss of vision and hearing, when the diagnosis of SVKH and hearing loss was made at the age of 49. In the same year, the patient presented with the onset of glaucoma and cataract, when treatment was initiated by the doctor with prednisone, which is still ongoing. The patient reported that in 2015, after 1 year of the medical diagnosis of the syndrome, her vision partially recovered in the left eye and her hearing improved compared to the previous year. She reported no family history of the syndrome and no parental consanguinity.
+
+She reported not understanding what was said on the phone and turning up the television to watch. She had worked in manufacturing for about a year. The patient also reported a continuous high-pitched ringing in both ears and vestibular symptoms such as attacks of postural vertigo and imbalance when walking, with a tendency to lean to the right.
+
+Liminal Tonal and Vocal Audiometry
+The threshold audiometry test showed a severe sensorineural hearing loss in the right ear and a moderate sensorineural hearing loss in the left ear. In relation to logoaudiometry, the Percentage Index of Speech Recognition (IPRF) indicated good recognition and the Speech Recognition Threshold (SRT) was compatible with the threshold audiometry.
+
+Acoustic Impedance Measurements
+Acoustic impedance measurements showed type A tympanogram and ipsilateral and contralateral acoustic stapedial reflexes present bilaterally.
+
+Evoked otoacoustic emissions (EOA) and TEPAs
+Transient Evoked Otoacoustic Emissions (EOAT) and distortion product otoacoustic emissions (DPOAE) were absent in both ears. The PEATE showed integrity of the auditory pathways to bilateral stimuli.
+
+Selection and Adaptation of Personal Sound Amplification Hearing Aids (PSAHA)
+In 2017, the patient was fitted in another health system with individual sound amplification hearing aids (AASI), behind the ear, using the devices for less than a year, as they broke.
+
+In 2018, given the hearing loss that she still had, a new bilateral AASI, micro-channels (CIC), with omnidirectional microphone, automatic volume control, WDRC compression and under the calculation of the NAL-NL2 prescriptive rule was performed. The measurements were performed with a probe microphone and adjusted according to the target and the patient's needs, and the patient makes effective use of the device, as verified by the datalogging, reporting that she is well adapted to the moment. In the same year, the Client Oriented Scale of Improvement (COSITM) was also applied, which allowed the speech therapist to know about the most important listening situations for the patient.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3395_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3395_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..969114c64e833d2ba8e0d76153f8e3f03fa74001
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3395_en.txt
@@ -0,0 +1,3 @@
+A 75-year-old man with body mass index of 30.5 kg/m2, severe OSA (apnea-hypopnea index [AHI] of 72 events/h) and Epworth Sleepiness Scale of 7 was referred for UAS therapy. He had difficulty adhering to CPAP treatment, which he was unable to tolerate due to sleep disruption. Past medical history was significant for cardiovascular disease, including congestive heart failure due to ischemic cardiomyopathy with impaired left ventricular function and ejection fraction of 35% by echocardiography. In addition, he had persistent atrial fibrillation and had received an implantable defibrillator 4 years previously, following atrioventricular node ablation. His functional status was New York Heart Association Class III. His preoperative AHI (72 events/h) was outside of the standard recommendations for UAS. However, given his failure to adhere to conservative measures, cardiovascular risk of untreated sleep apnea, and anatomic candidacy for UAS on drug-induced sleep endoscopy, he was deemed to be an appropriate candidate for UAS in an off-label indication outside of standard criteria. He underwent uncomplicated implantation.2
+
+Three months postoperatively, the patient and his bed partner reported no sleep apnea events. He described his sleep as “more refreshing” and reported overall improvement in quality of sleep and daytime fatigue. His body mass index had not changed. Polysomnography showed a titrated AHI of 0 events/h at 1.8 V and 4% oxygen desaturation index of 1.5. He further titrated his device to 2 V at a bipolar (+-+) configuration and had a repeat 2-night home sleep study 2 months later showing 4% respiratory event index of 3.9 and 2.3 events/h on respective nights. At 1-year follow-up, the patient reported continuous improvement in quality of sleep with usage of the device at 2 V. Cardiac evaluation revealed that ejection fraction had increased to 47% since implantation and chronic anemia had resolved. Functional class had improved to New York Heart Association Class I. No interval change in his medical management had occurred.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_342_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_342_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4cd6c656e568b6e8d8de30d704d970607c963d0d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_342_en.txt
@@ -0,0 +1,2 @@
+In 2001, a 58-year-old Caucasian man had radical nephrectomy for pT3N0 ccRCC, Fuhrman grade III. In 2009, lung metastasis was histologically proven. The patient had a favorable risk metastatic ccRCC, according to the IMDC (International Metastatic RCC Database Consortium). He was enrolled in a clinical trial and received a combination of sunitinib and trebananib (AMG 386) – a recombinant fusion protein which neutralizes interaction between angiopoietin-1/2 and its receptor . Trebananib was stopped in 2012 for toxicity, and sunitinb was maintained until progression in 2013. The patient was then included in the Checkmate 025 trial (NCT01668784) which compared second line treatment by nivolumab versus everolimus, and received nivolumab.
+In April 2014, he presented a single lung injury treated by stereotactic radiation and nivolumab continuation. In 2017, after four years of well-tolerated nivolumab administration, the patient developed pruriginous skin lesions. The histologic analysis of the cutaneous biopsy was compatible with BP. This hypothesis was reinforced by the presence of anti-basal membrane antibodies in the patient’s serum. Oral corticosteroid therapy with prednisone was introduced and then progressively decreased. In May 2020, after seven years of nivolumab administration and perfect disease stability, nivolumab was discontinued and surveillance was proposed. In October 2020, as systemic corticosteroids had been decreased to 10 mg per day, the patient presented new pruriginous skin lesions associated with cutaneous blisters, which biopsy and direct immunofluorescence revealed a junctional bullous auto-immune dermatitis, concordant with the BP diagnosis that had previously been established . Serum analysis revealed anti basal membrane (>80 UR/mL), antiBP180 (27 UR/mL, N <20) and anti BP230 (50 UR/mL, N < 20) antibodies, consistent with this diagnosis. Oral corticosteroid therapy was thus increased, and then very progressively decreased. In October 2021, as anti PD1 had been stopped for more than one year, the patient presented a new BP exacerbation, and oral corticosteroid therapy was reintroduced (60 mg per day), and then replaced by Methotrexate in December 2021. In the meantime, regular follow up of the ccRCC was continued, and computed tomography scan continued to show perfect stability of the disease at the last follow-up in August 2022. BP is relatively controlled by Methotrexate, even if he still presents pruritis than requires prolonged symptomatic treatment .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_349_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_349_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8a647223446d60902b5c9db666a6401e5bc9106c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_349_en.txt
@@ -0,0 +1 @@
+A 61-year-old Chinese male presented with a progressive painful swelling in the right parotid gland for one month prior to attending our hospital. The patient had a history of heavy smoking, but did not complain of hemoptysis or other symptoms related to lung cancer. A clinical examination showed the size of the mass to be approximately 1 × 1 cm, with a good activity and a moderate texture. An ultrasound showed there to be a hypoechoic nodule with a size of 1.3× 1.3 × 0.9 cm. Therefore our initial diagnosis was that of a primary parotid tumor and we recommended surgical treatment. However, in preoperative routine examinations, a chest X-ray showed there to be a high density shadow in the right hilar. At this stage we highly suspected that the mass was metastases and required further examination. A lung computational tomography (CT) scan revealed a shadow in the right upper lobe, with a size of approximately 5.4 × 6.3 cm. The CT value was 40HU, and the enhanced CT value was 60HU, with multiple lymph nodes in the mediastinum appearing enlarged. After consulting with the patient, we performed an operation constituting of a partial parotidectomy and facial nerve dissection. Postoperative pathology reported a small-cell lung cancer metastases to parotid . Immunohistochemistry showed TTF(thyroid transcription factor)-1(+), Syn (Synaptophysin) (+), actin (-), S-100(-), P63 (-), EMA (epithelial membrane antigen) (-), ck(cytokeratin)20 (-). Therefore, we recommended that the patient receive postoperative radiation and chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_370_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_370_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8b2d4b883869ffc37ee9974aa4e362f65c08bad7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_370_en.txt
@@ -0,0 +1,4 @@
+A 63-year-old male visited a nearby hospital with a chief complaint of nausea and epigastric discomfort in March 2009. He consulted our institution in April 2009. Esophagogastroduodenoscopy (EGD) revealed a type 0–IIc moderately differentiated adenocarcinoma in the posterior wall of the gastric angle and a tubular adenoma in the greater curvature of the gastric antrum . An abdominal computed tomography (CT) scan showed no lymph node swelling, but a chest CT scan revealed masses of size 5.2 × 4.0 cm in the right upper lung lobe and 2.3 × 2.2 cm in the left upper lung lobe . The pretracheal, subcarinal and hilar lymph nodes were swollen. Transbronchial biopsy revealed squamous cell carcinoma. An 18F-fluorodeoxyglucose (FDG) positron emission tomography (PET)/CT scan revealed a mass with intense FDG accumulation; the maximal standardized uptake values (SUVmax) were 18.6 in the right upper lung lobe, 22.3 in the left upper lung lobe, and 5.7 in the posterior wall of the gastric angle. The gastric cancer was cT1(SM), cN0, cM0, cStage IA according to the Japanese Classification of Gastric Carcinoma 13th edition . The pulmonary tumors were diagnosed to be right lung cancer with contralateral lung metastasis, staged as cT2, cN2, cM1(PUL), cStage IV according to the General Rule for Clinical and Pathological Record of Lung Cancer 6th edition .
+As the lung cancer was advanced and the gastric cancer was early, treatment was focused on the lung cancer. Chemotherapy was administered with four courses of S-1 plus cisplatin, six courses of triweekly docetaxel, three courses of triweekly carboplatin plus paclitaxel, six courses of weekly carboplatin plus paclitaxel with 55 Gy of radiotherapy, and four courses of carboplatin plus gemcitabine. Each chemotherapy regimen was terminated because of progressive disease (PD) of the lung cancer. During this period, EGD was conducted every 3–6 months, and endoscopic stable disease (eSD) was confirmed. During a chemotherapy break between November 2012 and September 2014, PD of the lung cancer and endoscopic PD of the gastric cancer to a type 3 tumor were recognized. Chemotherapy was restarted with six courses of carboplatin plus nab-paclitaxel, then two courses of nab-paclitaxel, four courses of carboplatin plus irinotecan, and 5 months of afatinib. However, these regimens resulted in PD of the lung cancer and eSD of the gastric cancer . Finally, nivolumab as the ninth-line setting was administered in February 2016. After ten courses of biweekly nivolumab (3 mg/kg), a chest CT scan showed shrunken lung consolidations of the bilateral upper lobes . An FDG PET/CT scan indicated that the lung consolidation of the right upper lobe had an SUVmax of 4.09, which could be well explained by atelectasis. EGD showed redness and smooth elevation of the posterior wall of the gastric angle and biopsy revealed no malignancy . From August 2016, he was chemotherapy-free in a good general condition. During this period, chest CT and FDG PET/CT scan showed no progression of the lung cancer. The chemotherapy regimens and the transition of tumor markers including serum carcinoembryonic antigen (CEA) and squamous cell carcinoma antigen (SCC) are summarized in Fig. . Transition of cytokeratin 19 fragment (CYFRA) and FDG PET/CT scans are shown elsewhere .
+However, the type 0–IIa tumor in the greater curvature of the gastric antrum, which had been pathologically diagnosed as a tubular adenoma, was diagnosed as a well-differentiated tubular adenocarcinoma in August 2017, and a type 0–IIc lesion in the lesser curvature of the gastric angle appeared and was diagnosed as a well-differentiated adenocarcinoma in March 2020 . It seemed that the 0–IIc tumor had not arisen from the epicenter, but from the margin of the primary gastric cancer. An abdominal CT scan did not show wall thickening of the stomach, swollen lymph nodes, or other distant metastases. An FDG PET/CT scan showed no progression, with an SUVmax of 3.89 in the right upper lung lobe.
+We diagnosed that the lung cancer was in CR and that the gastric cancer had relapsed after endoscopic CR. Preoperative diagnoses were M, less, Type 0–IIc, ycT1a, ycN0, ycM0 ycStage I and L, Gre, Type 0–IIa, ycT1a, ycN0, ycM0, ycStage I according to the Japanese Classification of Gastric Carcinoma 15th edition . Laparoscopic gastrectomy with D1+ lymphadenectomy and Billroth-I reconstruction was performed. As the intraoperative frozen section revealed a small adenocarcinoma on the posterior wall of the proximal resection line, the stomach was additionally resected to confirm a negative proximal margin . Histopathological examination revealed three carcinoma lesions and a tubular adenoma : [I] M, Less, Type 0–IIc, 15 × 8 mm ; [II] L, Gre, Type 0–IIa, 15 × 12 mm; [III] M, Post, Type 0–IIb, 2 mm; [I–III] tub1, pT1a(M), Ly0, V0, pN0, M0, H0, P0, CY0, pStage IA ; [IV] tubular adenoma, low grade. Other than these tumors, no viable tumor cells or signs of tumor regression, including scars, necrosis, fibrosis, granulation, or mucin lakes, were found in the section of the whole posterior wall of the gastric body and the additionally resected stomach. The postoperative course was uneventful. This patient is doing well 1 month after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_400_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_400_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ae9072e82023d41022e74d3cf58d3376d93db1b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_400_en.txt
@@ -0,0 +1 @@
+We describe an 80-year-old woman who presented with acute epigastric pain. She had a past medical history of hepatitis C-related liver cirrhosis and HCC in segment 6. She underwent multiple ultrasonography-guided percutaneous RFA sessions using LeVeen Super Slim 3.0 (Boston Scientific, Marlborough, Massachusetts, US). The initial treatment for HCC was performed 25 months previously, without artificial pleural effusion or ascites. The duration of the procedure was 114 min. Three months later, she underwent second treatment for recurrent HCC in segment 6/7 using the identical device with artificial pleural effusion. The duration of the procedure was 125 min. Follow-up computed tomography (CT), which was performed 1 month before admission (21 months after the 2nd RFA treatment), did not show HCC recurrence and DH. No history of trauma was reported. On the day of admission to our institution, she experienced sudden-onset, intense epigastric pain and visited the family doctor. Chest radiography revealed a massive abnormal intestinal gas above the right lobe of the liver . She was transferred to our hospital for further examination and treatment. Her vital signs, including blood pressure (100/70 mmHg), pulse rate (80/min), and SpO2 (94% at room air), were unremarkable. Physical examination revealed mild tenderness around the umbilicus, with no peritoneal signs. No findings of trauma were noted. Laboratory findings, including white blood cell count and C-reactive protein level, did not demonstrate abnormalities. Regarding hepatic function, she was classified as Child–Pugh Class B, with slight hypoalbuminaemia (3.2 g/dL) and prolonged prothrombin time (63% increase). Contrast-enhanced CT showed small intestine herniation into the thoracic cavity and an atrophic liver. The mesenteric fat of the small intestine was congested; however, no evidence of bowel perforation was noted . Emergent surgery was performed owing to the suspicion of strangulated DH. In the supine position, the patient underwent laparoscopic surgery under general anaesthesia. A 12-mm port was introduced above the umbilicus using the open Hasson technique. After creating a pneumoperitoneum by carbon dioxide insufflation, we inserted ports in the epigastric region and the left and right flanks. Laparoscopic observation revealed that the small intestine was herniated into the right thoracic cavity through the diaphragmatic defect. The location of the RFA-treated tumour matched the site of the DH . We gently reduced the contents of the hernia. Pneumothorax occurred, but her haemodynamics and oxygenation were stable. The intruded small intestine showed ischaemic change and partial necrosis, although no fragility was noted. We performed mini-laparotomy and resected the ischaemic small intestine (approximately 100 cm). A chest drain tube was inserted. The diameter of the hernial orifice was approximately 2 cm . We confirmed by tactile sensation using forceps that the diaphragmatic tissue around the hernial orifice was not fragile. Ascitic fluid accumulated, and abdominal irrigation was performed with a normal saline solution. The defect was completely repaired using 1–0 absorbable braid polyglactin sutures via a continuous suture technique . The operative time was 161 min, and the blood loss was minimal. The patient was discharged on the 10th postoperative day without complications. Recurrent hernia was not noted in the patient 15 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_409_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_409_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cfbf3147e873b4470059e7a92b0566d7b2304d29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_409_en.txt
@@ -0,0 +1,4 @@
+A 69-year-old healthy male patient, on his first emergency department (ED) visit, presented with persistent hiccups, fever up to 38.4 °C, and mild left upper quadrant abdominal pain for 4 days. Except during sleep, his hiccup frequency was approximately several times per minute. The patient quit smoking 30 years ago after 10 years of one pack per day. He did not have URI symptoms such as cough, rhinorrhea, or sore throat. On physical examination, his vital signs included a temperature of 38.4 °C, a pulse of 107 beats/min, blood pressure of 130/73 mm Hg, respiratory rate of 18 breaths/minute, and an oxygen saturation of 95% measured by pulse oximetry while breathing ambient air. Except for mild tenderness in the left upper abdomen, the patient exhibited good oral hygiene, normal breath sounds, and all other physical examinations were normal. Fever workup revealed leukocytosis (15.34 K/µL) and minimal left pleural effusion on chest X-ray . The patient was discharged in a stable condition.
+His hiccups persisted, and his abdominal pain progressed despite the use of analgesics. Additionally, newly developed dyspnea was noted. The patient presented to our ED 2 days after the initial visit, exhibiting vital signs: a temperature of 38.3 °C, a pulse rate of 135 beats per minute, blood pressure at 145/77 mm Hg, a respiratory rate of 24 breaths per minute, and an oxygen saturation of 94%, measured through pulse oximetry while breathing ambient air. In the physical examination, the most significant difference compared to his initial visit was a noticeable decrease in breath sounds on the left side. Laboratory data revealed leukocytosis (white blood cell count 21.39 K/µL) and lactic acidosis. Chest radiography showed complete whitening of the left lung field. Computed tomography scans showed a collapsed left lower lung with massive left pleural effusion. Empyema was suspected.
+Thoracentesis with chest tube placement was performed, and pleural fluid analysis revealed elevated levels of total nucleated cells (349/µL), total protein (4.6 g/dL), and lactate dehydrogenase (1044 U/L). Empirical ceftriaxone was administered owing to the diagnosis of empyema. The persistent hiccups and mild abdominal pain significantly improved. However, the efficacy of chest tube drainage was limited. Therefore, we changed the antibiotic from ceftriaxone to piperacillin-tazobactam. Left video-assisted thoracoscopic surgical decortication was performed.
+After surgery, the patient was afebrile, and the infection profile improved with piperacillin-tazobactam. His hiccups improved and the frequency decreased to several times per day. Pleural effusion culture yielded Streptococcus intermedius 9 days after thoracocentesis. No bacterial growth was observed in his blood cultures by matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS) after 7 days. Antibiotic use was shifted to the oral form of amoxicillin-clavulanate after 14 days of intravenous antibiotic treatment. The patient was then discharged and returned to the clinic for follow-up. No significant symptoms suggestive of pulmonary infection recurrence were noted the following 6 months after discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_427_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_427_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..949fb0dab701fb306ecf77d421672ecea7a78404
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_427_en.txt
@@ -0,0 +1,8 @@
+A 68-year-old man presented to his primary care physician with a complaint of abdominal pain. He had a medical history of reflux esophagitis and benign prostatic hyperplasia. Esophagogastroduodenoscopy was performed, which showed a submucosal mass in the second portion of the duodenum with central ulceration. Upon admission, his carcinoembryonic antigen (CEA) and carbohydrate antigen (CA) 19-9 levels were within normal limits.
+Dynamic CT showed a circumscribed tumor measuring 26 mm in diameter in the second portion of the duodenum with ulceration. On the arterial and portal phase contrast-enhanced CT, the mass was greatly enhanced with, persistent enhancement on the equilibrium phase . The mass was in contact with the pancreatic head, and pancreatic invasion was suspected. However, there was no dilatation of the central common bile duct and middle pancreatic duct.
+The T1-weighted image showed the tumor as a hypo-intensity , and the T2-weighted image showed a tumor with modestly high intensity . The tumor showed a slightly high intensity on diffusion-weighted imaging (DWI) , and the apparent diffusion coefficient (ADC) map displayed slight visual intensity.
+Endoscopy showed a round, smooth, elevated mass in the second portion of the duodenum with central ulceration . Endoscopic ultrasonography of the lesion confirmed a hypoechoic mass arising from the fourth layer of the duodenal wall . A biopsy was performed from the central ulceration, but the cytological findings revealed no malignancy. Immunochemical studies were positive for smooth muscle actin (SMA) and negative for S100, C-Kit, and CD34.
+Preoperatively, we diagnosed the tumor as a leiomyoma or gastrointestinal stromal tumor (GIST). Therefore, after informed consent was obtained, pancreatoduodenectomy (PD) was performed.
+The resected specimen showed a yellowish-white tumor, 24 × 24 × 19 mm in diameter, arising from the submucosa of the duodenal wall with deep ulceration . The tumor was located at the oral site from the papilla of Vater and showed transmural growth in the duodenal wall.
+The tumor was a vascular-rich tumor without capsular and deep ulceration . The lesion was shown by the nested or perivascular proliferation of mildly atypical cells with round-to-oval nuclei and eosinophilic cytoplasm (glomus cell), accompanied by prominent small blood vessels, hemorrhage and hyalinized stroma . The resected pancreas was free of tumor cells. No mitosis was observed. Immunochemical studies showed that the tumor was positive for SMA and collagen type IV, and negative for C-Kit, CD34, desmin, and S100. The Ki-67 labeling index was 4% in the hot spot . As a result, the tumor was diagnosed as GT arising from the duodenum. There was no evidence of malignancy.
+The patient was discharged from the hospital 38 days after the surgery. No sign of recurrence was found after a year of surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_441_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_441_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..735b46ffbfd72940ba3846992593ee93120e2669
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_441_en.txt
@@ -0,0 +1,26 @@
+A 78-year-old female was referred as an emergency to the ophthalmology department of the University Hospital Bonn. She reported blurred vision for seven days and loss of visual field as well as photopsia for 2 days. Amaurosis or diplopia were not reported.
+She had dry cough for 4 months. This was refractory to symptomatic and antibiotic therapy.
+In the past 5 weeks, the patient reported increasing diffuse thrusting, bilateral pain in the area of the mandible, while opening her mouth and while chewing. In addition, she noted a thrusting pain in her tongue, which initially increased postprandially but soon was present continuously, and led to difficulties in swallowing. The patient also reported weight loss of 4 kg over the past 4 weeks, increasing fatigue and subfebrile body temperatures as well as scalp tenderness. Severe headaches of the temporal area were denied, as well as myalgia and morning stiffness.
+All symptoms started on the left side, but affected both sides over time.
+Examinations by a dentist, an orthodontist and an otolaryngologist remained without any findings.
+The patient was alert, orientated and had appropriate affect on clinical examination.
+The neurological examination remained unremarkable, without dolorous nerve exit points and a negative swinging flashlight test. The tongue appeared normal, with no diversion, swelling or necrosis. Palpation of the temporal arteries was normal.
+Chest radiography was without pathologies.
+The patient reported neither a history of vasoconstrictive medication, nor was there a history of radiotherapy involving any site of the body.
+Laboratory results revealed increased inflammatory markers. C-reactive protein (CRP) was 71 mg/l (reference range, 0 to 5 mg/l) and erythrocyte sedimentation rate was 75 mm/h (reference range, < 30 mm/h).
+On admission, the best corrected visual acuity was 20/400 in the left and 20/25 in the right eye. Funduscopic examination of the left eye revealed optic disc edema with cotton wool spots along the upper temporal vascular arch. The macula and the retinal blood vessels appeared normal on fundoscopy .
+Optical coherence tomography (OCT) of the left macula was normal and OCT of the optic disc confirmed disc edema in accordance with the clinical appearance. Retinal nerve fibre layer thickness was increased in the superior, temporal and inferior segments and the optic disc showed diffuse leakage (“hot disc”) on fluorescein angiography . Based on these ophthalmological findings, anterior ischemic optical neuropathy (AION) of the left eye was diagnosed.
+Following this, the patient was referred to the Department of Rheumatology at the University Hospital Bonn for further evaluation. The patient underwent ultrasound examination of all arteries typically involved in GCA according to OMERACT protocol . A GE Logiq S8 XDclear ultrasound machine with software version R3 manufactured in 2018 was used. For sonographic examination of the axillary, vertebral and carotid arteries, a linear ultrasound probe with a range from 6 to 15 MHz was used, for all other small arteries including the central retinal artery an ultrasound probe with a range from 8 to 18 MHz was applied.
+Vascular ultrasound demonstrated a homogeneous, concentric thickening of the intima-media complex, known as halo sign, in several arteries of the head and neck area [, ]. Ultrasound was performed on axillary arteries, vertebral arteries, common carotid arteries, superficial temporal arteries with both frontal and parietal branches, occipital arteries, facial arteries, and due to the lingual pain, also the lingual artery. Vasculitic affection with increased intima-media thickness (IMT) values above published cut-off values was observed in the common superficial temporal arteries on both sides, both frontal and parietal branches (up to 0.49 mm), as well as in the right facial artery (0.59 mm) and right axillary artery (1.09 mm) . A halo sign was also visible in both vertebral arteries. Exact values and the respective cut-off values are depicted in Table .
+Furthermore, due to tongue claudication and lingual pain, the deep lingual artery, which is a branch of the lingual artery, branching from the external carotid artery, was also examined by ultrasound. It displayed a typical vasculitic halo-sign . Vasculitic IMT swelling led to markedly reduced blood flow and visible IMT thickening in B-mode. Peak IMT of the lingual artery was 1.38 mm. There was no occlusion of the lingual artery. This sonographic finding explained the patient´s symptoms of thrusting pain of her tongue.
+In addition, transocular ultrasound of the central retinal artery was performed on both sides. Retinal artery displayed a systolic flow velocity of 8.2 cm/s on the left eye, and 7.5 cm/s on the right eye. This meant a marked reduction on both eyes, including the asymptomatic right eye. Until now, we have examined 25 healthy individuals with a mean systolic velocity of 14.4 cm/s (SD ± 3.2) of the central retinal artery.
+The ocular ultrasound findings were in agreement with both the patient’s visual symptoms and the ophthalmological findings mentioned above.
+Diagnosis of GCA was made based on the patient´s symptoms, clinical examination, laboratory results and ultrasound findings, following the EULAR recommendations for imaging in GCA . Therefore, therapy was promptly initiated. Due to the characteristical sonographic findings no biopsy of the superficial temporal artery or any other artery was performed.
+The patient received an initial daily dose of 500 mg methylprednisolone intravenous for five days followed by a daily dose of 60 mg prednisolone per os, tapered over 26 weeks according to the GIACTA treatment protocol . Furthermore, tocilizumab treatment was initiated with a weekly dose of 162 mg subcutaneously due to the widespread affection of the arterial vascular bed.
+With treatment symptoms and laboratory markers quickly improved. Jaw claudication and tongue pain resolved within days and did not reoccur. The patient was dismissed five days later in stable clinical condition.
+Three months after dismissal a follow-up examination was performed. The patient was on 9 mg prednisolone per day, 162 mg tocilizumab subcutaneously per week and free of symptoms. CRP was normal. On ultrasound examination a relevant decrease of IMT values could be observed in all affected arteries. IMT of the deep lingual artery had decreased from 1.38 to 0.77 mm. Systolic flow velocities of both central retinal arteries had increased from 8.2 to 21.6 cm/s on the left eye and from 7.5 to 19.1 cm/s on the right eye.
+At ophthalmological and sonographic follow-up examination 6 months after the patient´s dismissal, best corrected visual acuity increased from 20/400 to 20/40 in the left eye, the right eye was still without pathological finding. Funduscopic examination of the left eye showed a decrease of optic disc edema with a pale optic disc and narrow vessels.
+OCT of the left macula revealed atrophy of inner retinal layers , while OCT of the optic disc confirmed absence of disc edema and a decrease of retinal nerve fibre layer thickness.
+The patient was on 12.5 mg prednisolone per day and 162 mg tocilizumab subcutaneously per week and free of symptoms. The dose of prednisolone was increased for a short time by an external rheumatologist, due to recurring headaches and CRP-elevation between the follow-up examinations.
+On ultrasound examination, a further decrease in IMT values could be observed . Flow velocity of both central retinal arteries showed stable values with 19.1 cm/s on the left eye and 17.2 cm/s on the right eye. IMT of the deep lingual artery had decreased from 0.77 to 0.34 mm.
+Therefore, tapering of prednisolone and therapy with tocilizumab was continued following the GIACTA protocol .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_444_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_444_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c925bbd7db71d8630c2e03d647480c5212dd088a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_444_en.txt
@@ -0,0 +1,4 @@
+Fifteen years ago, this now 40-year-old female had undergone a L5S1 discectomy . Ten months before this admission, due to complaints of low back pain and left leg numbness, she had undergone a lumbar; MR; it documented significant cauda equina compression at the L4-L5 level due to a large central disc herniation and marked stenosis/OYL (i.e., isointense on T2-weighted sequences) [ and ]. She now acutely presented to an emergency room with the sudden onset (i.e., over several hours) of 4/5 weakness in both lower extremities, bilateral leg numbness, and urinary retention.
+The new magnetic resonance imaging (MRI) and CT both demonstrated worsening of her L4-L5 cauda equina compression due the large central disc herniation and severe stenosis/OYL; the CT further confirmed ossification of the OYL [-].
+Notably, the patient should have undergone emergent surgery following the completion of the MR/CT studies. However, surgery was delayed for 9 h by which time she was fully paraplegic (0/5 motor function, L4-S1 loss of sensation, and urinary retention (JOA 2/29).
+Following a L4-L5 laminectomy for stenosis, OYL, and a partial central discectomy (i.e., not completely removed because of its central location), the patient never fully recovered; she had just 1/5 motor function bilaterally (i.e., residual loss perineal sensation and urinary incontinence – final JOA score 9/29) 1 month later. Of interest, the postoperative MR and CT studies, despite showing mild residual ventral disc, confirmed adequate cauda equina decompression [-].
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_458_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_458_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e19a539d6cbf41586b503da9abbd7bd73e27aec1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_458_en.txt
@@ -0,0 +1,2 @@
+A 15-year-old boy suffering from SWS was born from the third pregnancy of nonconsaguine young and healthy parents as a hypotrophic infant with a perinatal risk factor which included intrauterine growth retardation and asphyxia. Complex phenotypic dysmorphic features were observed at birth. The phenotype of our patient includes multiple facial and skeletal disorders: midface retrusion, prominent forehead, frontal bossing, shallow orbits, downslanted palpebral fissures, narrow nasal bridge, large filtrum, micrognathia, small hands with short metacarpal bones and short distal phalanges of fingers with consequent brachydactyly, knee flexion contracture, pseudoarthrosis, calcaneovalgus deformity, thoracic scoliosis, lumbar hyperlordosis, coxa valga, skeletal dysplasia, pectus carinatum, generalized hypotonia, global developmental delay, cognitive impairment, complete lack of adipose tissue with consequent pseudohypertrophy of muscles, bilateral cataracts and progeroid facial appearance ( and ). As a part of the syndrome, an extremely short stature, body weight of 15 kg and body height of 100 cm were observed.
+Computed tomography (CT) scan of cranio-cervical junction revealed bifid arch of the atlas as a part of skeletal disorders. Additional preoperative magnetic resonance imaging (MRI) revealed a critical stenosis of cranio-cervical junction with concomitant myelopathy .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_471_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_471_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d844e769a03a854f93b80929695024dbfe02d2f4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_471_en.txt
@@ -0,0 +1 @@
+A 72-year-old woman (40.3 kg, 139 cm) was referred to our pain clinic for the treatment of low back pain after two back surgeries. She had first undergone back surgery [posterior lumbar interbody fusion (PLIF at L4–5) plus spinal stabilization (L3)] for lumbar spinal canal stenosis 4 years prior to the current presentation. Two weeks after the initial surgery, she underwent reoperation because of screw placement errors, and her symptoms disappeared after surgery. However, her low back pain recurred after a fall 5 months before the current presentation. Paralysis of the lower limbs was not apparent after this episode. A sensory disturbance that had existed before the surgeries remained unchanged. No new lesions such as a lateral recess or foraminal stenosis, herniated nucleus pulposus, or fracture were found on radiographs or magnetic resonance images . The previous medical institution prescribed acetaminophen and tramadol for low back pain and performed a caudal epidural block with 5 ml of 1% lidocaine and dexamethasone 1.65 mg. However, neither treatment provided pain relief, and the patient was referred to our pain clinic. She had several comorbidities, including diabetes mellitus, hypertension, renal dysfunction, hypothyroidism, rheumatic arthritis, and gastroesophageal regurgitation, and was prescribed 27 different drugs by clinicians from five different facilities. Accordingly, we decided not to use additional medication for first-line therapy because of polypharmacy concerns and renal dysfunction and performed bilateral ESP block with the patient in the prone position. A convex type transducer was placed in a longitudinal orientation at the level of the L2 transverse process, 3 cm lateral to the midline. The L4 and L5 transverse processes could not be identified because of the echogenic artifacts due to the surgical instruments. The posterior surface of the L2 transverse process was identified using an aseptic technique. After the puncture point was anesthetized with 2 ml of 1% lidocaine, the needle was inserted in the plane of the ultrasound beam in a cephalad to caudal direction. Following confirmation of the needle tip on the surface of the transverse process of L2, 20 ml of 0.1875% ropivacaine (fourfold dilution of commercial product) was injected into the target plane between the erector spinae muscles and the transverse process . This procedure was repeated on the contralateral side. Twenty-five minutes later, the patient reported a warm feeling in her low back and almost complete relief from pain, which was approximately < 10% of its original severity. There was an area of diminished cold sensation extending from T12 to L5, with no change in the anterior and lateral abdomen. Unfortunately, the pinprick test was not performed. Pain relief lasted for approximately 10 h after the initial block. We repeated this procedure for a total of three times in a month. Finally, the patient reported that her daily baseline level of low back pain had diminished to < 40% of its original severity. She was satisfied with the extent of pain control and did not wish to undergo further treatments such as epiduroscopy or spinal cord stimulation (SCS).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_479_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_479_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..83fff20731b25603d771d7d1bed7ad18b8696395
--- /dev/null
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@@ -0,0 +1,11 @@
+A 47-year-old woman presented with decreased visual acuity associated with white retinal lesions in both eyes. A history of pneumonia of unknown aetiology closely preceded the deterioration of vision. Five years previously the patient was diagnosed with follicular non-Hodgkin’s lymphoma (December, 2004). She underwent eight cycles of combination chemotherapy that included cyclophosphamide, adriamycin, vincristine and prednisone with later addition of the anti-CD20 antibody rituximab. The patient was in remission for 19 months. Following a relapse with involvement of the retroperitoneal lymph nodes (February, 2007), rituximab and 90Y-ibritumomab tiuxetan were administered. A second relapse occurred 22 months post radioimmunotherapy (April, 2009). Four combination cycles of fludarabine, cyclophosphamide, and mitoxantrone were then undertaken leading to partial remission. Subsequent therapy included rituximab administered once per month for four months and once every third month thereafter. No further relapses were experienced from April, 2009 to April, 2010.
+At presentation (April, 2010), her best-corrected Snellen visual acuity (BCVA) was 6/12 in the right eye and 6/9 in the left eye. There were large keratic precipitates and a mild anterior chamber cellular reaction present in both eyes . Examination of the fundus revealed bilateral findings of moderate vitreous opacities, pale optic discs, retinal necrosis with retinal infiltrates, several hemorrhages in the posterior pole and areas of peripheral retinal atrophy. Some vessels displayed extensive white sheathing providing them with the appearance of frosted branch angiitis . Despite prophylactic antiviral therapy (valganciclovir 900 mg twice per day and valaciclovir 500 mg once per day) and maintenance treatment with rituximab (800 mg once per three months), the most likely diagnoses were CMV retinitis or intraocular non-Hodgkin’s lymphoma. Blood tests revealed neutropenia (0.9 × 109/L) with a normal lymphocyte count of 1.2 × 109/L. Serology was negative for HIV.
+Pars plana vitrectomy was performed in the right eye for both - diagnostic as well as therapeutic purposes (June, 2010). Vitreous fluid analysis confirmed CMV by means of PCR testing. Furthermore, cytologic examination revealed atypical lymphocytes with lobulated nuclei and basophilic cytoplasma on a background of lytic cells. Two specialists confirmed the finding of highly suspicious malignant elements in the vitreous fluid. Treatment with intravenous foscarnet was given continually for three weeks followed by oral valganciclovir given in a dose of 900 mg twice per day. Rituximab therapy was also maintained and administered every three months. The diagnosis of intraocular lymphoma is usually an indication for intravitreal treatment with methotrexate in addition to systemic therapy. Intavenous methotrexate therapy was not considered in this case as PCR testing confirmed infectious uveitis of cytomegalovirus aetiology. In such infectious cases, methotrexate could probably worsen the course of ocular disease.
+Retinal findings responded well to treatment and retinitis regressed. However, BCVA decreased to 6/24 in the right eye and 6/12 in the left eye, perimetry revealed scotomas and moderate vitreous haze persisted in the left eye . The main cause of visual impairment was most likely pallor of the optic disc.
+A relapse of retinitis in the three weeks following discontinuation of foscarnet treatment necessitated its reinduction and administration once again continually for three weeks (August, 2010). BCVA reduced to hand movements in the right eye and 6/18 in the left eye and further progression of visual field defects was demonstrated . A further recurrence developed within one week of cessation of this therapy. Consequently, the patient was retreated with foscarnet administered as a bolus three times per week (September, 2010). This therapeutic regime proved to be insufficient as retinal lesions once again showed signs of reactivation. Moreover, an increase in plasmatic CMV DNA copies was detected . The patient was admitted to a hematologic clinic and treatment with intravenous foscarnet was administered continually for further three weeks (October, 2010). Systemic examination for restaging of the follicular lymphoma was also undertaken. An MRI of the brain showed no signs of lymphoma. Cerebrospinal fluid was negative for CMV. No pathological changes were revealed by immunophenotyping and cytologic examination of cerebrospinal fluid.
+Retinal lesions were in regression, but plasma CMV DNA copies were still positive giving rise to consideration of cidofovir therapy. The patient declined this treatment. Maintenance therapy with rituximab was also discontinued.
+Two months after the most recent foscarnet therapy (December, 2010), negativity of CMV DNA copies in the plasma was detected. However, BCVA had decreased to hand movements in the right eye and 1/60 in the left eye due to a combination of optic disc atrophy and progression of cataract.
+Patient follow-up was scheduled for every 8-10 weeks as retinal lesions were inactive . Nevertheless, moderate vitreous haze remained in the left eye resembling that which occurs in patients with intraocular lymphoma. It is therefore believed that both CMV retinitis and intraocular lymphoma contributed to the intraocular findings. This opinion was strongly supported in the results of vitreous fluid analysis of the right eye. Undertaking diagnostic-therapeutic pars plana vitrectomy in the left eye imposed a high risk and the patient declined this surgical procedure.
+In August 2011, trepanobiopsy confirmed a transformation of follicular lymphoma into secondary acute myeloid leukemia. Palliative treatment was indicated for this disease.
+At the last follow-up in March 2012, no visual acuity was recordable in the right eye (blind eye) and hand movements in the left eye. Bilateral progression of cataract prevented good fundal views although some white retinal lesions were apparent.
+The patient died in another hospital in June 2012 where unfortunately no post-mortem examination was performed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_47_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_47_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6a730e1af1a034c870dbc62d917b97df9e75a09d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_47_en.txt
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+A 78-year-old asymptomatic male patient underwent evaluation for prostate cancer. CT revealed a 56 × 77 mm mass at the posterior mediastinum ; subsequently, he was diagnosed with AVA. Apart from prostate cancer, his medical history was unremarkable. He did not have history of liver disfunction nor trauma.. In addition, the physical examination results and laboratory data were normal. When we had extensive discussion with the general thoracic surgeons, there was concern that there could be a strong adhesion to the surrounding tissues.The orifice of the azygos vein was larger than in previous cases reported as well. The chest surgeons suggested that it would be safer to perform the surgery under the cardiopulmonary bypass by cardiac surgeons considering the risk of major bleeding. We anticipated from the preoperative images that resection of the AVA would be difficult. Therefore, we planned to occlude the AVA inflow with coil embolization, and to surgically close the outflow from inside of the superior vena cava (SVC), thus excluding the aneurysm from the SVC. Any compression of the adjacent structures, thrombus formation, or pulmonary embolism were not evident. First, we performed the coil embolization of the caudal AVA inflow and the second, third, and fourth intercostal veins via the right internal jugular vein approach . Next, through a reversed L-shaped sternotomy (right fourth intercostal space) , a cardiopulmonary bypass was established by right femoral artery cannulation and venous drainage from the right atrium and both brachiocephalic veins. Intraoperative findings revealed no adhesion of the AVA to the lung and SVC ; therefore, we considered AVA resection. The orifice of the azygos vein was 20 × 50 mm on the posterior wall of the SVC . Subsequently, AVA was depressurized, allowing the aneurysm excision by a stapler. We excised the AVA with a stapler device (Powered ECHELON FLEX® 7; Ethicon, Tokyo, Japan) and closed the orifice. The cardiopulmonary bypass time was 64 min, operative time was 394 min, and bleeding volume was 105 ml. Histopathologic examination confirmed the preoperative diagnosis; it showed few inflammatory cell infiltration around vasa vasorum, intimal thickening and hypertrophy of the medial smooth muscle cell. The subsequent surgical and clinical courses were uneventful, and the patient was discharged in stable condition 8 days later. Postoperative CT showed no abnormalities, with the aneurysm having disappeared.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_486_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_486_en.txt
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index 0000000000000000000000000000000000000000..b3147e6ccfb76f640ee62fda5d16779e1b4db66f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_486_en.txt
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+A 26-year-old Japanese male presented with severe headache and nausea for approximately 3 weeks. He had a prior episode of suspected convulsion of which magnetic resonance imaging (MRI) revealed a cystic nodular lesion measuring approximately 60 mm in diameter, located in the left parietal lobe of the cerebrum. The patient was administered medication, and symptoms were subsequently relieved. However, 12 days later, he experienced worsened symptoms and was transferred and admitted to the emergency department of the University of Miyazaki Hospital.
+MRI showed a mass of 70 × 53 × 57 mm in the left temporoparietal lobe . A solid element with slight hypointensity on T1-weighted and hyperintensity on T2-weighted images along the dura mater was noted. Cystic changes were likely associated with the sanguineous fluid. A peritumoral band with hyperintensity on T2-weighted image was observed at the periphery of the lesion, suggesting an extra-axial lesion . A dural tail sign was also noted on the gadolinium-enhanced T1-weighted image . The lesion appeared to be focally infiltrative to the brain surface, but no apparent connection to the ventricle was observed . Preoperative clinical diagnosis was meningioma, but hemangiopericytoma and ependymoma were included as differential diagnoses. Left parietotemporal craniotomy was performed. The tumor was an extra-axial mass and had partially infiltrated the dura mater and surface of the brain parenchyma in the left temporal lobe. Small pieces of tumor tissue were removed for intraoperative diagnosis. Under an emergency setting, near-total resection was achieved even if the lesion was in the eloquent area. The patient received postoperative adjuvant radiotherapy (total dose 54 Gy). However, within 1 year postsurgery, the tumor recurred and a second resection surgery was performed. Four years after the first surgery, the tumor metastasized to the spinal cord and the patient eventually died (total postoperative follow-up period was 4 years and 4 months).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_489_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_489_en.txt
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index 0000000000000000000000000000000000000000..004f5e0a6c03b05ea877fd7e53922f6e0f136ba0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_489_en.txt
@@ -0,0 +1,4 @@
+A 43-year-old Caucasian woman presented in her 32nd week of gestation with a tumor of the parotid gland. She had noticed the swelling increasing over the past six months. She was otherwise asymptomatic, without any pain, mouth-opening difficulties or facial nerve dysfunction. Ultrasonography of her neck showed a parotid lesion 40 × 30 × 27.5 mm in size, with an heterogeneous appearance. Considering her advanced state of pregnancy, we advised conservative management in the form of watchful waiting and regular review until the birth.
+At our patient's next review, only five weeks later, we noticed rapid growth of the lesion with expansion into the parapharyngeal space. There was still no facial nerve involvement, although our patient's mouth opening was slightly limited. Magnetic resonance imaging (MRI) of the neck showed that the tumor had increased to 70 × 60 × 60 mm, reaching the parapharyngeal space with marked obstruction of the oropharynx of about 50% . Further diagnostic tests such as fine-needle aspiration cytology (FNAC) were discussed. We were concerned about the risk of malignancy and increasing local complications due to the rapid growth. Considering the risk of spreading tumor cells and the unreliability of FNAC in identifying the malignant nature of parotid carcinoma , we decided to perform surgical resection to prevent further complications and to obtain a secure diagnosis.
+After discussing this case with the gynecologists at our interdisciplinary tumor board meeting, it was decided to deliver the baby by caesarean section in the 38th week of gestation with epidural anesthesia using mepivacain and sufentanil. The surgical resection of the tumor was performed four days later. It was possible to completely remove the tumor via a standard cervicofacial incision without the need to resect the mandible. Although the tumor had stretched the facial nerve to double its usual length, there was no postoperative nerve dysfunction (House Brackmann grade I).
+On histological analysis, the lesion was identified as a pleomorphic adenoma without evidence of malignancy . Immunohistochemistry did not show any positive expression of oestrogen or progesterone receptors. Our patient remained well with no evidence of recurrence after a follow-up of one year.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_507_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_507_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2298958eb22194a9acd18a896fe39a70584325c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_507_en.txt
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+A 49-year-old Caucasian male was referred to Cardiology Clinic with progressive shortness of breath on exertion; New York Heart Association (NYHA) functional Class II. He denied any other symptoms suggestive of heart failure, arrhythmias, or ischaemia. He had no history of diabetes mellitus, hypertension, respiratory illnesses, renal disease, or coronary artery disease. The patient smoked since adolescence but quit 4 years prior to his visit. The patient was not on chronic medications. He was estranged from his family for a very long time, and he had no details about their medical history or care.
+On physical examination, the patient was found to be tall at 198 cm, and weighed 101 kg. He had a blood pressure of 90/60 mmHg sitting, heart rate of 70 beats per minute, cardiovascular examination revealed jugular venous pulsation to be within normal limits, a normal S1 and S2, no S3 or S4, and a systolic ejection murmur, Grade 1/6 on the Levine scale, over the aortic area with no radiation. There was no evidence of heart failure, including no pedal oedema. He had a positive wrist sign, and dysmorphic features including enophthalmos, malar hypoplasia, retrognathia, and pectus carinatum. The rest of his physical examination was unremarkable.
+Laboratory workup included a normal haemoglobin and creatine of 151 g/L and 84 μmol/L, respectively. Electrolytes and liver function results were within normal limits.
+An electrocardiogram was performed and was normal . Heart failure biomarkers (BNP or NT-proBNP) would have been useful to diagnose heart failure but were not available within the regional health care system. He underwent stress myocardial perfusion imaging that ruled out ischaemia but demonstrated a left ventricular ejection fraction (LVEF) of 36% at rest and 43% post-stress. A transthoracic echocardiogram revealed left ventricular (LV) global hypokinesis, with LVEF of 40–45%. There was mild aortic insufficiency. The aortic root was dilated at 4.9 cm in diameter and Z-score of 4.66 .
+Computed tomography angiography of the thoracic aorta revealed dilated coronary sinuses at 4.4 cm × 4.6 cm × 4.8 cm . A cardiac MRI study revealed a mildly reduced LVEF at 43%, with evidence of mild concentric LV hypertrophy (Video 1).
+Given the patient’s clinical features, and the dilated aortic root, MFS was suspected, but he did not meet the criteria for diagnosis when applying the revised Ghent Criteria for Diagnosing Marfan Syndrome , with only the presence of aortic Z-score > 2 and 4 points for systemic findings. Therefore, genetic investigations were sent. The molecular genetics report for MFS and related aortopathies revealed that this patient is heterozygous for a sequence variant in the fibrillin-1 gene (FBN1), designated NM_000138.4: c.7016G>C , which is predicted to result in the amino acid substitution p. Cys2339Ser. Cysteine residues in fibrillin-1 (FBN1) form disulfide bonds which are important for proper protein folding. The substitution of a different amino acid in FBN1 can create or destroy a cysteine residue and results in disruption of the disulfide bonds which causes protein misfolding that has been reported to cause MFS phenotypes., This particular variant has not been reported previously and is absent in the Genome Aggregation Database (GnomAD) population database, as well as ClinVar, which are the resources that aggregate, harmonize, and archive sequencing data and the relationships among genetic variations and phenotypes.
+Different substitutions affecting the same amino acid residue (p.Cys2339Tyr; p. Cys2339Arg; p. Cys2339Gly) were reported to be pathogenic for MFS.,
+The patient was started on ramipril and metoprolol with titration as tolerated. According to guideline recommendations,, the patient underwent a valve-sparing root replacement, an excellent outcome, and recovery . There were no postoperative complications. At 13 months of follow-up, the patient’s shortness of breath was resolved and he was pleased to return to his excellent premorbid status. The patient’s echocardiogram at 13 months post-operatively revealed an intact aortic repair and graft, with only mild aortic valve insufficiency and an improved LVEF at 55%. The patient remains clinically well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_639_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_639_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e2a222dec74dd7bb7d4060a634e6d129b947642
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_639_en.txt
@@ -0,0 +1,3 @@
+A 74-year-old man with sick sinus syndrome and a St. Jude Abbott DCPPM, placed 8 months prior, presented for routine device check. Presenting rhythm was atrial paced (AP) ventricular sensed (VS) at 70 b.p.m. Atrial and ventricular impedance, sensing, and thresholds were appropriate and consistent with prior values. Device settings were DDDR with base rate 70 b.p.m., maximum tracking rate 105 b.p.m., and maximum sensor rate 130 b.p.m., and paced and sensed AV delays were 250 ms. Ventricular intrinsic preference was enabled, allowing intermittent AV delay to promote intrinsic conduction and mitigate ventricular pacing. A ventricular high rate episode with corresponding electrogram (EGM) was noted . This episode commenced with a 1:1 atrial tachycardia (AT) at a rate of 150 b.p.m. with prolonged AV conduction, prompting AMS from DDDR to DDIR. Unexpectedly, this was followed by a period of rapid atrial pacing at 180–190 b.p.m., well exceeding the maximum tracking and sensor rates. Notably, there was no atrial anti-tachycardia pacing programmed on this device, and the native AV conduction was longer than the programmed AV delay. In addition, the observed AV interval during rapid atrial pacing appeared implausibly short. To understand the mechanism for this phenomenon, one must consider how pacemaker timing cycle parameters determine the pacing rate.
+In ventricular-based timing modes, the cycle length between two atrial-paced events is determined by the calculated VAI, not the A–A interval as in atrial-based timing. This calculation depends on the base rate, or sensor indicated rate, and the programmed paced AV delay. This patient’s device was initially set to DDDR. While in an episode of AT, the device mode switched from atrial-based timing mode to a ventricular-based timing mode (DDIR). As shown in , the initial AT cycle length was ∼395 ms triggering AMS to DDIR, and intrinsic AV time was prolonged at 285 ms. Then, a perfectly timed premature atrial complex (PAC) fell within the post-ventricular atrial blanking period (PVAB) and was not sensed, thus failing to reset the VAI timer. With further AV nodal decrement, this PAC conducted with an AV time of 320 ms. However, the calculated VAI (atrial escape interval) had already elapsed at 258 ms, leading to an AP beat just before the PAC conducted to a ventricular-sensed event. This ‘pacemaker crossover’ created a short ‘pseudo-AV interval’ of 66 ms, and the ventricular-sensed event from the conducted PAC resets the VAI timer just after the AP beat. Ventriculo-atrial interval was then reached again at ∼260 ms, triggering another AP event with even slower AV time of 398 ms, once again ‘crossing over’ with AP occurring before VS event from the preceding paced beat. This consistent but prolonged AV conduction led to repetitive crossover with short pseudo-AV intervals resetting VAI. The VAI was calculated based on sensed activity, due to enabled rate responsive pacing, and an assumed paced AV time of 250 ms, leading to atrial pacing well above the max sensor rate.
+This event was stored as a ventricular high rate episode because the ventricular rate exceeded 175 b.p.m.; however, it lasted <20 s, and the stored EGM did not capture the termination. Presumably, it terminated with an atrial-paced beat that failed to conduct, or due to a spontaneous PAC or pemature ventricular contraction. Importantly, there were no associated symptoms with this brief episode, nor were there any other similar episodes recorded before or within 6 months following. To prevent this episode from happening again, multiple programming changes could be made including changing the AMS from DDIR to a non-sensor setting such as DDI or VVI; reducing the maximum sensor driven rate, or shortening the programmed AV delay. However, each of these changes would have other implications. Therefore, another option would be to make no programming changes given that this was a single short episode with no associated symptoms. Even if lightning did strike twice, these episodes would be unlikely to sustain for any significant length of time given reliance on extremely long yet necessarily fixed 1:1 AV conduction. In the case of this patient, the company representative was contacted and agreed with our proposed mechanism and potential programming changes to prevent recurrence. However, ultimately no changes were made, and the phenomenon has not recurred since this initial episode.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_646_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_646_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea4a0421728d3918d3119d892bc22e44d144a605
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_646_en.txt
@@ -0,0 +1,4 @@
+A 51-year-old woman was admitted to our hospital presenting with a two-month history of dry cough, dyspnea, and pain localized to the left chest and precordial region. The patient is a lifelong non-smoker and reported no infective, cardiac symptoms or myasthenia gravis (MG). Her weight was stable and there was no history of thoracic trauma or tuberculosis infection. Physical examination revealed rapid breathing for 28 breaths/min, decreased breath sound on the left chest and mild tenderness in the third thoracic vertebra region. No signs of hepatomegaly, splenomegaly, or skin lesions were observed.
+Blood tests showed mild leukocytosis (13.30 × 109/L) with lymphocytosis (9.98 × 109/L). Absolutely CD4-positive T cell count and CD8-positive T cell count in the peripheral blood were 4,180 cell/ul and 1,679 cell/ul, respectively. Subsequent flow cytometric analysis confirmed that these lymphocytes were polyclonal T-cells. Her serum levels of procalcitonin (PCT) and C-reactive protein (CRP) were normal and no abnormalities in her liver and kidney functions. Ultrasound examination of the superficial lymph nodes revealed enlargement in the bilateral neck, axillary, and groin regions. Immunohistochemical staining of biopsy specimens from the cervical lymph nodes and bone marrow indicated CD3-positive, CD5-positive, CD7-positive small T-cell lymphocytosis. Moreover, gene rearrangement analysis did not detect any clonal rearrangement of the T-cell receptor (TCR). Flow cytometric examination of bone marrow showed mature T-cell lymphocytosis with normal phenotype.
+Contrast-enhanced chest CT scan depicted diffuse nodular thickening of the left pleura with mild enhancement, leading to the collapse of the left lung. This was seen infiltrating the mediastinum and pericardium . Bronchoscopy revealed stenosis of the left lower lobe bronchus, yet no malignant cells were detected in the bronchial mucosal biopsy specimens. The subsequent 18F-FDG PET/CT study indicated increased 18F-FDG uptake in the left pleura (SUVmax 8.3) . Additionally, compression with increased FDG uptake was observed in the second thoracic vertebrae (SUVmax 8.2) . Considering these findings, our differential diagnoses included malignant pleural mesothelioma, lung cancer with pleural metastasis, and T-cell lymphoma.
+Pleural biopsy revealed plenty of small-sized lymphocytes with scattered distribution of medium-sized cells in hematoxylin and eosin (H & E) staining . Immunohistochemical (IHC) stain showed medium-sized cells were positive for multiple epithelial-derived markers, including PCK , CK19 and P63 . Additionally, these cells exhibited weak positivity for TdT and Ki-67 , but were negative for CD5 , the mesothelial marker CR , and the pulmonary-origin marker TTF-1 . The small-sized lymphocytes were positive for CD3 , CD5 , CD8 and Ki-67 (80%, Fig. F), but negative for CD20 in IHC stain. Based on above findings, the patient was finally diagnosed as ectopic pleural thymoma (type B1 according to the WHO classification) with T-cell Lymphocytosis and bone metastasis. Regrettably, the patient declined further chemotherapy or radiotherapy options.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_676_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_676_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5ebcd628b8542a82c8dd71cfe8ca0f02317830ab
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_676_en.txt
@@ -0,0 +1,10 @@
+A 67-year-old Chinese male, chronic smoker, with past medical history of hypertension, asthma, and untreated hepatitis B presented to our emergency department (ED) with complaint of sudden onset of frank hemoptysis of 1 day duration. He reported that he had a productive cough with significant amount of blood and clots measuring about a cupful. He mentioned that his cough had been present for over a month but only now was present with frank blood. The patient also complained of generalized fatigue and endorsed losing over 15 pounds over the course of the last several months unintentionally. He denied any shortness of breath, chest pain, fever, chills, night sweats, epistaxis, dry eyes, dry mouth, vision changes, photosensitivity, oral ulcer, dysphagia, abdominal pain, nausea, vomiting, constipation, or diarrhea. He denied any urinary disturbance, muscle pain, joint pain or swelling, blood in urine or stool, and any Raynaud’s type symptoms. The patient had immigrated to United States about 20 years prior, with a questionable history of treated tuberculosis about 20 years ago, and no recent travel history. He endorsed a family history only significant for lung cancer in his father. He reported drinking 1–2 alcoholic beverages every day and smoking one pack of cigarettes for the past 20 years.
+Few days prior to this admission, patient had presented to our ED with complaints of bilateral lower extremity and upper extremities numbness, and rash that has started 1 month prior. The rash at the time was described as a palpable purpura over the lower extremities. The patient denied any associated joint pain or joint swelling at that time. He was discharged from the ED with a short course of prednisone, and the rash improved.
+In the ED, the patient’s vitals were blood pressure 127/72 mmHg, pulse 60/min, temperature 98.3 F, respiratory rate 14 breaths/minute, and pulse oximetry 98% on room air, and he was not in need of any supplemental oxygen. On physical exam, patient was not in acute distress. He was able to answer questions appropriately, alert and oriented to time, place and person. Head and neck examinations were unremarkable for lymphadenopathy or Jugular venous distension (JVD). Oral examination showed blood spots that were noted on the roof of the mouth and the base of the tongue and poor oral dentition, but no ulcerations or any other lesions found. On chest auscultation, scattered coarse crackles were noted and decreased breath sound in the right and left middle and lower fields. Cardiology, gastrointestinal, and neurological examinations were unremarkable. No joint tenderness or swelling appreciated at the musculoskeletal examination. Skin examination revealed dark red non-blanching rash on the bilateral shins and calves.
+Initial complete blood count and complete metabolic panel were all within normal limits . Erythrocyte sedimentation rate (ESR) initially was 13 mm/hr., and on subsequent follow up increased to 44 mm/hr. C-reactive protein (CRP) was elevated at 21.9 mg/L. Urinalysis was negative, with no protein or cells. Hepatitis C antibody negative. Hepatitis B surface antigen was positive, and viral load detected by quantitative nucleic acid amplification test (NAAT) at 530 IU/mL. Coagulation profile was within normal (INR: 0.9, activated PTT: 31). Infectious work-up over the next subsequent days was found negative including for tuberculosis.
+Further work-up was performed during the admission and yielded highly elevated rheumatoid factor (2460.00 U/mL), reduced complement levels (C3 54.8, C4 < 2).
+A computed tomography angiography of the chest showed no evidence suggestive of pulmonary embolus but was suggestive of ground-glass and mixed density nodular opacities with increased bilateral peri-bronchial thickening with tracheal and bronchial mucous stranding and increased right middle lobe mucous plugging indicating chronic low-grade inflammatory process .
+At that time, most of serology work-up were pending including cryoglobulins level and anti-neutrophil cytoplasmic antibody (ANCA), therefore patient was started on oral Azithromycin 500 mg daily, and intravenous Ceftriaxone 1 g daily for 7 days for pneumonia concern. His hemoptysis resolved during his hospital stay and hemoglobin remained stable. He was also initiated on antiviral therapy for hepatitis B. The patient was discharged home on empiric azithromycin for outpatient treatment for presumable pneumonia and follow-up bronchoscopy while waiting for serology.
+One day after discharge, patient experienced another episode of hemoptysis, was readmitted for closer monitoring and further evaluation. At that time, the remaining serology was resulted revealing elevated cryoglobulins IgG and IgM level, and immunofixation electrophoresis of the cryoprecipitate disclosed a Type II Cryoglobulinemia. Patient was found negative for serine PR3 (protease3)-ANCA and MPO (myeloperoxidase)-ANCA.
+The patient underwent bronchoscopy at the 2nd hospital admission, which revealed a friable and necrotic bronchial mucosa with blood clots in the right lung, but no active bleeding was noticed. Analysis of the bronchoalveolar lavage (BAL) revealed no malignant cells, and no fungal elements identified, but few bronchial epithelial cells and hemosiderin-laden macrophages on a hemorrhagic background confirming the suspected diagnosis of alveolar hemorrhage. Bronchoalveolar lavage cultures were negative.
+Therefore, the patient was diagnosed with cryoglobulinemic vasculitis and started on high dose oral corticosteroid, 60 mg Prednisone daily. His hemoptysis resolved, and kidney function remained stable. He was stable for discharge to follow up outpatient with rheumatologist for closer monitoring and to start Rituximab as an outpatient. The patient was continued on Entecavir for hepatitis B treatment under the follow up of hepatologist. He received Rituximab intravenous infusion of 1000 mg on week 0 and 2 (for total of two doses). Prednisone was tapered off on weekly basis over the following 3 months. With the treatment, hemoptysis resolved, purpuric skin rashes cleared, kidney function remained stable with no active urinary sediment, and C3, CRP, and ESR normalized. Hepatitis B viral load became undetectable on treatment with Entecavir.
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index 0000000000000000000000000000000000000000..95e93dcfeaedc995fa760b98b13306d59c25f4f9
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@@ -0,0 +1,3 @@
+A 60-year-old Chinese male presented to our hospital complaining of pain, coldness and numbness in the right lower limb for one month. On physical examination, he was afebrile and had a pulsatile, firm subcutaneous mass with a diastolic and systolic murmur on the medial aspect of the right thigh. Peripheral pulsations could be palpated well at the right common femoral artery, but not the popliteal artery, dorsalis pedis artery and the tibialis posterior artery, indicating the occlusion of superficial femoral artery (SFA). Additional imaging, including the color Doppler ultrasonography (CDUS, Fig. ) and computed tomography angiography (CTA, Fig. ) conducted to evaluate the potential embolic sources, revealed the formation of two aneurysms in the middle and lower segment of the right SFA , accompanied by the presence of mural thrombus. The proximal aneurysm was located higher than the Hunter’s canal with the maximal diameter of 15 mm, while the distal aneurysm (which was ruptured, but only with localized hematoma, not progressive bleeding) was located within the Hunter’s canal with the maximal diameter of 26 mm. The normal neurological, cardiovascular systems examinations and no significant medical history of hypertension, heart diseases, diabetes mellitus, blood transfusion, genital ulcer and skin rash seemed to indicate our case was less possibly caused by the complications of these diseases. The popliteal lymph nodes were not palpated and clearly swollen in CDUS and CT examinations, excluding the lymph nodes origin. However, he recounted he had heterosexual extramarital unprotected sexual contacts twenty years ago, but denied any sexual activity since his wife died eighteen years ago. His wife had one previous abortion before death, but no syphilis testing was performed. These promoted us to perform the syphilis tests for this patient. As a result, the patient tested positive for Treponema pallidum hemagglutination antibody and rapid plasma regain (RPR, titer 1/16). The patient denied any recent inoculations, vaccinations or complementary treatments that may cause a false positive syphilis serology . Additional laboratory tests revealed the elevated levels of both the erythrocyte sedimentation rate (ESR, 58 mm/1 h) and the serum C-reactive protein (CRP, 15.4 mg/L), suggesting the inflammatory arteritis. A presumptive diagnosis of right femoral aneurysm secondary to the tertiary syphilis from unprotected sexual contacts was given.
+In view of the active syphilis infection and the high vascular inflammatory reaction that may cause pseudoaneurysm and rupture of the artery anastomosis if surgery was performed, the patient was firstly treated with benzathine penicillin (2.4 MU, i.m) once a week. Four weeks later, the titer of RPR, the concentration of CRP and ESR were respectively reduced to 1:12, 12.5 mg/L and 42 mm/1 h, demonstrating the effectiveness of anti-syphilis therapy. However, the patient presented aggravated pain at the right thigh, which was considered to result from the hematoma enlargement due to the rupture and hemorrhage of the aneurysm. Thus, the operation treatment was prepared. In an effort to minimize the morbidity and mortality of femoral aneurysm repair, implantation of the Viabahn covered stent graft (Gore & Associates) was performed to isolate the aneurysm . Intraoperatively, a 90-cm, 6-F Flexor sheath (Cook) was advanced into the right common femoral artery in a retrograde fashion. Nevertheless, the distal occlusion of the right femoral artery was still displayed on the digital subtraction angiography (DSA, Fig. ), which may be attributed to the tortuous arterial wall compressed by the aneurysm and hematoma. Then a single 5-F, cobra-shaped catheter (Terumo) combined with a 0.035-inch smooth Radiofocus hydrophilic guidewire (Terumo) were inserted but they could also not pass through the distal end of the aneurysm. Subsequently, an incision was made below the right medial malleolus to expose the right tibialis posterior artery and the retrograde puncture was performed to place a 5-F dilator catheter (Cook). A 0.018-inch guide wire (Boston Scientific) was inserted through the dilator, however, the distal end of the aneurysm was still not opened. The routine open operation via a medial incision was eventually carried out to remove the right femoral aneurysm under the general anesthesia. Pathological examination of the resected aneurysm showed the proliferation of adventitial vasa vasorum, with sporadic infiltration of inflammatory cells ; the fibroplasia in the arterial wall accompanied by local calcification and mucoid degeneration . Accordingly, the patient was ultimately confirmed with right femoral aneurysm due to syphilis.
+Postoperatively, the anti-syphilis treatment continued. After three months, the laboratory findings indicated that RPR and Treponema pallidum hemagglutination antibody were negative. The CDUS demonstrated that the stenosis, occlusion and re-formation of aneurysm were all not found in the arteries of the right lower limb. The patient was also well and asymptomatic.
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index 0000000000000000000000000000000000000000..fabcdf43d0eed9fa44a74861a19c9a8724b3aed4
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+A 49-year-old female presented to the emergency department with sudden vision loss in the left eye (LE) with onset 5 h before. The patient also reported 2 episodes of sudden blurring of vision in her LE (10 and 8 days before) that lasted about 15 min and then fully recovered. Best corrected visual acuity (BCVA) was 10/10 in the right eye (RE) and 1/20 in the LE. An anterior segment examination revealed a left relative afferent pupillary defect. A left fundus examination revealed few intraretinal hemorrhages, mildly dilated and tortuous retinal veins, narrowed retinal arteries and a mildly cream-colored edematous appearance of the retinal posterior pole. The RE examination was normal. The past medical history included anxiety, venous peripheral insufficiency, 2 spontaneous abortions and 1 episode of deep venous thrombosis of the leg 12 years before. Her usual medication was zolpidem 10 mg once a day.
+Fluorescein angiography (FA) of the LE showed a delay of dye emergence in retinal arteries (19 s after injection) and a prolonged arteriovenous transit time with laminar flow in the retinal veins only 55 s after the injection. Also, venous network filling was delayed and was not completed 79 s after the injection . No embolic material was seen. Optical coherence tomography (OCT) showed an increase in thickness and hyperreflectivity of the inner retinal layers with hyporeflectivity of the outer retinal layers . This clinical picture was consistent with the diagnosis of combined CRAO and CRVO.
+Initial treatment consisted of urgent HBOT, which begun 3 h after presentation with 100% oxygen at a pressure of 2.4 ATA for 90 min and acetylsalicylic acid at 150 mg/day. Another HBOT session was done 7 h after the first session. There was marked improvement in vision after these HBOT sessions, with BCVA of 5/10.
+The laboratory data only showed hyperlipidemia. An autoantibody screening was negative and inflammatory markers were normal. Echocardiography, neck vessel Doppler ultrasound and brain magnetic resonance imaging results were normal. The patient was sent to a hematology consult to complete thrombophilia screening.
+The patient completed a total of 9 sessions of HBOT in 7 days (2 sessions on days 1 and 2 and then 1 daily session until stabilization of visual acuity). BCVA improved to 10/10 with significant improvement in FA .
+Forty-five days later, she developed a new LE CRVO, and BCVA decreased to 5/10 . At that time, she started oral anticoagulation with acenocoumarol because an underlying hypercoagulable state was suspected. After 2 weeks, the thrombophilia screening results were available and revealed an abnormal resistance to activated protein C (1.21; normal value: >2.14), and a genetic study showed homozygosity for FVL mutation. After 2 months, BCVA decreased to <1/20 because of significant macular edema , and the patient was submitted to 3 monthly injections of 1.25 mg bevacizumab.
+At present (after 10 months), the patient is in a stable condition with BCVA of 6/10; the hemorrhages were absorbed, the dilatation and tortuosity of the retinal veins had subsided , and OCT showed no macular edema . Humphrey 24-2 visual field testing showed nasal and paracentral scotoma . Oral anticoagulation will become a life-long treatment in this patient in order to prevent recurrences.
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index 0000000000000000000000000000000000000000..370efce85c82ac3d1ffb7d00f497626cae833f1a
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+A 61-year-old obese Caucasian female with a previous history of bipolar 1 disorder and hypothyroidism, presented for an out-patient psychiatric follow-up review accompanied by her Community Psychiatry Nurse. She was found to have pressured speech, elated mood, increased energy, and very poor personal hygiene. She was disheveled, unkempt, wearing dirty clothes, and was foul smelling. She was very agitated, and was verbally and physically abusive to staff. She had no insight, and refused any form of treatment. She was diagnosed with having a manic relapse secondary to non-adherence to medication, and was involuntarily admitted to the in-patient psychiatric ward. Complete blood count, electrolytes, glucose, liver function, and lipid profile were all within normal limits. Thyroid stimulating hormone was slightly elevated, although T4 was within normal limits. Vitamin B12 was on the low end of normal. She was re-started on her previous psychiatric medication, namely divalproex and clonazepam.
+The following day she was adamant about having to go feed her cats and dogs, and eventually gave permission for a Community Mental Health Nurse enter her house to attend to her pets. Upon entering the house, it was found to be in complete disarray. The house was crammed with filthy clothes, garbage, dirty dishes, and rotting food. There was no kitchen sink in sight, and it looked as if some dishes were being cleaned in the toilet (see Figures and
+). Any clear space of floor was strewn with cat and dog feces. An unbearable stench emanated from the entire two-story home. Upon questioning the patient regarding the state of her home and personal hygiene, the patient had no insight into any problems. At this time, a diagnosis of Diogenes syndrome was suspected.
+Diagnosis of DS can be difficult as no one constellation of symptoms has been established. Hoarding, which can occur in DS, can also be found in many psychiatric conditions such as obsessive-compulsive disorder (OCD), schizophrenia, dementia, and others
+. The act of accumulation in DS is more likely ego-syntonic however, in contrast to the anxiety and intrusive thoughts that accompany collection in OCD
+. DS can be distinguished from personality disorders in that the personality in DS deteriorates, while the true personality disorder does not
+. Self-neglect can also be a part of dementia, schizophrenia, OCD, and affective disorders
+. Frontal lobe dementia tends to occur approximately 10 years prior to the typical age that DS patients are affected though
+. A diagnosis of schizophrenia can include delusions, hallucinations, and disorganized speech
+, which are not classical characteristics of DS. Clearer delineations between disorders need to exist however. An alterative suggestion was that DS “may be a final common pathway of different psychiatric disorders”
+.
+Management of DS can be difficult, as patients often deny that there is a problem, may refuse any help, and can present late to medical attention
+, often in crisis. Ethical and legal issues can then arise, such as finding a balance between autonomy and beneficence
+. For example, a patient’s notion of self-neglect can be quite different than the view of their healthcare provider
+. Public Health issues may also arise concerning the patient’s housing. Fire, mould, and biological material can pollute the surrounding environment, so the health of nearby residents needs to be considered.
+Establishing good rapport is vital in order to decrease the patient’s resistance to aid. A physical exam should be completed. Blood tests may include potassium, calcium, vitamin B12, iron, thyroid stimulating hormone, folate, and albumin
+. Functional inquiries and cognitive testing may be useful. Treatment usually begins by looking at any other possible psychiatric issues such as mania or psychosis. Risperidone has been suggested for use in DS even when there are no underlying psychotic features
+. Other pharmaceuticals that may be of benefit include zolpidem for sleep, paroxetine for hoarding, and sodium valproate or quetiapine for secondary bipolar disorders
+. Flexible outpatient treatment through community care providers is preferable if there is little risk to the patient or to others
+. This can include counseling and cleaning services, and individualized case management
+. The mental health act can be used if difficulties are experienced in managing higher-risk patients. If management is not conducted in a sensitive manner, patients will simply return to the same living condition, with much more resistance to support and follow-up.
+The prognosis of affected individuals depends on their capability of re-integrating into society, and often relies on the patients making small changes away from unhealthy living conditions
+. Other poor prognostic factors include poor physical health, which may already be advanced due to neglect, and early age at onset.
+As time progressed as an in-patient, the patient’s mood settled, although she remained guarded, with little insight into her self-care. The patient required persistent and gentle pressure in order to even start thinking about de-cluttering and improving her personal hygiene. She was eventually persuaded to allow a company to help her clean her home, at a cost of $8,073. The patient was present at the clean up. The sink was eventually found under a large pile of debris. The patient is now living at home, and receiving close follow-up with her Community Psychiatry Nurse and Psychiatrist. It remains to be seen whether these interventions will make any long-term impact to her living condition and health.
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+In May 2017, a 51-year old female presented to our hospital with over 1 week of fatigue. She has medical history of donating both bone marrow and PBSCs 8 yrs ago for her brother with severe aplastic anemia (SAA). G-CSF was used to mobilize hematopoietic stem cells for PBSC collection. Complete blood count (CBC) showed lymphocytosis (Lymphocyte 10*10^9/L), moderate anemia (Hb 61 g/L) and thrombocytopenia (PLT 20*10^9/L). Peripheral blood smear demonstrated 30% of blast cells. Bone marrow biopsy showed lymphoblastic leukemia involving a markedly hypercellular marrow . Flow cytometry showed the blasts expressed CD10, CD19, CD22, CD38, HLA-DR, but not CD13, CD33, CD117, or cytoplasmic MPO. Chromosomal analysis showed a normal female karyotype. The diagnosis of B-ALL was made. VDP regimen (Vindesine, Daunorubicin, Prednisone) was started after her diagnosis and bone marrow aspirate 14 days later revealed complete remission (CR). Then 2 cycles of VDLP regimen (Vindesine, Daunorubicin, Prednisone, Pegaspargase) and 2 cycles of MA (Mitoxantrone, Cytosine arabinoside) + Pegaspargase (PEG-Asp) regimen were administered. During this period, the patient remained in remission and cerebrospinal fluid (CSF) remained clear after intermittent four time lumbar punctures. Minimal residue disease (MRD) monitoring by flow cytometry after each cycle did not detect blast cells with abnormal phenotype. Considering she has no other HLA-identical siblings or unrelated donors from China Bone Marrow Bank at that time and her brother, who was perfectly stable, a special type of auto-HSCT using her brother’s PBSCs was performed in December 2017. Before the transplantation, whole exome sequencing (WES) was done for both the donor and recipient to rule out occult genetic abnormalities in the stem cells. Results showed that only the patient, not her brother, has genetic mutations including SF3B1 and BRAF mutation associated with hematological malignancies in her hematopoietic cells, not oral mucosal cells [–]. Myeloablative conditioning regimen (Melphalan 140 mg/m2 d-3/d-2/d-1, Cytarabine 1 g/m2 d-3/d-2, Cyclophosphamide 60 mg/Kg d-3/d-2) was used. A total of 2.34*10^6/kg CD34+ cells, 13.0*10^8/kg MNCs from peripheral blood were collected and transfused into the patient. Neutrophil engraftment occurred at day + 11 and platelet engraftment occurred at day + 14. VP regimen (Vindesine, Prednisone) and MTX + 6-MP regimen were used for maintenance therapy. Bone marrow aspirate and flow cytometry showed that the patient remained in complete remission 3 months after transplantation. In May 2018, the patient’s CBC showed leukocytosis and bone marrow aspirate indicated disease relapsed with 53.33% blast cells. Flow cytometry showed the blasts expressed CD10, CD19, HLA-DR and partially expressed CD11b. Genetic testing using polymerase chain reaction (PCR) technique found that SF3B1 and BRAF exome mutation was negative. Re-induction chemotherapy with VDP regimen was administered, the patient achieved CR. However, after another 2 cycles of high-dose MTX+ PEG-Asp regimen, disease relapsed. In November 2018, CD19 CAR-T therapy followed by HLA-identical unrelated hematopoietic stem cell transplantation was applied and the patient remains in remission for 7 months till now.
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+A 51-year-old man was referred to this hospital for a follow-up cardiology visit after a right cerebellar ischemia occurred 1 month prior to presentation, from which the patient had rapidly recovered without residual deficits. He had no history of hypertension, arthritis, uveitis, mouth ulcers nor crystalline lens subluxation. He had been smoking until 2 years before presentation; his anamnesis was negative for alcohol or illicit drug abuse and his family history was unremarkable. His only medication was acetylsalicylic acid.
+During the previous hospital stay, extensive examinations had been performed, including electrocardiogram (ECG), lipid panel, transthoracic echocardiography (TTE) and doppler ultrasonographic assessment of the supra-aortic vessels and of the lower extremities’ veins, all of which resulted unremarkable.
+A few days after hospital discharge, the patient had suffered a single episode of intense subjective vertigo, tinnitus, confusion and orthostatic imbalance, which had resolved spontaneously in about 20 min without referring to any physician.
+On presentation the patient was asymptomatic, eupneic and apyretic. His blood pressure was 155/90 mmHg on both arms. On physical examination a mild pectus excavatum was noticed. Cardiac tones were valid and regular, and a third tone was heard. Radial pulses were symmetrical and valid, while the femoral and pedidial pulses were slightly attenuated.
+The ECG revealed a sinus rhythm at 66 bpm with normal atrioventricular and intraventricular conduction; a Q wave was documented in leads D2, aVF, D3, V5 and V6 and a negative symmetrical T wave was present in the same leads ; these signs were absent in previous ECGs. A TTE was performed, which documented a moderate depression of the left ventricular ejection fraction (LVEF) (39%) and infero-posterior and apical akinesia with left intraventricular “smoke”. The patient was thus admitted to the hospital ward for further investigations.
+On admission blood tests were mostly within normal range, including haemoglobin (13,8 g/dL), C-reactive protein (2,4 mg/L), high-sensitivity troponin T measurement (12 ng/L, upper limit of normal 50 ng/L), creatine phosphokinase (90 UI/L), creatinine (0,99 mg/dL), urea (31 mg/dL), aspartate transaminase (16 UI/L), alanine transaminase (12 UI/L), total bilirubin (0,6 mg/dL), INR (1,02), aPTT ratio (0,95), fibrinogen (292 mg/dL). N-terminal prohormone of brain natriuretic peptide was slightly elevated (636 pg/mL, upper limit of normal 300 pg/mL).
+Because of the recent stroke, the patient’s rhythm was monitored with ECG telemetry during the whole hospitalization period in order to exclude silent paroxysmal atrial fibrillation episodes. Besides, a transcranial doppler was performed, which documented the presence of a moderate right-to-left shunt. Moreover, the transoesophageal echocardiography (TEE) showed a PFO along with a double lumen in the descending thoracic aorta, rising the suspicion of aortic dissection. Consequently a computed tomography angiography (CTA) was performed documenting a TBAD extending from the thoracic descending aorta just below the origin of the left subclavian artery to the iliac arteries bilaterally, the false lumen prevailing over the true lumen . The right renal artery and the inferior mesenteric artery originated from the false lumen, whereas the left renal artery, the superior mesenteric arteries and the celiac trunk all originated from the true lumen; the supra-aortic trunks and the ascending aorta were not involved in the dissection process. Within the coronary vessels, the CTA documented one-vessel disease with two small eccentric plaques in the proximal left anterior descending (LAD) artery conditioning a moderate stenosis (> 50%). A hypodense area was observed in the subendocardial ventricular myocardium at the apical and middle segments of the inferior wall and at the middle segment of the anterolateral wall; no pericardial effusion was documented. A cardiac magnetic resonance (MR) was then carried out, which showed the presence of ischemic apical, apical-anterior and inferior late-gadolinium enhancement along with intraventricular thrombosis and severe left ventricular systolic disfunction .
+Venous ultrasound of the lower limbs was normal.
+Because of the recent episode of dizziness and orthostatic imbalance, following neurologist review, a brain MR was also performed, documenting multiple areas of altered signal due to previous old and recent ischemic events in the cerebellar and cerebral hemispheres .
+Takayasu arteritis, giant cell arteritis and rheumatic diseases were considered in the differential diagnosis ; a rheumatologic screening was performed, including complement components, rheumatoid factor, anti-nuclear antibodies, anti-neutrophil cytoplasmic antibodies, anti-cardiolipin antibodies and β2-glycoprotein 1 antibodies, all of which resulted within the range of normality.
+A thrombophilic screening was performed, including tests for protein C and protein S deficiencies, factor V Leiden and prothrombin 20,210 mutations, antithrombin deficiency, hyperomocysteinemia and antiphospholipid syndrome, and resulted negative.
+The presence of mild pectus excavatum along with a history of surgery for foot deformity raised suspicion for collagen diseases such as Marfan and Ehlers-Danlos syndrome ; the genetic experts, however, due to the lack of significant physical signs of collagen disease and the absence of aortic root aneurysm and ectopia lentis , considered these diagnoses unlikely and genetic testing was not recommended.
+From a cardiovascular point of view, two theories were hypothesized. According to the first one, the patient had suffered from a silent recent type 1 myocardial infarction leading to LVEF reduction with consequent thrombus formation in the left ventricle and subsequent embolization to the brain causing multi-infarct encephalopathy ; in this scenario, the PFO would be a mere bystander. The second theory infered that the patient had suffered from deep vein thrombosis from unknown origin, causing encephalic and myocardial infarction on embolic basis due to the right-to-left shunt of the PFO; in this latter case, the atherosclerotic LAD stenosis would be an incidental finding. Unfortunately, whatever the main event was, either the recent myocardial infarction or the deep vein thrombosis, the question remained unsolved due to its silent course.
+Following discussion between the cardiologist, the interventional radiologist and the cardiac surgeon, after multiple interviews with the patients regarding risks and benefits of the different treatment options, it was jointly decided not to perform endovascular treatment regarding the aortic dissection due to the lack of symptoms and the absence of parenchymal involvement, but careful monitoring was deemed necessary and strenuous exercise was contraindicated . A coronary angiography exam was then performed showing 50% stenosis of the proximal LAD coronary artery at angiographic estimation with patency of its distal segment ; a “minus” image along with slow-flow appearance distal to the lesion raised suspicion for coronary artery dissection and induced the operator to evaluate the stenosis with intravascular ultrasound imaging, which revealed a critical minimal lumen area of 4,0 mm2 with 80% plaque burden as compared to the patent lumen of the adjacent segment . Due to the high-risk features of the coronary lesion, after communicating benefit and risk information to the patient and acquiring informed consent, the operator performed angioplasty with the deployment of a Synergy™ drug-eluting stent. The patient was started on triple antithrombotic therapy with warfarin (because of the left ventricular thrombus), acetyl-salicylic acid and clopidogrel; low-molecular-weight heparin bridging was utilized until target INR (2.0–2.5) was achieved. The PFO closure procedure was temporarily postponed .
+During the hospital stay the patient remained asymptomatic. Cardiac anti-remodelling therapy with angiotensin converting enzyme inhibitor and a potassium sparing diuretic was started and it was well tolerated. No arrhythmic events were documented on telemetry. At discharge the patient was asymptomatic and in stable haemodynamic condition.
+After 1 month acetyl-salicylic acid was interrupted. After 6 months the CTA showed no progression of the aortic dissection ; LVEF was almost unchanged (38%) on TTE and a small intraventricular thrombotic formation, albeit reduced in diameter, still persisted on cardiac MR imaging . The patient was asymptomatic and he was advised to prolong his therapy with both clopidogrel and warfarin until future assessment with TTE and CTA after 12 months. PFO closure was not deemed necessary as long as the patient was on anticoagulation therapy.
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index 0000000000000000000000000000000000000000..e412a1cda3fe318e8b8a3fb40d9ca457deb67374
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+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_719_en.txt
@@ -0,0 +1 @@
+A 49-year-old man presented with exertional dyspnea. Physical examination revealed a loud S1 and a diastolic murmur in the apical region. Transthoracic echocardiography revealed severe rheumatic MS with mild MR, as well as mild functional tricuspid regurgitation and a pulmonary pressure of 55 mmHg. Then, the patient underwent a three-dimensional transesophageal echocardiography to assess the mitral apparatus more accurately and exclude the presence of left atrial appendage thrombus . His Wilkins score was 8. This is a borderline score to take BMV. However, the patient prefers to take the percutaneous intervention rather than thoracotomy. Thus, BMV was performed via the antegrade approach under local anesthesia and X-ray fluoroscopy guidance. After transseptal puncture, a 24-mm balloon was used to achieve a single dilatation of 22 mm, after which the mean transmitral pressure gradient decreased from 19 to 11 mmHg. Intraoperative transthoracic echocardiography performed immediately afterwards revealed a significant increase in mitral regurgitation. However, the subvalvular structure could not be observed clearly because the patient was in a supine position. His vital signs remained stable with no definite symptoms, and he refused mitral valve replacement. He was discharged 4 days later after undergoing BMV. Two-dimensional transthoracic echocardiography follow-up performed one month later revealed severe MR caused by a freely mobile part of the mitral papillary muscle . The left ventricular cavity and the two groups of papillary muscle were then imaged using three-dimensional transthoracic echocardiography, which showed avulsion of the posterior papillary muscle (PMA) from the left ventricular trabecular muscle. No residual papillary muscle attachment to the left ventricular wall was observed, confirming avulsion of the posterior papillary rather than its rupture . In addition, the left ventricular end-diastolic dimension increased from 45 to 53 mm. The estimated systolic pulmonary pressure increased from 55 mmHg to 81 mmHg. Therefore, the patient underwent mechanical mitral valve replacement and tricuspid annuloplasty. After surgery, the patient recovered without symptoms. At 1-month and three-month follow ups, the patient was asymptomatic, and transthoracic echocardiography showed that the left ventricular volume and pulmonary systolic pressure were significantly lower than before surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_721_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_721_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ddefb1c97c9bcda2285f768caced6f5f332fbaa3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_721_en.txt
@@ -0,0 +1,3 @@
+A 71-year-old male patient was admitted to our hospital with pneumonia, and chronic diseases such as Parkinson’s disease, Alzheimer’s disease, lacunar cerebral infarction, and cardiac insufficiency. He had a 15-year history of hypertension and 5-year history of prostatic hyperplasia with stones. The day before admission, the patient’s body temperature rose to 37.6 ℃, with elevated neutrophils and high-sensitivity C-reactive protein (hs-CRP). Physical examination showed crackles in the lungs. Computer tomography (CT) scan showed multiple inflammations in both lungs, suggesting a pulmonary infection. Coagulation tests were normal (PT: 13.9 s, APTT: 30.2 s) . Biochemical tests showed increased urea, 7.29 (normal, 3.60–9.50) mmol/L, B-type brain natriuretic peptide BNP, 1050.0 (normal, 0.0-100.0) ng/L, creatine kinase CK, 172 (normal, 55–170) U/L, its isoenzyme CK-MB, 9.3 (normal, 0.0–24.0) U/L and cardiac troponin I cTnI, 0.575 (normal, 0.000-0.034) ng/ml. Therefore, the patient was treated with piperacillin/tazobactam (4.5 g three times daily, intravenous infusion), as well as symptomatic treatment including reducing phlegm, diuresis and control of Parkinson’s disease symptoms. In addition, Metoprolol and 4100 IU low-molecular-weight heparin were given to control the heart rate and prevent cerebrovascular accidents. Due to dysphagia, a gastric tube was inserted to improve his nutritional status.
+The patient was unable to cough up sputum spontaneously on day 3 after admission and developed a high fever (38.6 ℃), so piperacillin/tazobactam was switched to meropenem (1.0 g three times daily, intravenous infusion) to intensify anti-infective therapy. However, sputum and blood culture results were negative. On day 11 after admission, the patient’s temperature dropped to normal, then meropenem was switched to cefmetazole (2.0 g twice daily, intravenous infusion). On day 15 after admission, the patient again developed fever (38.4 ℃), which was considered to be aspiration pneumonia probably due to prolonged bed rest and neurological disease. On day 18 after admission, the serum potassium value rose to 6.11 (normal 3.50–5.30) mmol/L. Calcium gluconate was used to antagonize potassium toxicity, along with high glucose plus insulin, furosemide, and potassium-free nutrient solution. In view of poor infection control and renal insufficiency, cefmetazole was again switched to meropenem (1.0 g once daily, intravenous infusion) on day 19 after admission.
+The patient presented with severe coagulation abnormalities on day 20 after admission . Coagulation tests showed greatly prolonged PT (136.1s) and APTT (54.8s). However, the patient had a normal platelet count, no bleeding symptoms, and had not taken warfarin or other anticoagulant drugs. The results of the mixing study then showed a significantly lower PT (16s) , indicating the lack or anergy of coagulation factors. On day 21 after admission, 20 mg of vitamin K supplementation rescued the coagulation dysfunction . A chest CT showed obvious resorption of the infection lesions of bilateral lungs, so meropenem was replaced with cefodizime (2.0 g twice daily, intravenous infusion) to continue anti-infective therapy. The laboratory results of coagulation function returned to normal on day 22 after admission . In the following days, the pneumonia improved significantly, and the patient was discharged on day 33 after admission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_729_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_729_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7e94f356bfa21affe233549fac7ea8dda7af7f65
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_729_en.txt
@@ -0,0 +1 @@
+A 64-year-old white European man presented with right knee pain due to an isolated medial meniscal tear of non-traumatic origin, confirmed on X-ray and computed tomography (CT) arthrogram . An arthroscopic partial medial meniscectomy was performed and in the same session a grade 1a International Cartilage Repair Society (ICRS) cartilaginous lesion was revealed. His early postoperative course was favorable, without fever or other signs of infection. Unfortunately, his knee pain reappeared 2 months postoperatively and became invalidating within the following month, leading to another set of X-rays (anterior-posterior and lateral) that showed complete medial femorotibial joint thinning. A clinical examination showed neither effusion nor redness; he had a good range of motion (0/0/125°), no laxity, a slight varus morphology and anterior medial femorotibial pain with no meniscal pain. The X-rays were completed by a schuss view that confirmed an Ahlbäck stage III joint thinning and a CT arthrogram showed complete chondrolysis of his medial femorotibial compartment . Standing long leg films showed an 8° varus deviation compared to 3° on his left knee. All blood work was normal, and no rheumatologic cause was identified. No genetic testing was performed. As there was no argument for infection, no aspiration was performed. Infiltration and viscosupplementation were proposed but refused by the patient. He is now waiting for a unicompartmental knee replacement.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_75_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_75_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2730bf42d4a8532c0d7f25c0cb145292ec46b928
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_75_en.txt
@@ -0,0 +1,5 @@
+A 63-year-old male presented to the First Hospital of Jilin University with a 2-month history of a cervical mass. He had no history of neoplasms and no family history of tumors. Blood tests showed slightly increased thyroid stimulating hormone levels (56 μIU/mL) and decreased T3 (2.4 pmol/L) and T4 (10 pmol/L) levels. His antithyroglobulin antibody levels were within the normal range. Computed tomography imaging showed a mass, approximately 4.5 × 4.0 × 4.5 cm in size, with calcification in the left thyroid lobe and two smooth and homogeneous nodules in the right thyroid lobe. The trachea was compressed and deflected toward the left side . The patient underwent total thyroidectomy with cervical lymph node resection. Neck MRI showed that the epicenter of the left lobe mass was in the thyroid gland and that it did not originate from the surrounding thyroid cartilage .
+Macroscopic examination of the resected specimen revealed a lobulated mass with calcification that occupied the majority of the left thyroid lobe and two homogeneous, oval nodules in the right thyroid lobe .
+Histopathologically, the majority of the tumor in the left thyroid lobe comprised low-grade hyaline-type cartilage, and some spindle cells were observed around the hyaline cartilage . In some areas, the tumor infiltrated the remaining thyroid tissue . A high-grade spindle cell sarcoma could be seen in some areas , in which the high-grade sarcoma cells exhibited extensive pleomorphism, atypia, and a high mitotic rate . One of the two nodules in the right thyroid lobe had a gray-white appearance, and it comprised a prominently collagenous stroma and some bland spindle cells infiltrating the surrounding thyroid tissue . The other nodule had a brown appearance; it was completely enclosed within a thin, fibrous capsule and exhibited normofollicular and microfollicular architecture . We carefully examined all hematoxylin and eosin–stained sections; however, we did not observe any definite necrosis.
+Table shows the summary of immunohistochemical findings. The spindle tumor cells in both thyroid lobes were positive for vimentin but negative for cytokeratin and epithelial membrane antigen. These spindle cells showed high expression of Ki-67 . The low-grade hyaline-type cartilage in the left thyroid tumor was positive for vimentin . The positive rate of expression of vimentin in both the thyroid tumors was 90%. The positive rate of expression of Ki-67 in the spindle cells of the left thyroid tumor was 50%. The positive rate of expression of Ki-67 in the spindle cells of the right thyroid gray-white nodule was 20%.
+The patient received postoperative radiotherapy and was free of local and regional recurrence or distant metastases at the 8-month follow-up evaluation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_775_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_775_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6de1de32d9c511a4c355a65ab8bc431934c46a0f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_775_en.txt
@@ -0,0 +1 @@
+A 24-year-old man presented with a 4-week history of side-locked attacks of excruciatingly severe stabbing and boring left-sided pain located in the orbit. The attacks were associated with nasal obstruction, clear nasal discharge, conjunctival injection and restlessness. No continuous background pain was identified. The duration of the attacks was about 40 minutes and the frequency 3 per 24 hours, 5 days a week. There was no history of headache. His medical and family history was otherwise unremarkable. He was not on any medications and used no drugs. Vital signs, physical examination, and neurological examination were normal. Local tenderness over the sinuses was not found. Laboratory testing was normal. He satisfied the revised International Classification of Headache Disorders criteria for cluster headache. A diagnosis of CH was made and subcutaneous sumatriptan as well as oxygen 100% (7 L/min) were prescribed. The patient responded to subcutaneous sumatriptan/oxygen with relief within 20 minutes. A follow-up was planned. An otologist consultation was performed to rule out an acute sinusitis. Low-dose computer tomography scan after 2 weeks displayed a left-sided acute maxillary sinusitis . A sinus puncture was performed and it displayed acute inflammation/high leukocyte count. Bacterial culture displayed Haemophilus influenzae. The headache attacks resolved completely after treatment with antibiotics and sinus puncture. A low-dose computer tomography scan was repeated after 6 weeks and it displayed normal findings . The prescribed medication was discontinued. No additional treatment was given. He remained headache-free and had not experienced any headache attacks at follow-up after several years.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_810_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_810_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..55fe3ceefe5a2c122d12840d8d20f13897c9109a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_810_en.txt
@@ -0,0 +1,36 @@
+A 15-year-old female, the eldest sibling of patient 1, was diagnosed with
+tyrosinemia type III at eight years of age, after a family screening
+following her brother’s diagnosis.
+She was born at term by cesarean section (pelvic presentation) following an
+uneventful pregnancy, with an Apgar score of 8 and 9 at 1 and 5 minutes,
+respectively. Her birth weight was 4,030 g (87th percentile),
+length 53 cm (87th percentile), and head circumference 36 cm
+(83rd percentile). Her neonatal period was unremarkable, as
+was her early psychomotor development. She had a history of primary
+nocturnal enuresis and vesical instability, treated with desmopressin and
+oxybutynin hydrochloride since the age of six.
+She was diagnosed with ADHD at the age of five and treated with
+methylphenidate and risperidone. She presented learning difficulties when
+she attended elementary school (2nd grade), and was included in a
+special education program at the age of ten.
+At the time of diagnosis, her initial tyrosine level was 1,769 µmol/L. On the
+first nutritional status evaluation, her daily natural protein intake was
+1.4 g/kg. This value dropped to 1.08 g/kg, and she started taking
+supplementation with 0.7 g of amino acids/kg from phenylalanine- and
+tyrosine-free amino acid mixtures, enabling a consistent decrease of
+tyrosine levels below 300 µmol/L.
+Her physical examination and growth were normal (weight and height at the
+50‒85th percentile), with an unremarkable neurological
+examination. The genetic study revealed the same mutation as her brother in
+homozygosity.
+After initiating a low-protein diet, her behavior and school performance did
+not improve. The minimum level of daily natural protein intake reached was
+0.65 g/kg at 14 years of age. She is currently in 7th grade,
+still in the special education program, and under treatment with
+methylphenidate. Her latest formal developmental assessment (Wechsler
+Intelligence Scale for Children®, third edition, Portuguese
+version) revealed a global IQ score of 68, with a verbal IQ of 68 and a
+performance IQ of 77 .
+She slowly began diet liberalization and is now with a daily natural protein
+intake of 0.9 g/kg, combined with 0.8 g of amino acids/kg, maintaining
+tyrosine levels below 300 µmol/L nevertheless.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_83_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_83_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7289dca72ad12082839e742d6c4b6525f8626cd1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_83_en.txt
@@ -0,0 +1,3 @@
+A 38-year-old male with no past medical history asked a bystander to call emergency medical services (EMS) after he had fallen 12 feet off a fire escape and landed on his right ankle. An Advanced Life Support ambulance was dispatched and, upon arrival, paramedics found the patient on the ground and unable to ambulate. He complained of 8/10 pain to his right ankle. Airway, breathing, and circulation to all four extremities were intact, and initial vital signs were heart rate (HR) of 100 beats per minute, blood pressure (BP) of 142/76 millimeters of mercury (mm Hg), respiratory rate (RR) of 20 breaths per minute, and oxygen saturation (SpO2) of 98%. Physical exam was notable for a right ankle deformity.
+Paramedics on scene immobilized the patient’s leg in a splint, after which they contacted their online medical control (OLMC) center to discuss options for analgesia. The OLMC physician authorized the delivery of a dose of nebulized ketamine via BAN at 0.75 milligrams per kilogram (mg/kg) mixed with three milliliters (mL) of normal saline. During administration, the patient reported dizziness, which was rated one on a scale from zero to four using the Side Effects Rating Scale of Dissociative Anesthetics. This is a scoring system used to grade severity of medication side effects where zero represents “no change” in symptoms and four represents “very bothersome” symptoms. He did not become agitated, dissociated, or sedated.
+Thirty minutes after the start of nebulization, pain was measured at 3/10. Repeat vitals at this time were HR 103 beats per minute, BP 128/79 mm Hg, RR 18 breaths per minute, and SpO2 97%. In the ED, at one hour after administration of nebulized ketamine, the patient reported a return of his pain, and was given a dose of four mg IV morphine. Radiograph revealed a right tibial pilon fracture. He was placed in a posterior short leg splint and admitted to the orthopedic service; he was operated on the next day for open reduction and internal fixation of the right ankle joint. He was subsequently discharged post-procedure with orthopedic follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_854_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_854_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d286c0b22607c711c855f3b78f57495bb8b5b229
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_854_en.txt
@@ -0,0 +1,20 @@
+A 53-year-old female patient who had been suffering for ten years from atypical facial pain combined with a partial facial spasm was referred to our outpatient clinic.
+She presented with continuous distorsions of the mimic musculature in the region of the lower left lip, which had appeared following severe osteomyelitis of the left side of the mandible that had been treated surgically. For several weeks following the operation the patient experienced hypesthesia in the left mandibular region and skin. Thereafter, constant, disturbing spasms of the mimic musculature occurred combined with dyskinesia and deep spasmodic pain attacks located in her lower left lip region. In addition, a distinct cutaneous erythema appeared in the region of the dyskinesia .
+The patient reported that pain attacks occurred daily immediately after awakening in the morning, continued during the day without any improvement and subsided only at bedtime.
+There had been no satisfactory response to various neurological or dental therapy attempts nor to acupuncture. Only therapy with carbamazepine had brought a slight and transient relief of her symptoms.
+The patient felt herself immensely restricted by her symptoms and was socially and professionally disabled. She had had to retire because of the intolerable pain attacks, and reported having suicidal thoughts from time to time.
+During the following years she detected alleviation points in her left hand and behind the left ear with which she was able to stop the convulsions and the pain as long as pressure was applied to the points .
+The patient had had no history of movement disorders such as hemifacial spasms nor of allergy, smoking or alcoholism. She had no history of medication except for carbamazepine.
+On physical examination, no anatomic disorders, infections or tumors were found except for a discrete septum deviation. We observed continuous spasms in the region of her left lower lip, accompanied by an intense eczema in this region. She was able to stop the spasms and the pain by pressing the points on her hand or behind the ear.
+After the patient had given informed consent, BTX-A-treatment was begun. She was treated over a period of 67 weeks with seven different injections of BTX-A at different time points.
+The dose of BTX-A was increased from initially 5 units to 25 units at the seventh treatment. We also augmented the number of injection points from 2 points to 10 points in the affected area. Injections were made with 2.5 units per site (Botox®, Allergan Inc, Irvine, California; 0.1 ml = 2.5 units BTX-A). The time between the treatment sessions varied from 3 weeks to 24 weeks up to the last treatment. For details see table .
+BTX-A was injected into the inferior depressor labii muscle in the left lower lip region. The seventh injection with 25 units injected into 10 points was the most effective with an effect lasting 24 weeks .
+The patient was immediately pain-free after the injections and experienced other positive effects such as relief of spasms and eczema. The symptoms improved already after the first injection of botulinum toxin type A. At the check-up, three weeks after the first injection, the patient was free of symptoms and was very satisfied.
+As agreed upon with the patient, she returned to our outpatient clinic for further treatment whenever any symptoms reappeared.
+The BTX-A injection was repeated after 5 weeks with a total dose of 10 units at 4 injection points (4 injections à 2.5 units) because of mild spasms.
+After the second injection, the patient again experienced a reduction in pain, spasms and eczema for a period of 7 weeks, at which time we injected 15 units into 6 injection points.
+In the further course, the patient returned four more times after 3, 11, 17 and 24 weeks for further injections with 20 to 25 units BTX-A into 8 to 10 injection sites. Fourteen weeks after the last series, she reported in a telephone interview that the excellent positive effects were long lasting and that she was not suffering from pain, spasms or eczema.
+The patient was able to reduce the dose of carbamazepine considerably.
+In the course of the treatment period, the duration of the symptom-free period increased from a minimum of 3 weeks to 24 weeks. The longest positive effect was seen after the injection of 25 units BTX-A into 10 injection points in the lower left lip region.
+The patient did not note any side effects except for a slight leakage at the corner of her mouth lasting a few days, which she did not find very irritating as the positive benefits were much more important for her. A total follow-up period of 62 weeks was observed in this patient.
+In summary, the patient expressed great satisfaction and stated: "A completely new period in my life began" after the first injection.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_859_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_859_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..794ae5b3570b021f2e0e87fb399c4529b8957fe1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_859_en.txt
@@ -0,0 +1,3 @@
+A 57-year-old gentleman, presents to the accident and emergency department with acute onset, severe, colicky left loin pain radiating to the anterior chest with associated shortness of breath. Two months previously he was investigated for chest pain and was found to be in atrial fibrillation. He was commenced on warfarin and amiodarone while awaiting cardioversion.
+On examination following pain relief, the patient was comfortable, afebrile and had stable observations (BP 120/80, pulse 60 irregularly irregular, oxygen saturations 97% on room air). There was however marked tenderness of the left renal angle and left lower quadrant but no signs of peritonism. Bloods (Hb 16.1), blood gases and urine dipstick performed at the time were all entirely normal and the patient was found to have an INR of 2.8 (in keeping with treatment for AF); however of note earlier in the week the INR had been reported as 5. An IVU showed no filling defects and therefore CT imaging was performed.
+The CT showed a massive retroperitoneal bleed behind the left kidney and thus was difficult to interpret; the radiologist initially reported the bleed as arising from the psoas. Despite the use of FFP and Vitamin K his Hb continued to drop over 24 hrs from 16.1 to 5.9. Repeat examination of the CT revealed multiple angiomyolipomata found in the left kidney with the bleed originating from a sub-capsular angiomyolipoma (see Figure ). The patient was transfused and underwent selective interpolar arterial embolisation of the left kidney. At embolization it was found that there was a large psuedoaneurysm arising from the interpolar artery as well as the abnormal vessels consistent with the vessels supplying the angiomyolipoma. Post-treatment contrast injection into the left renal artery confirmed adequate embolization and the patient was stable enough to be discharged one week later with no further evidence of bleeding.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_879_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_879_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e271001f355dba454fe182878727540f9cea513e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_879_en.txt
@@ -0,0 +1,3 @@
+A 69-year-old Japanese man was admitted to our hospital for further evaluation of weight loss and deterioration of diabetes mellitus. He was a smoker as well a social drinker with no signs of obesity; he had no history of pancreatic disorders. His latest serum HbA1c level had risen to 9.8%. His vital signs were as follows: body temperature of 37.6°C, blood pressure of 146/80 mmHg, pulse rate of 80 beats/min, respiratory rate of 18/min, and oxygen saturation of 98% on room air temperature. Physical examination revealed mild left-upper quadrant tenderness without rebound tenderness. Laboratory tests showed that a complete blood count and coagulation function were unremarkable. Serum biochemistry analysis revealed increased lactic dehydrogenase levels (LDH; 1118 U/L), C-reactive protein (CRP; 5.16 mg/dL), and decreased total protein and albumin levels. Tumor markers showed a mild elevation in carcinoembryonic antigen (CEA; 7.5 ng/mL), carbohydrate 19–9 (CA19–9; 109 U/mL), and a marked elevation in neuron-specific enolase (NSE; 270 ng/mL; normal value: <16.2 ng/mL). The level of duke pancreatic monoclonal antigen type 2 (DUPAN-2) was within the normal limits. Abdominal ultrasonography showed a well-defined, irregular-shaped, heterogeneous mass at the pancreatic tail . The MPD was dilated with hyperechoic structures . Abdominal precontrast computed tomography (CT) showed a 97 × 77-mm irregular hypodense mass in the pancreatic tail. Ascites was noted around the liver and pelvis. Dynamic contrast-enhanced CT revealed that the mass in the pancreatic tail had solid and cystic components. The solid components of the lesion showed hypo-enhancement, whereas the cystic components of the lesion showed non-enhancement during all phases . The MPD was diffusely dilated up to 27 mm (predominantly in the tail) without both obstruction and wall thickness, accompanied by marked atrophy of the pancreatic parenchyma. Multiple, well-defined, predominantly solid nodules were observed in the peritoneum and omentum, suggesting tumor dissemination. Following magnetic resonance imaging (MRI) , T2-weighted images showed a heterogeneous and hyperintense mass in the pancreatic tail . The area corresponding to the solid component seen on CT showed hyperintensity on diffusion-weighted images with b factor of 800 s/mm2 and hypointensity on the apparent diffusion coefficient map, indicating diffusion restriction . The signal intensity of the MPD in the tail was high on the T1-weighted image and low on the T2-weighted image , suggesting the presence of a highly viscous substance like mucin within the MPD. The correlation between the cystic components of the lesion and MPD was suggested but not confirmed following CT and MRI. The MRI signal pattern of peritoneal and omental nodules was similar to the solid component of the pancreatic mass. Contrast-enhanced harmonic EUS (CH-EUS), the solid component of the pancreatic tail tumor, showed mixed hypo- and non-enhancement patterns . Additionally, the hyperechoic lesions in the MPD showed non-enhancement, suggesting mucus clots. EUS-TA for the pancreatic mass was not performed owing to the intervening cystic components of the tumor and the avascular areas suggesting tumor necrosis.
+The features of the pancreatic tumor with cystic components that were communicated with the MPD favored the possible diagnosis of IPMC. Since the MPD was diffusely dilated, POPS-guided direct tumor biopsy under endoscopic retrograde cholangiopancreatography (ERCP) guidance was planned to confirm the histological diagnosis. The ampullary orifice was dilated to the so-called fish-mouth appearance . After ERCP catheter insertion into the MPD, extrusion of highly viscous mucus from the pancreatic orifice of the ampulla was observed . Contrast injection during ERCP confirmed the correlation between the MPD and the mass at the pancreatic tail . Pancreatography revealed that the MPD was filled with contrast defects, suggesting large amounts of mucus. A pancreatoscope (SpyGlass DS, Boston Scientific Corporation, Marlborough, MA, USA) was inserted into the pancreatic tail along with the guidewire kept in the MPD. The wall of the MPD was smooth and no papillary lesions suggestive of mucinous neoplasm were observed. POPS revealed an irregular-shaped solid mass in the pancreatic tail after the removal of the abundant and highly viscous mucin . Visually directed biopsies were performed from the reddish and raised part of the mass in the pancreatic tail to confirm the histological diagnosis. Histopathological examination of the biopsied material with hematoxylin and eosin staining showed a marked proliferation of small round atypical cells with hyperchromatic nuclei and scanty cytoplasm . Immunohistochemical analysis showed that the constituent cells were positive for synaptophysin , chromogranin A, and CD56 and negative for leukocyte common antigen, MUC1, MUC2, and MUC5AC. They had a Ki-67 labeling index of 90% . The findings on pathology and immunohistochemistry suggested the diagnosis of small-cell-type PanNEC.
+Due to the patient's rapid deterioration, chemotherapy could not be initiated. Although the best supportive care was given to the patient, he died 28 days after the diagnosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_899_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_899_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d958f947a3fa901c747c6f09a5795595ec50610a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_899_en.txt
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+A 65-year-old male patient was referred to our hospital due to interventricular septal perforation following myocardial infarction. The patient was presented to the previous hospital with chest pain. Despite undergoing percutaneous coronary intervention (PCI) and attempted thrombus aspiration, reperfusion could not be achieved (See Fig. ). The patient’s condition became unstable, and transthoracic echocardiography (TTE) revealed interventricular septal rupture and left-to-right ventricle shunt. Consequently, the patient was transferred to our hospital. Upon arrival, the electrocardiogram (ECG) showed QS wave on V1-V3 and persistent ST elevation, along with acute kidney injury (AKI) characterized by serum creatinine levels 4–5 times higher than baseline. TTE showed an ejection fraction (EF) of 50%, a mosaic flow near the apical septum, leading to the diagnosis of ventricular septal perforation (VSP), with an akinesia of the anterior left ventricular wall. The patient opted for emergency surgery. The initial procedure involved general anesthesia and cardiopulmonary bypass (CPB) with drainage from the right atrium and a venting tube in the left ventricle (LV). Cardiac arrest was induced through mild hypothermia using antegrade and retrograde cold blood cardioplegia.
+Briefly, a median sternotomy was performed, the pericardium was opened, and the heart was exposed and examined. The right chamber appeared enlarged, and the apex displayed pallor with a wide infarct area. An incision was made in the infarcted region of the LV myocardium, parallel to the interventricular septum, extending approximately 7 cm toward the apex, the VSP then been located . The double patch technique, as previously described by Takahashi et al. , was employed using bovine pericardial patches. The bovine patch was cut with a diameter 2 cm larger than the VSP for the right ventricle (RV) patch (R-patch), while the left ventricle (LV) patch (L-patch) was sized adequately to exclude the VSP, the infarcted area of the LV, and the LV incision. After confirming hemostasis, the heart was closed, and the patient was transferred to the intensive care unit (ICU) (See Fig. ).
+The patient remained in the ICU for 9 days. Dialysis was required initially due to worsening kidney injury from the preoperative AKI, but the patient’s condition stabilized, and continuous dialysis was no longer necessary. TTE performed 2 weeks after surgery indicated a shunt, but no signs of heart failure were observed. Thus, the patient received medication and was discharged 23 days after the surgery.
+As an outpatient, the patient returned to the hospital after 22 days with chest discomfort. Mild pleural effusion was confirmed, and transesophageal echocardiography (TEE) revealed a left-to-right shunt through the previous patch. Following approximately 6 days of medication administration in the hospital, the patient’s condition stabilized, and discharge was granted. However, the patient returned again after 2 weeks of being discharged, presenting with general malaise and decreased kidney function. TTE showed blood flow from the left to right ventricle, with EF of 55% and Qp/Qs = 1.7. Cardiac computed tomography (CT) and magnetic resonance imaging (MRI) confirmed the presence of a midventricular perforation measuring approximately 12 mm in diameter, leading to the decision to proceed with VSP repair surgery (See Fig. ).
+The second surgery was performed on the 15th day after initiating medication in the hospital. A median incision was made, carefully exposing the heart, and establishing a CPB machine. The second surgery employed a double patch technique. Briefly, trans epicardial echocardiogram was performed to locate the VSP. The RV was accessed near the right ventricular outflow tract (RVOT) through a 4 cm incision toward the apex, positioned 1 cm laterally to the left anterior descending artery (LAD). As the distal LAD had already been damaged from the previous myocardial infarction, the RV was cautiously dissected to avoid injury to the first diagonal branch of LAD. The ruptured wall was confirmed, and RVOT was observed, with trabeculae being cut to enhance visibility . A bovine pericardium patch, measuring 3 cm in diameter and circular in shape, was prepared. The thread was passed from the LV lumen to the LV free wall and from the interventricular septal wall to the RV lumen using 3 − 0 MH sutures. The patch was then pulled into the LV chamber by pulling the thread, and a single ligation was used for suturing, as shown in Fig. Another patch was prepared in a similar manner, with the thread applied from the opposite side and sutured with continuous sutures, securing it to the front side of the interventricular septum. A thread was passed from the LV free wall, near the previous suture, to the RV free wall, closing the RV with teflon felt and tying it with a mattress suture. An additional continuous suture was applied externally between the LV teflon felt and RV teflon felt to ensure closure. A pacing lead was placed in the right atrium and right ventricle, and an intra-aortic balloon pump (IABP) was inserted through the right common femoral artery. After confirming hemostasis, the chest was closed.
+The patient remained in the ICU for 5 days, with a maximum creatinine level of 1.55, and experienced no postoperative complications. The IABP was removed 3 days after surgery, and the pacing lead was removed 4 days later. The patient was discharged 4 days after the removal of the pacing lead, displaying stability and no signs of heart failure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_900_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_900_en.txt
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index 0000000000000000000000000000000000000000..1edec71fe813be630d570d13fbbcdce80c741e0d
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+During the course of a respiratory infection, a 26-year old male exhibited gait imbalance, numbness and “pins and needles” the lower-limbs. Based on the patient´s description, the sensory symptoms were present in whole lower legs from the hips and proximal thigh distally (i.e. approximately in the distribution from L3 to S1). The patient suffered from cough and fever for 2 days prior the onset of neurological symptoms. His C-reactive protein (CRP) was 160 mg/L (normal range 0-5 mg/L). The chest X-ray, abdominal ultrasound and echocardiography were normal. The paranasal sinuses radiography revealed a mild gas-fluid level in the left maxillary sinus. Starting from the 4th day of the respiratory symptoms (2 day after the onset of neurological symptoms), the patient was treated with amoxicillin/clavulanic acid for seven days, first five days intravenously 1000 mg/200 mg every eight hours in the department of internal medicine of a small local hospital and two last days per orally 875 mg/125 mg twice a day with the good effect on respiratory functions and fever, but without any impact in neurological symptoms and signs. The neurological symptoms were, however, not dominant from the patient’s perspective and the patient was not examined by any neurologist at the beginning of the symptoms. The residual neurological symptoms (numbness in the lower legs and difficulties running and tandem-walking) remained stable for another three years. Since the level of disability was considered mild, the patient was still not referred to a neurologist. The patient’s family history was unremarkable, patient’s mother suffers from high blood pressure and type 2 diabetes mellitus, his father has high blood pressure. No neurological or autoimmune diseases appeared in the family. The patient suffered from mononucleosis at the age of ten and mumps at the age of 17, otherwise is the patient’s medical history unremarkable.
+By the time the patient had reached the age of 29, a subacute progression (two weeks) of imbalance had resulted in severe walking problems and he was admitted to the neurological department of the secondary hospital. Neurological examination revealed perianogenital hypesthesia with sphincter dysfunction (urinary retention¨and incomplete empting) and severe positive and negative sensory symptoms in the lower limbs, including L3-S2 hypoesthesia, impaired joint position sense and loss of vibration sense, and severe lower limbs and gait ataxia. Deep-tendon reflexes and the plantar reflex were absent. The patient was unable to walk correctly in tandem gait, or to run due to ataxia, he was unable to walk unsupported for more than few meters and did not exhibit any muscle weakness. His EDSS was 6.0. The clinical findings in the cranial nerves and upper extremities were completely normal and his cognitive status was intact.
+An MRI (1.5 T) scan of the brain and cervical, thoracic, and lumbar spine performed ten days after symptoms onset proved normal . In the cerebrospinal fluid (CSF), there were no indications of neuro-infection, no oligoclonal bands appeared in CSF or in the serum. CSF protein was elevated to 2.24 g/L (normal range 0.15-0.45 g/L). Initial nerve conduction studies and needle electromyography (NCS/EMG) examinations were normal.
+Based on the clinical presentation, relapsing-remitting course, elevated CSF protein levels and normal brain and spine MRI, a diagnosis of inflammatory polyneuropathy considered and the patient was therefore treated with high-dose steroids (3 g of methylprednisolone), resulting in a significant reduction of complaints with residual symptoms. Thus, the chronic treatment with prednisone (20 mg/day) commenced, and the patient was referred to a tertiary neuromuscular center.
+In this center, a follow-up NCS examination confirmed the absence of demyelinating changes in all the peripheral nerves examined in both upper and lower limbs. The spinal MRI did not show any abnormality of the lumbar or sacral nerve roots (i.e. no thickening or a tube-shaped enlargement). The diagnosis of inflammatory neuropathy including chronic immune sensory polyradiculopathy (CISP) was therefore considered improbable and further investigation undertaken [, ]. Visual, brainstem auditory and motor-evoked potentials were normal. Somatosensory-evoked potentials established a central lesion of the spinal somatosensory pathway to the lower extremities (with no abnormality in the upper extremities) .
+A range of laboratory tests was performed to investigate the following antibodies: the paraneoplastic (anti-Hu, anti-Ri, anti-Yo, anti-CV2, anti-Amphiphysin, anti-Ma1, anti-Ma2), the infectious (including syphilis and HIV) and the autoimmune (including anti-nuclear antibodies, antibodies against extractable nuclear antigens, anti-double- and single-stranded DNA; anti-neutrophil cytoplasmic antibodies, anticardiolipin antibodies, anti-cyclic citrullinated peptide antibodies and anti-aquaporin-4 (AQP4)), all proved negative. The blood levels of creatine kinase, myoglobin, vitamin B12, B9, Cu, thyroid-stimulating hormone, thyroxine and carbohydrate-deficient transferrin were normal. Eventually, anti-MOG antibodies were detected by immunofluorescence Euroimmun fixed cell-based assay (titer 1:80).
+A diagnosis of MRI-negative MOGAD myelitis was established and, in response to persisting neurological symptoms, the patient was retreated with high-dose steroids (3 g of methylprednisolone), to no significant effect. Long-term treatment with 100 mg azathioprine was started (a reduced dose in the light of lower thiopurine methyltransferase activity). The previous treatment with 20 mg prednisone was progressively discontinued over the course of six months . The medication is well tolerated; the patient had no complaints related specifically to the drug. The course of the disease was relapsing. There were no signs of relapse-independent progression.
+Currently, the patient has been relapse-free and clinically stable for almost three years. MRIs of the brain and the spinal cord six months later remained normal. Anti-MOG seropositivity was repeatedly proven during remission by visual observation on a fluorescence microscope immunofluorescence Euroimmun fixed cell-based assay (titer 1:80 to 1:40). The patient’s optical coherence tomography remained normal.
+At the age of 31, the patient currently exhibits mild negative sensory symptoms in the distal parts of the lower limbs, areflexia of the lower limbs, impaired sense of vibration and joint position, and moderate gait and lower limb ataxia. Tandem walking and running are not possible. His expanded disability status scale stands at 3.5 (cerebellar and sensitive 3, other functional systems normal). Patient´s cognitive functions are within normal range.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_908_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_908_en.txt
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index 0000000000000000000000000000000000000000..598a647d4a0d0cfbe7fb0202c8b957a54d33b0c9
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+A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals.
+A 44-year-old Filipino lady presented with a 11-d history of right hypochondrium and epigastric pain which worsened after meals. There was no history of fever, night sweats, cough with hemoptysis, tea-coloured urine, pale stools or unintentional weight loss.
+She had no significant past history.
+On examination, there was no scleral icterus and Murphy’s sign was positive. There was no cervical lymphadenopathy. Physical examination was otherwise unremarkable.
+Serum biochemistry revealed neutrophil-predominant leukocytosis with normal liver and renal function tests. Her blood cultures did not reveal microbial growth.
+Chest x-ray was normal and computerized tomography scan of the abdomen and pelvis (CTAP) showed heterogeneous density of the gallbladder wall with marked gallbladder wall edema and a gallstone . The gallbladder wall thickness was 15 mm; the size of the extrahepatic common bile duct was 8.5 mm and the intrahepatic bile ducts were not dilated. CTAP also showed mesenteric and retroperitoneal lymphadenopathy which was deemed non-specific by size criteria.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_953_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_953_en.txt
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index 0000000000000000000000000000000000000000..d9c404a7f649b57ee649b2f71dc9cfa7404db694
--- /dev/null
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+A 54-year-old white man with a past medical history of right maxillary sinus adenoid cystic carcinoma with metastatic lesions to lung and vertebrae, hypertension, hypothyroidism, and nonalcoholic steatohepatitis presented to our emergency room in June 2016 with mental status changes accompanied by abdominal pain, dyspnea, and fever. He was not on active therapy for his malignancy. He previously received a trial regimen of coenzyme Q10, 12 g every 3 days, from October 2015 to April 2016. His past medical history was remarkable for two prior episodes of ascites and 3 months of progressive liver dysfunction and coagulopathy . He had atorvastatin-induced myalgias leading to its discontinuation in April 2016 although his creatine kinase levels were not elevated. He was taking increasing doses of acetaminophen (2 grams daily) prior to admission. His physical examination vital signs were stable with one recorded febrile episode. In general, he appeared ill and lethargic, and was only oriented to person. He exhibited diminished bibasilar breath sounds, ascites with guarding, hypoactive bowel sounds, right lower quadrant tenderness, and hepatosplenomegaly.
+Laboratory data were remarkable for hyperferritinemia, hypofibrinogenemia, anemia, and thrombocytopenia along with elevated transaminases and coagulopathy . A peripheral blood smear showed neutrophilia, monocytosis, and reticulocytopenia. No microangiopathic changes were seen. Extensive platelet clumping was noted.
+Imaging studies revealed small pleural effusions, ascites, and hepatosplenomegaly with no evidence of portal hypertension or splanchnic thrombosis. We were suspicious of HLH in light of laboratory and physical examination findings. Additional differential diagnosis workup – infectious, autoimmune, acetaminophen levels – yielded unremarkable results, including: serology for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), hepatitis E virus (HEV), cytomegalovirus (CMV), Epstein–Barr virus (EBV), herpes simplex virus (HSV), alpha 1-antitrypsin levels, and antinuclear, anti-mitochondrial, anti-smooth muscle, and transglutaminase antibodies (immunoglobulin A (IgA) and immunoglobulin G (IgG)). ADAMTS 13 activity was >34%. HLH-specific laboratory studies were sent, including soluble CD25 (sCD25), NK cell activity studies, and bone marrow biopsy.
+He continued to deteriorate with multiple organ failure including renal failure, myocardial injury, and respiratory failure requiring intubation. Empiric therapy, considering the evidence of liver injury and the possibility of HLH, with N-acetylcysteine on a 20-hour intravenous protocol and dexamethasone 8 mg intravenously administered three times daily was initiated. HLH chemotherapy was not done during this time as hepatotoxicity risk outweighed benefits and a definite diagnosis was not confirmed.
+As an attempt to expedite the evaluation of possible HLH, we isolated mononuclear cells from peripheral blood and evaluated expression of surface markers in cytokine-producing NK cells and cytotoxic NK cells by flow cytometry. We compared the profile with normal controls. The results, available after 36 hours, were remarkable for an increased expression of CD69 in cytotoxic NK cells, and decreased NKG2A in cytokine-producing NK cells in our case. The expression of CD69 and NKG2A in NK cells was evaluated in four other normal donors and the results were similar to the one acquired in parallel to the HLH sample . No differences in protein expression of other markers were observed by flow cytometry (data not shown). These findings included similar surface levels of OX40, GITR, 4-1BB, TIM-3, PD-1, CTLA-4, LAG-3, and ICOS in CD8+ CD3+ T cells, as well as effector (CD127+, FoxP3-) and regulatory (CD127-, FoxP3+) CD4+ CD3+ T cells; similar expression of NKp44, NKG2C, NKG2D, 4-1BB, NKp30, and NKp46 in NK cells (CD56+ CD3-); and similar expression of CD28, CD27, ICOS, Eomes, Blimp-1, Bcl-6, T-bet, Ki-67, and cMyc in naïve (CCR7+ CD45RA+), effector (CCR7- CD45RA+), effector memory (CCR7-CD45RA-), and central memory (CCR7+ CD45RA-) CD4+ and CD8+ T cells. The frequency of all the evaluated immune cell populations was also similar, when comparing cells from our patient with those ones from a healthy control.
+Our patient’s bone marrow biopsy was performed 10 days after admission and delayed due to severe coagulopathy and demonstrated normocellularity (40 to 50%), megakaryocytic hypoplasia, and clusters of foamy histiocytes with ingested marrow cells. Fifteen days after admission, he fulfilled multiple HLH-2004 diagnostic criteria including hyperferritinemia, fever, splenomegaly, cytopenias, hemophagocytosis on biopsy of bone marrow, elevated CD25, and decreased NK cell activity by standardized studies .
+He steadily recovered with the steroid therapy instituted for 12 days and supportive measures. He was weaned off intubation and sedation. However, he refused further interventions for HLH, namely etoposide-based therapy and continuation of steroid treatment; he chose palliative care and died 2 weeks later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_978_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_978_en.txt
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index 0000000000000000000000000000000000000000..025e681c90a95a86fd6baf28a798c7ae26a2287d
--- /dev/null
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@@ -0,0 +1,5 @@
+A 78-year-old Chinese woman, gravida 2, para 2, with menopause at age 51, presented to the Department of Endocrinology with a 2-week history of 5 × 3 × 1.5 cm mushroom-like lump in her right thigh . According to the medical history, the patient was a housewife and confirmed that she was not exposed to excessively professional, accidental, or medical UV radiation. She had a 30-year history of type 2 DM and her HbA1c was 8.4 % (68mMol/mol) upon admission. There were several scars caused by chronic ulcers adjacent to the lesion . She denied any history of neoplasms.
+The lesion was resected under local anesthesia. The sample was fixed in 4 % buffered formalin and embedded in paraffin using conventional techniques. Serial tissue sections were studied using hematoxylin and eosin staining, histochemistry, immunohistochemistry , and HPV type-specific PCR and genotyping. Blind evaluation of all results was performed by two independent pathologists.
+Light microscopy examination showed that the lesion was mainly composed of malignant clear cells and signet-ring cells arranged in thick trabeculae or solid nests . The clear cells contained prominent vacuoles which were sharply demarcated and appeared empty. Each of the signet-ring cells contained a large cytoplasmic vacuole and an eccentric nucleus . Atypical mitotic figures were plentiful.
+Periodic-acid Schiff (PAS), Alcian blue (AB), and mucicarmin techniques were employed to explore the nature of the observed clear cell/signet ring cell structures. The septa rather than the vacuoles showed positivity for PAS indicating the existence of glycogen . However, neither septa nor vacuoles expressed AB or mucicarmine, suggesting that neither mucin nor mucopolysaccharides existed (data not shown). In line with the above results, the septa expressed cytokeratin AE1/AE3, CK5/6, CK14, and CK19 . CK5/6 is a high molecular weight cytokeratin wihic is usually up-regulated in neoplasms of epithelial origin, including cSCC. Although malignant cells did not express mutant p53, they displayed strong and diffuse positivity for p63, another member of the p53 family playing an important role in normal epithelial development and differentiation . We also found the increased expression of fibroblast growth factor receptor-2 (FGFR2), a downstream effector of p63 . Nucleus immunoreactivity for Ki-67 is a hallmark of high cell proliferation. In the sections, less than 5 % of cancer cells expressed Ki-67 . Malignant cells exhibited negativity for CK7, CK8, CK18, CK20, P16, and c-erbB-2 (data not shown).
+DNA was extracted from FFPE tissue sections and purified using the TIANamp FFPE DNA Kit (TIANGEN, Beijing, China). The operation was performed according to the manufacturer’s protocol. Subsequently, HPV DNA was amplified with the L1 consensus HPV PGMY09/PGMY11 primer set as described previously . PCR was performed with a 25 ul reaction system, which contained 1 ul (89 ng) DNA template and 0.75 ul DNA Taq polymerase. Amplification was carried out for 40 cycles in the CFX96 TouchTM Real-Time PCR Detection System (BIO-RAD, USA). HPV genotyping was performed using the HPV GenoArray test kit (Hybribio, Chaozhou, China), which identifies 15 high-risk HPV types (HPV type 16, 18, 31, 33, 35, 39, 45, 51, 52, 53, 56, 58, 59, 66, and 68) and 6 low-risk HPV types (HPV type 6, 11, 42, 43, 44, and 81) using flow-through hybridization and gene chips. The result of genotyping indicated that this patient was not infected with HPV .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_993_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_993_en.txt
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index 0000000000000000000000000000000000000000..053677697cdb22f9944f653499690d89340c9987
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+A 4-year-old Persian boy, 10 kg in weight and diagnosed with MMA, was referred and admitted to our hospital because of progressive lethargy after frequent vomiting since a day before hospitalization and excessive crying and irritability, upward gaze, and muscular hypotonia on the day of hospitalization.
+He was the second child of healthy, related parents (cousins), born after an uneventful pregnancy and delivery with a birth weight of 2,750 g. His older brother was healthy. His family had a low-class income. His father works at a university and his mother is a housewife. The diagnosis of MMA was made at the age of 3 months on the basis of the clinical presentation and series of laboratory tests (metabolic acidosis, high level of ammonia, and high urinary concentration of methylmalonic acid). The patient had a history of frequent hospitalization owing to imbalanced electrolyte levels and he was regularly taking prescribed medications for 6 months including oral solution of cyanocobalamin 1000 mcg daily, l-carnitine (100 mg/kg/day), Shohl’s solution (sodium citrate) 30 ml every 6 hours.
+Upon the patient’s arrival in the emergency room, owing to abnormal vital signs [temperature (T): 36.3 °C, pulse rate (PR): 280, respiratory rate (RR): 45, blood pressure (BP): 100/90 mmHg, and O2 saturation: 97%]. Electrocardiography (ECG) was performed and showed wide QRS complex ventricular tachycardia .Physical examination revealed pale skin, lethargy, and upward gaze. The muscular examination revealed hypotonia. Neurological examination: all cranial and peripheral nerve examinations were normal. During the present episode, the patient’s laboratory test results were as follows: red blood cell (RBC), 3,530,000/µl; white blood cell (WBC), 8210/µl; hemoglobin (Hb), 9.2 gr/dl; platelet (plt), 375,000/µl; alanine transaminase (ALT), 13; aspartate aminotransferase (AST), 24; alkaline phosphatase (ALP), 499; hepatitis B surface antigen (HBSAg), negative; and human immunodeficiency virus antibody (HIVAb), negative. Urine analysis: WBC, 0–1; RBC, 0; epithelial cell, 1–2; crystals, not seen; cast, not seen; and bacteria, not seen. Arterial blood gases (ABG) revealed severe metabolic acidosis (pH = 7.13, HCO3 = 9.5 mmol/L, pCO2 = 28.1 mmHg), hyperkalemia (K = 8.9 mEq/L, Na = 136 mEq/L), and renal insufficiency (serum creatine levels = 2.3 mg/dl and urea nitrogen = 80 mg/dl). Serum ammonium and lactate level was 95 mcg/dl and 26 mg/dl, respectively. Severe hyperkalemia and metabolic acidosis with respiratory compensation were diagnosed.
+The patient immediately underwent treatment, including calcium gluconate 10% intravenously infused over 10 minutes, sodium bicarbonate direct intravenous injection (2 mEq/kg) over 5 minutes, hydration with dextrose 10% intravenous serum, and regular insulin intravenous infusion (0.1 ml/kg/hour), and was transferred to the pediatric intensive care unit (PICU) for further assessments. His blood pressure (BP) was 100/70 mmHg, pulse rate was 180/minute and irregular, respiratory rate was 42/minute, body temperature recorded 35.9 °C by skin, pulse oximetry indicated 97% in the PICU. The frequency of ventricular tachycardia gradually decreased and the ECG showed sinus tachycardia. Repeated ABG showed improvement (pH = 7.43, HCO3 = 13.3 mmol/L, pCO2 = 21 mmHg), and serum potassium level came down to 6 mEq/L within the next 6 hours. This management was continued under the observation of a multidisciplinary team. Additionally, kayexalate (10 g every 6 hours) as a sodium potassium exchange resin therapy and MMA formula were added to the treatment routine for the next 2 days. The patient stabilized, serum potassium level reduced to 4.9 mEq/L, serum creatine level reduced to 2.1 mg/dl, and urea nitrogen reduced to 57 mg/dl. It is notable that brain magnetic resonance imaging (MRI) was normal and no growth was observed in patient’s blood culture. He was discharged with a good clinical condition. During the past 6 months, the patient has been regularly monitored every 2 months and has not exhibited any new neurological, cardiological, or other issues. Follow-up is ongoing.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_994_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_994_en.txt
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index 0000000000000000000000000000000000000000..52647ff9cf5a1da52dbb06d38d378cd21f18a6be
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_994_en.txt
@@ -0,0 +1,5 @@
+A 68-year-old married male presented with multiple swelling on the trunk, back, upper and lower extremities since one year. Lesions started on the trunk and gradually spread to involve upper and lower limbs. Initially lesions were small, flat and then gradually increased in size to become nodular. He also had bilateral submandibular swelling and cervical lymphadenopathy. Patient was heterosexual and moderately built. No history of fever, cough, diarrhoea, weight loss or history suggestive of AIDS sequelae was noted.
+On local examination, the swellings were multiple erythematous papules to nodular which were bluish in colour on the back, trunk and both extremities . The non-blanchable swellings were ranging from 0.5 cm to 7 cm in diameter and firm in consistency. Pallor was present with no hepato-splenomegaly seen and no other systemic findings. The two clinical differential diagnoses were of lipomatosis and neuromatosis, respectively.
+Patient was advised HIV- enzyme-linked immunosorbent assay (ELISA) and he was diagnosed for the first time as reactive to the HIV antibody ELISA test. All routine laboratory investigations were performed along with CD4 count of 239 cells/microlitre, which was low in this patient. The prothrombin time levels - 12 secs (control 35 secs), activated partial thromboplastin time kaolin levels more than two mins (control 35 secs), serum creatinine - 2.6 mg/dl (0.8 to 1.2 mg/dl), serum glutamic- oxaloacetic acid transaminase levels -130 iu/litre (8-33 iu/litre), serum glutamic-pyruvic transaminase levels -134 IU/litre (4-36 IU/litre). The patient's ultrasonography (USG) abdomen showed features suggestive of fatty liver with multiple hyperechoic lesions in liver and spleen (suggestive of metastases). Many subcutaneous lymph nodes were also noted on anterior abdominal wall.
+The patient was then referred to cytology OPD for FNAC. The FNAC was performed with 22-gauge needle from multiple sites of swellings over the trunk, back and submandibular lymph nodes. The aspirate obtained was hemorrhagic and the cytology smears were hypercellular which showed large cohesive clumps of oval to spindle cells . The cells had moderate amount of ill-defined, eosinophilic cytoplasm having oval to spindle nuclei with finely granular chromatin, inconspicuous nucleoli and mild pleomorphism. Few mitotic figures were seen. The background showed hemorrhage and macrophages . Cytological features were suggestive of low-grade spindle cell neoplasm consistent with KS.
+The biopsy from the subcutaneous nodule was performed with tumor mass comprised of proliferating blood vessels arranged in slit-like spaces and fascicles. These spaces were lined by endothelial lining separated by spindled cells having moderate amount of eosinophilic cytoplasm and filled with red blood cells with extravasation in surrounding collagen bundles. Perivascular spaces show plenty of lymphocytes, hemosiderin-laden macrophages and neutrophils . Diagnosis was confirmed on biopsy as KS. Special stain and immunohistochemistry were not performed as patient had financial constraints.
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