diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1015_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1015_en.txt
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index 0000000000000000000000000000000000000000..74fb5349f1c8d49d5625cbeab243f22328b2041b
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+A 9-year-old girl with Alagille syndrome was referred to our hospital. She had been diagnosed with biliary atresia at the age of 1 month and treated with surgical bile duct reconstruction, vitamins D and K, and ursodeoxycholic acid. However, her liver dysfunction and hyperbilirubinemia worsened. When she was running during physical education, she suddenly felt an acute pain in her right knee. She could not walk and was taken to the emergency department of another hospital. She was found to have a sustained pathological fracture of the right femoral shaft and was treated with skeletal traction. However, repositioning the fractured bone was difficult. Because of her low weight (19 kg), application of skeletal traction with a heavy weight was difficult. On examination, she was malnourished with stunted growth (height: 126 cm, < 3rd centile; weight: 19 kg, < 3rd centile). She had most of the features of Alagille syndrome, including a characteristic face, mild peripheral pulmonary artery stenosis, butterfly vertebrae, posterior embryotoxon, and hyperbilirubinemia. Blood tests revealed anemia (hemoglobin, 8.3 mg/dL) and liver dysfunction with high serum aspartate transaminase (186 U), alanine aminotransferase (253 U), gamma-glutamyl-transpeptidase (1445 IU/L), serum total cholesterol (23.5 mmol/L), and serum alkaline phosphatase (3546 U) levels, as well as hyperbilirubinemia (218.9 μmol/L). Radiographs showed a left femoral shaft fracture (Orthopaedic Trauma Association classification: 32–A3.2) . Elastic nailing was considered; however, because of her narrow intramedullary canal, this was judged to not be a viable fixation method. Furthermore, we wanted to prevent increased bleeding caused by use of a locking plate because of the anemia. The left femur was osteoporotic, with beaking and cortical thickening . Therefore, there appeared to be a risk of pathological fracture of the left femur. We decided to use a closed indirect reduction technique with an Ilizarov ring fixator and to decrease bleeding. One day after admission to our institute, Ilizarov ring fixator surgery was performed with the patient under general anesthesia in the supine position without a thigh tourniquet. For the Ilizarov technique, a closed indirect reduction technique was performed under image guidance, by first using ligamentotaxis to compress the fracture ends . Repositioning was simple and complete. There was no need to open the fracture site, fixation was stable, and the growth plate was preserved. The tota1 operative time was 69 minutes. The hemog1obin concentration decreased from 8.3 mg/dL preoperative1y to 8.1 mg/dL the next day. This patient was not transfused. Immediately after surgery, treatment with a low-intensity pulsed ultrasound stimulation (LIPUS) device (SAFHS 2000, Exogen, Inc., Piscataway, NJ) was started for 20 min/day in September 2000. This device had a frequency of 1.5 MHz, a signal burst width of 200 microseconds, a signal repetition frequency of 1 kHz, and an intensity of 30 mW/cm2. There was no need for additional external immobilization. Physical therapy involving walking with weight-bearing on the operated leg was started immediately after surgery. The patient could walk without any support 1 week later. The hospital stay was 14 days. The patient was well after being discharged from hospital and enjoying school life with the frame. Use of LIPUS was continued, and the patient was allowed to walk without crutches. Radiographs showed healing of the fracture at 53 days postoperatively . In such cases, before actually removing the frame, the patient may be allowed full weight-bearing, in which all the uprights connecting the proximal and distal segments of the bone are disconnected, and the patient is asked to use the limb in a functional manner with weight-bearing for the lower limb for 3 weeks. This was performed in our case. Seventy-four days postoperatively, the frame was removed, and the patient had anatomically and functionally recovered. Two years postoperatively, there was no leg-length discrepancy and no angular malalignment of the lower extremities as determined clinically and radiographically. Furthermore, 2 years postoperatively, the range of motion of the hip, knee, and ankle of the patient’s operative leg matched the range of motion in the nonoperative leg .
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index 0000000000000000000000000000000000000000..3fb664c5f9175d6700895dee481a032f9f840530
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+A 41-year-old primigravid woman, at 18 weeks gestation, with acute liver failure was referred to our transplant center for a trans-jugular liver biopsy and assessment for a potential liver transplant. Past medical history was unremarkable. The patient exhibited a ten-day history of persistent fever, headache, and acute hepatitis. Despite outpatient treatment with amoxicillin, cefixime, and acetaminophen, up to 1 gr three times per day for seven days, her symptoms did not improve. At admission (day zero), she was febrile (T 38.7 °C), alert, oriented, and hemodynamically stable. Physical examination revealed severe asthenia, pallor, sub-icteric sclera, and abdominal pain. Laboratory findings showed anemia (hemoglobin 8.3 g/dL), lymphopenia (1.4 × 103/μL), elevated transaminases (AST 7864 units/L, ALT 3012 units/L), hypoalbuminemia (1.5 g/dL), INR 1.4, increase in total bilirubin (1.6 mg/dL), and creatinine was 0.57 mg/dl. Inflammatory markers were elevated, with C-reactive protein (CRP) at 136 mg/L, (normal value 0–5 mg/L) procalcitonin (PCT) at 10.3 ng/mL, and ferritin at 36,185 ng/mL. Minimal peri-hepatic ascites was observed on abdominal ultrasound. Empiric antibiotic treatment with meropenem was initiated. The pathologist, at first evaluation of urgent liver biopsy, observed cytolytic liver damage with extensive centrilobular necrosis (acinar zone 3), suggestive of drug-induced damage. On day one after admission, the peripheral blood smear showed activated reactive and apoptotic lymphocytes. Serological tests for hepatitis A virus (HAV), hepatitis B virus (HBV), hepatitis C virus (HCV), cytomegalovirus (CMV), toxoplasmosis, and hepatitis E virus (HEV) were negative for acute infection. The plasma viral load of HSV-1 and 2, CMV, adenovirus, and varicella-zoster virus (VZV) was negative. Fecal samples tested negative for adenovirus, and molecular testing for respiratory viruses was also negative.
+Despite a negative HSV-1 and -2 viral load, serological analysis demonstrated positive HSV-1/2 IgM and borderline IgG antibodies. Consequently, a histological review of the liver biopsy was requested, revealing numerous cells with viral nuclear inclusions and a highly suggestive morphology for herpes virus cytopathic effects. Immuno-histochemical staining and real-time polymerase chain reaction (PCR) for HSV-2 were positive in the hepatic tissue , confirming the diagnosis. This was a primary HSV infection rather than a reactivation, as confirmed by the fourfold rise in IgG title observed four weeks after the first serological evaluation.
+Acyclovir treatment was initiated, leading to a progressive reduction in transaminases and inflammatory markers . However, on the fourth day, the patient’s clinical condition deteriorated, concomitantly with the development of anasarca attributed to severe hypoalbuminemia (1.8 g/dL) and an elevation in total bilirubin level (5.25 mg/dL). On the following day, the HSV-2 viral load became detectable, quantified at 28.750.000 copies/mL. The observed increase in inflammatory markers and high serum ferritin, despite optimized HSV-2 treatment, raised concerns of unregulated hyper-inflammation suggestive of a cytokine storm. Probability of hemophagocytic lymphohistiocytosis (HLH) using H score was 25–40% on day 4 and 80–88% on day 5 [, ]. By considering that steroids are usually not recommended in acute HSV infections and that cyclosporin may be unsafe during pregnancy .
+We decided to administer human polyvalent immunoglobulin at a dose of 400 mg/kg/day for five days . The patient started to recover with a reduction in H score (with probability of HLH 25–40% on day 7, 8, 10, and 16–25% on day 12), inflammatory markers and in HSV-2 viral load to 1.361.205 copies/mL within one week. The patient became afebrile while HSV-1/2 DNA on the vaginal swab remained detectable. Thus, we recommended a cesarean delivery.
+After a total hospital stay of 20 days, including 19 days of acyclovir treatment, the patient was discharged with normalized inflammatory markers and recovery of liver function. On the follow-up visit, a month after discharge, she was asymptomatic with a viral load of HSV-2 of 120 copies/mL and a detectable HSV-1/2 vaginal swab. Obstetric examination revealed no discernible abnormalities in the fetus. The patient underwent a cesarean delivery at 33+s3 weeks of pregnancy. The newborn was a healthy girl with a birth weight of 1800 gr. HSV-1/2 DNA in plasma and cerebrospinal fluid of the newborn was undetectable. Both mother and baby are alive and well at the 6-month follow-up.
+Using Luminex technology and the R software tool (version 4.1.2), we retrospectively analyzed plasma cytokine levels (stored at − 80 °C until their use) at five designated time points (day: 0–3–4–18–62) and correlated them with the clinical data after a z-score transformation. The heatmap generated in Fig. E revealed three discernible temporal biomarker clusters. The first cluster, represented by the acute phase (day 0 and day 3 after admission) in the absence of viremia, revealed an impaired specific antiviral immune response and, conversely, the production of cytokines and chemokines, including monokine induced by interferon-gamma (MIG), interferon-gamma (IFNγ), hepatocyte growth factor (HGF), monocyte chemoattractant protein-1 (MCP-1), interferon-gamma induced protein-10 (IP-10), C–C motif chemokine ligand 11 (CCL-11), and interleukin-8 (IL-8), IL-6, IL-1RA, IL-2R, and IL-10, all involved in inflammation. This profile was accompanied by increased hepatic (AST, ALT, bilirubin, gamma-GT, alkaline phosphatase, INR) and inflammatory (CRP, PCT, LDH, ferritin) biomarkers. In the second cluster, the viremic phase (day 4–18), we observed a reduction in the aforementioned inflammatory profile and an increase in total bilirubin, WBC, and neutrophils. Finally, in the third cluster (day 62, follow-up), we observed a complete recovery of hepatic markers and an increase in different cytokines involved in antiviral immunity, suggesting the onset of T cell responses involved in viral clearance and recovery from the infection. In Fig. F, we show the pairwise Pearson correlation analysis, which associates cytokine expression levels and laboratory values across the five-time points.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1051_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1051_en.txt
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index 0000000000000000000000000000000000000000..45516c89ad31395ee391511d1b13f5f67f2cad18
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+A 25 year old Sinhalese Sri Lankan female presented with a 1 day history of bilateral lower limb weakness, and numbness with urinary incontinence. She had no back pain and no history of constitutional symptoms such as fever, loss of appetite, or recent subjective weight loss.
+On examination she had atonic lower limbs, with absent muscle power, and absent bilateral lower limb reflexes below knee level, with sensory impairment up to T6 level. She had no spinal deformities or tenderness, and no papilloedema. Upper limb examination was unremarkable except for a hard non tender bony mass on the left scapular region. She had a blood pressure of 140/80 mmHg, pulse rate of 78 beats per minute and had no respiratory compromise.
+She was investigated with a suspicion of metastatic disease and X-ray of the left shoulder showed a soft tissue and bony mass on the dorsal aspect of the left scapula with multiple lytic lesions suggestive of a primary bone neoplasm , but chest radiograph, ultrasound scan of the neck, and Computed tomography (CT) of abdomen were normal. Magnetic resonance imaging (MRI) of the spine showed an intradural extramedullary mass with an extra spinal component at C7-T2 level causing severe cord compression , hence intravenous dexamethasone regimen was started.
+Ultrasound guided core needle biopsy from the left scapular mass showed malignant small round blue cell tumour suggestive of Ewing sarcoma. Blood investigations showed Heamoglobin of 9.2 g/dl, white blood cell count of 12 × 103/μl, Erythrocyte sedimentation rate (ESR)of 150 mm/h, C-reactive protein level of 96 mg/l, normal liver enzyme levels and liver functions tests, and serum alkaline phosphate level of 173 μ/l. Her blood picture showed increased rouleaux formation with anaemia of chronic disease.
+She had no improvement of symptoms following treatment with dexamethasone. Before implementing on oncological management, 3 days after onset of symptoms, she developed sudden onset progressive ascending neurological impairment with upper limb and bulbar involvement, and unfortunately resulted with respiratory failure and death.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1054_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1054_en.txt
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index 0000000000000000000000000000000000000000..3e8f708205fbffb4bd08c9295f4b54b8966078cb
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+A 10-year-old white girl presented to our emergency room in January 2015 with a 1-month history of headache and morning vomiting. On examination, she appeared slightly pale, with body temperature of 36.5 °C, heart rate of 90 beats per minute, blood pressure of 106/62 mmHg, respiratory rate of 18 breaths per minute, and oxygen saturation of 100% in ambient air. Her neurological status was normal. Laboratory test results are shown in Table . A chest X-ray was within limits. An urgent non-enhanced brain computed tomography (CT) scan showed a focal lesion in the left frontal subcortical region with prominent surrounding edema and mass effect . She was therefore admitted to our hospital. Magnetic resonance imaging (MRI) demonstrated ring enhancement on post-contrast T1-weighted (T1W) sequences; fluid-attenuated inversion recovery (FLAIR) sequences confirmed extensive vasogenic edema . She lived with her parents and siblings in Southern Italy. Before the onset of the current illness, at 5 years of age she had undergone surgical excision of a pleomorphic adenoma of the parotid gland. No evidence of a pre-existing congenital airway malformation was referred. She was not sexually active, and she did not smoke cigarettes, drink alcohol, or use illicit drugs. Her father, a heavy tobacco smoker, was a merchant. Her mother, a housewife, reported three miscarriages. Her maternal grandfather had died from colon cancer at 40 years. Her paternal aunt was affected by , and a second-degree cousin presented ovarian immature teratoma. After multidisciplinary discussion, neuronavigation and left frontal craniotomy with tumor resection with direct cortical and subcortical stimulation was done under general anesthesia. She received preoperative steroid medication which was tapered post-surgery. MRI scanning within 72 hours after surgery documented total resection .
+Microscopy on tissue sections showed malignant neoplasms with extensive necrosis, composed of atypical columnar and cuboidal cells, which had vesicular nucleolated nuclei and eosinophilic cytoplasm. Tumor cells covered papillary structures with fibrovascular cores or formed small glands and micropapillae lacking stroma. The surrounding brain parenchyma showed evidence of reactive gliosis and lymphohistiocytic infiltrate . On immunohistochemical examination, neoplastic cells were positive for cytokeratin 7, thyroid transcription factor 1 (TTF-1) , cytokeratin AE1/AE3, and epithelial membrane antigen (EMA), whereas all other markers tested were negative: cytokeratin 20, carcinoembryonic antigen (CEA), thyroglobulin, vimentin, cluster of differentiation (CD) 10, WT1, calretinin, inhibin, CD117, CD30, S100 protein, melan-A, actin, chromogranin, synaptophysin, and glial fibrillary acidic protein (GFAP). INI1 expression was retained. Thus, a diagnosis of metastatic lung adenocarcinoma was proposed. A chest CT scan showed a parenchymal nodular lesion in the lower lateral basal segment of the right lobe, measuring 32 mm × 18 mm × 17 mm, thought to be the primary lung cancer with mediastinal nodal metastasis. Tumor spread was confirmed by positron emission tomography (PET)/CT showing a primary lung tumor and with high fluorodeoxyglucose (FDG) uptake: maximum standardized uptake value (SUVmax) of 8.5 and 8, respectively .
+At fluorescence in situ hybridization (FISH) analysis, no rearrangements of anaplastic lymphoma kinase (ALK), c-ros oncogene 1, receptor tyrosine kinase (ROS1), and rearranged during transfection (RET) genes were found. ROS1 gene was found deleted in 57% of neoplastic cells. Next generation sequencing (NGS) analysis was applied to genomic deoxyribonucleic acid (DNA) extracted from formalin-fixed paraffin-embedded tissue. Both the “Cancer Hotspot Panel” (50 genes) and the “Comprehensive Cancer Panel” (444 genes) through the Personal Genome Machine with Ion Torrent™ technology (Life Technologies, Applied Biosystems) were applied. NGS analyses with Comprehensive Cancer Panel highlighted the presence of multiple non-targetable mutations in fms-related tyrosine kinase 4 (FLT4), ubiquitin-protein ligase E3 component N-recognin 5 (UBR5), ataxia telangiectasia mutated (ATM), and TATA-box binding protein associated factor 1 (TAF1). Epidermal growth factor receptor (EGFR) mutation status was negative.
+One month after admission our patient started chemotherapy treatment for NSCLC with cisplatin and vinorelbine for six cycles over a 5-month period. Two months later, an MRI 3 months after diagnosis revealed cerebral recurrence; therefore, she underwent a second surgical resection, followed by radiosurgery (CyberKnife). A brain MRI and PET/CT scan after completion of her last dose of chemotherapy showed absence of cerebral metastasis and partial regression of the lesion of the lower lobe of her right lung (RLL); thus, between 7 and 8 months after admission she received adjuvant thoracic radiation therapy. Unfortunately, 1 month later surveillance imaging revealed lung tumor progression and multiple brain metastases. She subsequently started whole brain radiotherapy (WBRT) and three cycles of docetaxel. One year after admission a rapid lung tumor progression was documented. One month later she developed headache and vomiting due to increased cerebral edema and growth of brain metastases. Therefore, she started corticotherapy and third-line pemetrexed treatment (five cycles), but 5 months later a PET/CT scan revealed further worsening of intracranial lesions and skeletal metastases. She underwent radiosurgery by CyberKnife technique on brain metastases and the following month she received nivolumab at 3 mg/kg intravenously every 2 weeks compassionately. Due to worsening of clinical conditions, a month later PET/CT was performed, revealing disseminated (skeletal, pulmonary, cerebral, lymphonodal) disease. She continued nivolumab, receiving a total of five cycles without adverse events. Given the ongoing clinical and imaging deterioration, palliative treatment was initiated and she died of respiratory failure 23 months after diagnosis of metastatic lung adenocarcinoma . Autopsy was declined by parents.
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index 0000000000000000000000000000000000000000..f9640df6e60787968ee5ed056c2bbc24cc8d1bc7
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+A 74-year-old man was intubated in emergency for acute ischemic stroke, and then referred to Anesthesiology and Intensive Care Unit of our hospital. The patient’s medical history included cardiac disease and COPD. PDT was then performed, and patient returned to spontaneous breathing 15 days later. Despite systemic administration of broad-spectrum antibiotics (Vancomycin, Cefepime, and Azithromycin), he developed APF following necrotizing pneumonia that complicated with pneumothorax, empyema and subcutaneous emphysema . A 32 French tube was placed at the 5th intercostal space anterior axillar line with drainage of 1.500 l of brownish, putrid, and foul-swelling fluid. A negative suction (− 20 mmHg) was applied to chest drainage and daily chest X-ray showed the expansion of upper and middle lobe, but a loculated pneumothorax within lower lobe was seen on chest CT scan performed 15 days . A second 28 French chest tube was then placed using ultrasound as guide at the 8th intercostal space posterior axillar line with drainage of 500 mL of purulent material. The microbiological cultures of pleural fluid showed the presence of Pseudomonas aeruginosa; thus, ofloxacin (400 mg every 12 h) and ceftazidime (2 g every 8 h) were intravenously administered, in addition to clindamycin to provide empiric coverage against anaerobes and gram-positive cocci bacteria. The pleural space was also irrigated with 0.1% povidone-iodine solution (Betadine; 40 mL/h) until the eradication of pleural infection was obtained. However, the formation of dense adhesions trapped the lower lobe, and prevented its expansion ; yet, the persistence of large bubbles in the drainage suspected the presence of APF. Methylene blue (1 ampoule diluted in 1-l saline solution) was injected via chest drainage into the pleural cavity, and was bronchoscopically identified within RB9 segment . The resolution of air leaks obtained by occluding the RB9 segment with an inflated-balloon catheter confirmed it to be the culprit segment. Thus, a Zephyr 5.5 EBV (Zephyr, PulmonX Corporation-Redwood City, CA, USA) was placed within RB9 segment with temporary resolution of air leaks that recurred 4 days later due to valve dislocation. The valve was removed and the RB9 segment closed by intrabronchial injection of 10 mL of FG (Tisseel: Baxter Healthcare Corp, Deerfield, IL, USA) . The procedure was repeated twice at 1-week interval, but in both cases the fibrin clot dislocated.
+Finally, fiber bronchoscopy, introduced through the chest drainage, explored the pleural cavity and showed a small APF that was marked by methylene blue following intrabronchial injection of the blue solution within RB9 segment . The APF was filled by 20 mL of FG using a dedicated double-lumen catheter introduced through the working channel of fiber bronchoscopy . Furthermore, the RB9 segment was occluded by intrabronchial injection of 10 mL of FG. The chest drainage was then clamped, and a bronchial blocker was left with the balloon inflated within intermedius bronchus to prevent the intrapleural, and intrabronchial dislocation of fibrin clot, respectively. Two days later, the bronchial blocker was deflated, and the chest drainage opened. No recurrence of air-leaks occurred; drainage of non-purulent fluid was < 100 mL/24 h; chest CT scan showed no evidence of worsening pneumothorax, and of progressive subcutaneous emphysema; thus, chest tube was removed . Patient was then transferred to a rehabilitation center. He died 11 months later for cardiac failure. The entire procedure was summarized in Additional file 1: Video S1.
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index 0000000000000000000000000000000000000000..8629650bc95d4d400885542dfe29b28bcaa85c7d
--- /dev/null
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+A 48-year-old Chinese woman with no smoking history presented to the Union Hospital of Tongji Medical College of Huazhong University of Science and Technology in October 2020 for chest tightness and chest pain. The 18F-fluorodeoxyglucose positron emission tomography/computed tomography (18F-FDG PET/CT) revealed a soft tissue density shadow in the right lower lobe with a size of 3.4*2.4 cm; enlarged bilateral supraclavicular and mediastinal lymph nodes, thickened bilateral pleura and increased pericardial effusion were metabolism increased; the metabolism in thoracic vertebrae T4, lumbar vertebrae L1, L5, and right ilium were also increased . Baseline lung enhanced CT images are shown in . Brain MRI showed no abnormalities . In October 2020, the patient underwent ultrasound-guided pericardiocentesis of pericardial effusion. Upon pathological examination of the pericardial effusion, cancer cells were detected, which was consistent with lung adenocarcinoma . Immunohistochemistry yielded the following: PCK (+), TTF-1(+), i+), CK5/6 (–), EGFR (–), C-met (–), Ros-1 (–), ALK (+). Next-generation genetic sequencing (whole-exome sequencing by company of gloriousmed) suggested the ALK EML4 (, ) - ALK (, ) fusion. Variant allele frequency (VAF) was 3.81%. Another driver mutation was CUX1 (mutation region: chr7: 101821924, 11 exon c.1004delA, p. Asn335fsTer20, VAF 1:00%), and others were somatic mutations of no clinical value, such as INPP4A, MED12, CDC73, CIC, SACS, NOTCH3, ARID2, RPS2, IRS2, INHA. Therefore, the patient was initially diagnosed with lung adenocarcinoma stage cT2N3M1c IVB with EML4-ALK gene fusion (AJCC 8th Edition). She started treatment with crizotinib (p.o. 250 mg bid) in October 2020 for financial reasons. In January 2021, the patient’s lung CT showed that the lesion in the lower lobe of the right lung was 2.2*1.7 cm, and the pericardial effusion was significantly reduced (. According to the criteria of resist1.1, the therapeutic effect was evaluated as partial response (PR). The patient started to have headache and dizziness in September 2021, and brain MRI showed that the pituitary gland was full in shape on September 7, 2021, approximately 1.4*1.4*1.3 cm in size, and the lung lesion was stable . Then, a lumbar puncture was performed, and no significant abnormalities were seen in the cerebrospinal fluid panel, cerebrospinal fluid biochemistry or cerebrospinal fluid cytology. ACTH (0 am): 5.83 pg/ml, ACTH (8 am): 10.20 pg/ml, ACTH (4 pm): 7.03 pg/ml (normal value: 7-64 pg/ml); cortisol (0 am):7.0μg/L, cortisol (8 am):3.0μg/L, cortisol (4 pm): 1.0μg/L (normal values: 37.0-194 μg/L); prolactin: 113.35 ng/ml (normal values: 1.2-29.9 ng/ml). No abnormalities were seen in sex hormones, thyroid hormone, growth hormone, or insulin-like growth factor. Afterward, our team conducted a multidisciplinary consultation with neurology, neurosurgery, and endocrinology and recommended a follow-up MRI after 1 month of supplemental hormone therapy. However, one month later, the patient’s symptoms of headache and dizziness worsened, and the brain MRI re-examination showed that the pituitary gland was enlarged with a size of approximately 1.8*1.4*1.6 cm. On November 15, 2021 , the patient underwent sphenoid sinus exploration and nasal endoscopic saddle area tumor excision in our neurosurgery department. During the operation, the neurosurgery team found an occupying lesion in the sellar area with high dural tension, approximately 2*1.5 cm in size, pink in color, and tightly adherent to the surrounding tissues. The postoperative pathology showed that it was consistent with metastatic adenocarcinoma with neuroendocrine marker expression in some areas of pulmonary origin. Immunohistochemistry yielded the following: PCK (+), TTF-1 (+), Napsin A (+), ACTH (–), GH (–), PRL (–), FSH (–), LH (–), TSH (–), Ki67 (Li: 5%) . The next-generation sequencing (whole-exome sequencing by company of gloriousmed) conducted on the pituitary metastasis suggested EML4 -ALK fusion with VAF of 2.63%. Interestingly, the ALK gene then revealed a missense mutation (mutation region: chr2: 29445213, 22 exon p. Ile1171Ser, VAF: 29.2%). Four non-clinically relevant somatic gene variants (missense mutations) were also detected, namely INPP4A, MAGI2, AMER1, MED12.The patient’s postoperative headache and dizziness were significantly relieved compared to before. The patient’s hormone levels were reviewed on November 29, 2021, and most of the abnormal hormone levels returned to normal. On December 01, 2021, the pituitary gland MRI was reviewed and showed that the pituitary tumor was significantly smaller than before. Based on the patient’s gene sequencing results, we recommended that the patient replace crizotinib with ceritinib. On February 7, 2022, the patient’s lung CT showed that the lesion in the lower lobe of the right lung had shrunk further with a size of 1.8*1.4 cm, and the brain MRI re-examination showed no abnormalities . The patient was reexamined every two months by brain MRI and lung CT. The latest reexamination was on August 7, 2022, and no progression was observed .
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+A 71-year-old woman was diagnosed with diabetes mellitus at 56 years of age. She had a history of hyperthyroidism due to Basedow disease when she was 52 years of age. After three years of anti-thyroid therapy, her hyperthyroidism went into remission. She received oral drugs after being diagnosed with diabetes mellitus at 56 years of age.
+Seven months later, blood examination revealed an elevated level of anti-glutamic acid decarboxylase antibody (869 U/ml). She then received insulin injection therapy for type 1 diabetes mellitus. Her glycated hemoglobin (HbA1c) level was approximately 8%, and she had no history of ketosis or ketoacidosis.
+She was treated with insulin glulisine (13 units/day, pre-breakfast 4 units, pre-lunch 4 units, pre-dinner 5 units), insulin degludec (pre-dinner 3 units), and a SGLT-2 inhibitor, ipragliflozin (25 mg/day). Her fasting blood glucose levels in the morning before COVID-19 vaccination ranged from 93 to 169 mg/dl. Her HbA1c levels at approximately three months and one month before admission were 8.3% and 8.1%, respectively. She received the Pfizer-BioNTech COVID-19 (BNT162b2) vaccine (Pfizer, Inc; Philadelphia, Pennsylvania) three days prior to admission. Immediately after COVID-19 vaccination, she developed nausea and fatigue, and her water and dietary intake decreased. From the next day, the patient showed impaired consciousness, which made it impossible for her to inject insulin or take SGLT-2 inhibitor. Her symptoms worsened, and she was taken to the emergency room of Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan.
+On arrival, she had tachycardia and tachypnea, and her Glasgow Coma Scale was 12 (E3V4M5). A laboratory evaluation showed severe acidosis, ketonuria, ketonemia . Chest X-ray, electrocardiography, abdominal computed tomography, and urinary sediments showed no abnormalities. Thus, an infectious disease was unlikely. The patient was diagnosed with ketoacidosis. Immediately after admission, continuous intravenous insulin, Ringer’s solution, and glucose infusion were initiated in the intensive care unit.
+With the above combined treatment, her ketoacidosis gradually improved . On admission, the plasma glucose, HbA1c, and glycated albumin levels were 944 mg/dL, 8.0%, and 27.7%, respectively. She tested positive for anti-glutamic acid decarboxylase antibody, but was negative for insulinoma associated antigen-2 antibody and insulin autoantibody . Serum C-peptide and urinary C-peptide were undetectable. After her ketoacidosis improved, intensive insulin therapy without SGLT-2 inhibitor was resumed. Serum C-peptide was also below the limit of detection in a glucagon load test . When the patient was discharged, she was treated with insulin glulisine (17 units/day, pre-breakfast 7 units, pre-lunch 6 units, pre-dinner 4 units) and insulin degludec (pre-dinner 4 units).
+The patient was a 52-year-old woman who received insulin infusion therapy with multiple daily injections after being diagnosed with type 1 diabetes mellitus at 47 years of age. At the time of the diagnosis, she was admitted to another facility due to diabetic ketosis. She noticed thirst and >10 kg body weight loss in comparison to 6 months before her admission. A blood examination showed an elevated HbA1c level (15.5%), an elevated anti-glutamic acid decarboxylase antibody level (1230 U/ml), and an elevated islet antigen 2 antibody level (or*insulinoma-associated protein-2 antibody) (>41 U/mL). The urinary c-peptide level (45 µg/day) indicated that her insulin secretory capacity remained. She was diagnosed with latent autoimmune diabetes in adults and insulin treatment was continued.
+She was treated by a family doctor with insulin aspart (25 units/day, pre-breakfast 11 units, pre-lunch 8 units, pre-dinner 6 units) and insulin degludec (before sleeping 12 units). However, the transition of her HbA1c level was poor (10-11%). Her fasting blood glucose levels in the morning before COVID-19 vaccination ranged from 106 to 262 mg/dl. She received her second vaccination the day before admission. For both vaccinations, she received the Pfizer-BioNTech COVID-19 (BNT162b2) vaccine (Pfizer, Inc; Philadelphia, Pennsylvania). She had a drinking habit and consumed approximately 20 g of alcohol on the night before vaccination.
+Immediately after the second COVID-19 vaccination, she had symptoms of nausea, palpitation and respiratory distress. Her symptoms worsened, she could not inject insulin or eat from noon on that day. The following day she was taken to the emergency room of Tokyo Medical University Hachioji Medical Center, Hachioji, Tokyo, Japan.
+On arrival, she had tachycardia and tachypnea, but her consciousness was clear (E4V5M6). A laboratory evaluation showed severe acidosis, ketonuria, and ketonemia . The patient was diagnosed with diabetic ketoacidosis. Immediately after admission, continuous intravenous insulin, Ringer's solution, and glucose infusion were initiated in the intensive care unit. With these combined treatments, her ketoacidosis gradually improved . On admission, her plasma glucose and HbA1c values were 494 mg/dL and 11.6%, respectively . Serum C-peptide and the urinary C-peptide were slightly detected. Her thyroid hormone levels were normal. After her ketoacidosis improved, intensive insulin therapy was resumed.
+When the patient was discharged, she was treated with insulin glulisine (27 units/day, pre-breakfast 11 units, pre-lunch 8 units, pre-dinner 8 units) and insulin degludec (before sleeping 13 units).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1123_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1123_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..95ef2fad3e9d8f0fac1a587923009d64a0eb1524
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1123_en.txt
@@ -0,0 +1,3 @@
+A 21-year-old Caucasian woman presented to an outside facility with altered mental status after being found lethargic by family. On arrival to the emergency department, plasma glucose was 20 mg/dl. The patient was hospitalized and started on dextrose infusion, including 10% dextrose in water but remained hypoglycemic with capillary glucose ranging between 50 and 60 mg/dl. She was transferred to our facility on suspicion of an insulinoma as the patient was unable to recall her prior diagnosis.
+Medical records from our hospital revealed treatment for hypoglycemia as a neonate. The patient reported repeated episodes of seizures, syncope, dizziness, headaches, palpitations, and sweating around age 12; however, symptoms were never formally investigated as she did not seek expert care. These symptoms were also reported to have been present since birth but had been intermittent and of varying severity. She remained seizure-free and without syncopal episodes until 17 when she experienced another syncopal episode. At that time, she underwent extensive inpatient hypoglycemia evaluation with the following results: blood glucose of 47 mg/dl after 2 h of fasting, proinsulin levels varying from 10.4 to 84.1 pmol/l (normal range 0–10 pmol/l), C-peptide level 3.1 ng/ml (normal range 1.1–4.4 ng/ml), negative insulin antibodies and sulfonylurea screen. Magnetic resonance imaging of the abdomen showed no insulinoma, but genetic studies revealed Val452 Leu activating mutation of the GCK gene. She was successfully treated with diazoxide and discharged home on oral diazoxide 250 mg daily, which she discontinued due to side effects of hirsutism and fluid retention.
+On current admission, the patient was treated with dextrose boluses initially. Her blood glucose level remained low in spite of a continuous infusion of 5% dextrose necessitating transfer to an intensive care unit. Both fasting and postprandial blood glucose levels were low. As review of her medication list did not show any implicating drugs, no additional work-up was pursued. She was then placed on octreotide 200 µg subcutaneously twice daily and diazoxide suspension 100 mg three times a day on consultation with the pediatric endocrinologist. Neuroglycopenic symptoms of hypoglycemia improved. The patient's hypoglycemia improved with capillary glucose of 55–110 mg/dl by the time of discharge. Importance of compliance with the treatment and follow-up with an endocrinologist was emphasized.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1127_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1127_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..961e82f58a13f2ad1689c8e622cc2d1fb3c0db4b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1127_en.txt
@@ -0,0 +1,2 @@
+A 19-month-old girl with no known immunocompromise presented with persistent unilateral neck lumps two weeks after lacerating her chin on a wooden shelving unit. While the laceration and swelling had healed uneventfully without specific therapy, neck swelling and overlying erythema developed following her injury, further increasing over the following four weeks. An ultrasound revealed several mild to moderately enlarged left submandibular and upper cervical lymph nodes—changes in keeping with inflammation.
+Examination revealed two prominent lymph nodes on the left side of her neck but was otherwise unremarkable. An 18 mm lymph node was located in the submandibular area, and another node (22 mm) towards the tail of her parotid . Both were fluctuant with erythema of the overlying and surrounding skin. There were no fistulae present. Incision and drainage with curettage was performed under general anaesthesia. Copious purulent discharge was drained and sent along with tissue for histological review and culture. A full blood count performed was within normal limits and C-reactive protein was not elevated. A ten-day course of Clarithromycin 150 mg twice daily was taken post-operatively. The wound healed without complication and no further therapy was required.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1130_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1130_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2b7a094a549a2450518904295aba85c36b60a47
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1130_en.txt
@@ -0,0 +1,3 @@
+A 43-year-old female presented to the Department of Neurology of the Second Affiliated Hospital of Zhejiang University in March 2021. She was diagnosed with WD 12 years ago. Physical examination showed the patient had reduced facial expression and impaired articulation. The patient's left hand mildly trembled when she was asked to raise it flatly. She was also found to have increased extremity muscular tension, upper extremity tendon reflex +++++, and was unable to walk straight. Laboratory tests showed a low ceruloplasmin level (23 mg/L, reference 200–600 mg/L), and no abnormal serum copper concentration was found. Skull MRI showed hepatolenticular degeneration. Abdominal ultrasound revealed liver cirrhosis and splenomegaly. The patient was hospitalized and given sodium dimercaptopropane sulfonate for copper removal, zinc gluconate to inhibit copper metabolism, and supportive treatment such as amantadine and vitamin C supplements. During hospitalization, the patient complained of progressive bilateral vision decrease over 10 years, for which she was referred to our Eye Center. She volunteered that the night blindness began in early childhood, and her parents were close relatives. Her parents and sister were healthy, denying a similar medical history. The patient's best corrected visual acuity (BCVA) at presentation was 0.8 (logarithm of the minimum angle of resolution, logMAR) in both eyes, and intraocular pressure (Non-contact tonometer, Topcon CT-80, Topcon Corporation, Tokyo, Japan) was 10.0 mmHg in the right eye (OD) and 13.5 mmHg in the left eye (OS), respectively. Slit lamp biomicroscopy (SL-D8Z; Topcon Corporation, Tokyo, Japan) revealed bilateral corneal K-F ring and sunflower-like cataract . Fundus photography (TRC-NW8; Topcon Corporation, Tokyo, Japan) showed thinner retinal blood vessels and retinal osteocyte-like pigmentation in bilateral eyes . Cystoid macular edema (CME) and outer retina atrophy was observed in both eyes via optical coherence tomography (OCT) . Visual field examination (Octopus 900, Haag-Streit, USA) revealed binocular tunnel vision . The patient was subsequently diagnosed with WD combined with binocular RP and complicated cataract.
+After informed consent form the patient, phacoemulsification and posterior chamber intraocular lens implantation was performed in the right and left eye, respectively. Postoperatively, topical Tobradex (Tobramycin and Dexamethasone, Alcon) and Pranoprofen (Senju Pharmaceutical Co.Ltd, Japan) eyedrops were prescribed four times a day for anti-inflammatory treatment. Drug therapy for CME was not started before the surgery, and there was no significant change in the central retinal thickness (CRT) of both eyes during the 8-months follow-up. Unfortunately, there was limited improvement in her visual acuity. The BCVA remains 0.8 logMAR for both eyes at her last visit .
+Whole exome sequencing (WES, by Beijing Giantmed medical diagnostics Lab) was performed on the patient and her parents . The results showed an ATP7B gene c.G2333T: p.R778L homozygous mutation, CNGA1 gene c.C453A: p.Y151X homozygous mutation, RP2 gene c.T248C: p.l83T heterozygous mutation, and SNRNP200 gene c.C1898T: p.A633V heterozygous mutation in the patient . Both parents were heterozygous carriers of ATP7B and CNGA1 genes. The mother was of the RP2 heterozygous genotype, and the father was of the SNRNP200 heterozygous genotype, which were both found in the patient. However, the parents did not show any WD or RP-related manifestations.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1133_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1133_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e9dd54831a2bb9dc6a9072d1a9805fffae1bcc7c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1133_en.txt
@@ -0,0 +1,2 @@
+A 27-year-old male involved in a motor vehicle accident was brought to Emergency Department room with respiratory distress. He was intubated upon arrival due to low Glasgow Coma Scale (GCS) with extensive maxillofacial injuries. Thoracic examination showed reduced air entry at right chest wall region with palpable crepitus on his right neck region due to subcutaneous emphysema from the neck to the anterior chest wall. The heart sound was barely audible. A curvilinear transducer on the right second intercostal ribs shows the absence of sliding signs, suggestive of right pneumothorax. A FAST scan was performed, but, on subxiphoid view of the heart, only the right ventricle is seen during diastole. Part of the cardiac image was obscured by A-lines . This raised a suspicion of pneumopericardium given the subxiphoid window was showing partly A-lines and the other half of anatomy partially obscured. We proceeded with focused cardiac ultrasound, and only A-lines were visible on parasternal long axis (PLAX), parasternal short axis (PSAX), and apical four chamber (A4C) views.
+The patient underwent head and chest CT scan that confirmed the diagnosis of Le Fort II facial bone injury, right pneumothorax, and right pulmonary contusion with pneumopericardium . The pneumopericardium was treated conservatively, but other injuries were treated accordingly.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1168_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1168_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..59ea930321d42f3a94058fb6a865eb7e5ae4438f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1168_en.txt
@@ -0,0 +1,11 @@
+A 39-year-old Caucasian man presented in 2009 with an 8-week history of fevers, night sweats, nausea, abdominal pain and distension and 5 kg weight loss. He reported no respiratory or other gastrointestinal symptoms and did not have any unwell contacts or history of overseas travel. He cared for an aviary of Gouldian finches (Erythrura gouldiae), which included cleaning and removing dead birds. There is no personal or family history of recurrent or opportunistic infections.
+Three years earlier, he was diagnosed with acetylcholine receptor (AChR) antibody-positive myasthenia gravis (MG) after presenting with ptosis, dysarthria and dysphagia. A type B2 thymoma was confirmed on surgical resection and treatment with prednisolone and pyridostigmine was commenced.
+In 2008, he suffered a myasthenic crisis with severe bulbar and respiratory muscle involvement necessitating a feeding tube (Myasthenia Gravis Foundation of America (MGFA) grade 4b). This improved with treatment (3-weekly plasma exchange, cyclosporine 150 mg two times per day, azathioprine 50 mg daily and prednisolone 25 mg alternate days) and he remained clinically stable until this presentation. At presentation, he had mild residual bulbar features, including dysarthria, dysphagia and fatigable chewing.
+On examination, he was afebrile, and had splenomegaly, periumbilical and epigastric tenderness. There was no palpable lymphadenopathy.
+Full blood examination showed haemoglobin of 111 g/L (130–170 g/L) and lymphocytes of 1.0×109/L (1.2–2.7 x 109 /L). C reactive protein was 63 mg/L.
+Lymphocyte subsets, including CD4 T-cell counts, were all within normal limits except for reduced CD19 pan B-cell count at 0.03×109/L (0.05–0.41×109/L). Immunoglobulin levels were not reduced, and HIV screen was negative. Bacterial and mycobacterial blood cultures were unrevealing.
+CT scan demonstrated splenomegaly (15 cm) and periaortic and mesenteric lymphadenopathy with no evidence of thymoma recurrence or residual thymic tissue. Gastroscopy showed a macroscopically abnormal duodenum with a fine, nodular appearance. Gastric and duodenal biopsies revealed broad, shortened villi and marked diffuse to confluent infiltrates of histiocytes in the lamina propria. Innumerable acid-fast bacilli were seen on Ziehl-Neelsen stain . Mycobacterium genavense was identified on molecular sequencing, leading to a diagnosis of disseminated M. genavense infection in an immunocompromised patient. Empirical therapy with rifampicin, ethambutol, moxifloxacin and clarithromycin was started. Cyclosporine and azathioprine were discontinued and the frequency of plasma exchange was increased with sequential intravenous immunoglobulin.
+Despite treatment, interval abdominal CT scan revealed progressive splenomegaly (17.8 cm) and intra-abdominal lymphadenopathy, raising concerns of refractory infection or lymphoma, as well as potential splenic rupture. Further biopsies of the mesenteric lymph nodes, stomach and duodenum demonstrated countless mycobacteria, consistent with ongoing infection. Drug sensitivities were unavailable as M. genavense could not be cultured.
+Following a multidisciplinary discussion, subcutaneous interferon-gamma (IFN-γ) was trialled, resulting in substantial fever. Dose was reduced to induce only low-grade fevers and chills (25 μg three times a week). Over the next 12 months, the patient’s symptoms resolved. Repeat CT scan demonstrated a reduction in the degree of splenomegaly and intra-abdominal lymphadenopathy. Antimicrobials were slowly weaned off over 6 years and he remains well 11 years later, with controlled myasthenia.
+Given the rare opportunistic infection, stored and newly collected blood samples were investigated for cytokine antibodies producing immunodeficiency. Due to ease of use and wide availability, the tuberculosis IFN-γ release assay was used to screen for reduced IFN-γ production. After incubation, a multiplex assay was used to measure cytokine production within the supernatant. The patient’s sample showed a markedly reduced IFN-γ response to mitogen stimulation compared with healthy controls . Moreover, the analysis also revealed a reduced concentration of interleukin-12 (IL-12).
+Research-based inhibition studies showed that adding the patient’s sample to IL-12p40 resulted in inhibition of analyte recovery at sample concentrations above 1:16 , suggesting the presence of an IL-12p40 inhibitor. This inhibitory effect was similar to that seen with ustekinumab, a human monoclonal antibody specifically directed against the p40 subunit shared by IL-12 and IL-23. Interestingly, plasma exchange did not substantially reduce inhibition , suggesting that the patient had a very high inhibitor concentration.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1177_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1177_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3a052d260e52c472522aef39eae7c8cc3916182a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1177_en.txt
@@ -0,0 +1 @@
+A 75-year-old woman was referred to our hospital with a gastroesophageal lesion. Upper gastrointestinal endoscopy revealed a raised lesion with ulceration on the posterior wall of the greater curvature of the cardia. The endoscopy also indicated tenderness in the lower esophagus and tumor invasion was suspected . Immunostaining of the tumor biopsy showed positive staining for Melan-A, human melanoma black-45 (HMB45), and S-100 protein (+), indicating malignant melanoma of the esophagogastric junction. Contrast-enhanced computed tomography (CT) of the abdomen showed a mildly stained lesion protruding into the cardiac part of stomach and enlarged perigastric lymph nodes (the right paracardial lymph node and lesser curvature lymph node were lumped together) . No obvious distant metastasis was observed. Serum analysis indicated that squamous cell carcinoma antigen, carcinoembryonic antigen, and carbohydrate antigen 19–9 were within normal limits. A positron emission tomography (PET)– CT scan showed a high degree of fluorodeoxyglucose accumulation (maximum standardized uptake value: early = 13.2, delayed = 19.2) in the upper stomach and enlarged lymph nodes. Based on these findings, we performed proximal gastrectomy, lower esophagus resection, and double-tract reconstruction. We also performed resection of the enlarged lymph node in the lesser curvature of stomach and no obvious distant metastasis in the abdominal cavity was found. Histological examination of the resected tissue indicated an elastic, soft tumor that was located in the esophagogastric junction (6 × 5 cm, Fig. a). Analysis of the tumor cell morphology demonstrated large, round tumor cells with nuclear atypia and high mitotic activity . Immunostaining was positive for Melan-A, HMB45, S-100 protein and SRY-box transcription factor 10 , and the patient was diagnosed with malignant melanoma of the esophagogastric junction with regional lymph node metastases. Postoperative recovery was good, and the patient was discharged on 22 days post-operation. Three months after the surgery, a follow-up CT showed subpleural masses in the lower lobe of the left lung, with bilateral pleural effusion . As previous analyses of the primary tumor had revealed BRAF-wild-type, the patient was prescribed with nivolumab, human immunoglobulin G4 monoclonal antibody, and inhibitor of programmed death-1 (PD-1) in accordance with melanoma treatment guidelines. Following three courses of nivolumab treatment, the patient presented with grade 3 renal dysfunction (Common Terminology Criteria for Adverse Events version 5.0) . The patient was prescribed steroid therapy for the immune-related adverse events that developed in response to the nivolumab treatment. Despite improved renal function, chemotherapy was discontinued at the patient's request. Five months after the presentation of renal dysfunction, a CT scan demonstrated an unstained nodule in the pancreas with dilation of the caudal pancreatic duct , although the size of the pleural metastasis was unchanged. Intensity-modulated radiotherapy (IMRT) was initiated for pancreatic metastasis treatment at 66 Gy. Six months after IMRT treatment, a CT scan revealed pancreatic nodule and pleural metastasis was shrunk. Eight months after the IMRT (13 months after nivolumab treatment completion), the pleural mass and pleural effusion had disappeared . PET–CT showed no obvious abnormal accumulation . We hypothesized that the abscopal effect was caused by the radiation therapy, and further enhanced by the nivolumab treatment, which had finished 5 months earlier; the timeline of these events is shown in Fig. . Twelve months after the onset of the abscopal effect, no additional lesions were observed and the patient had discontinued all treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1184_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1184_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c85e3e30c00a9198d4a4c6567cdfb9938931224f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1184_en.txt
@@ -0,0 +1,5 @@
+A 68-year-old man was examined in the outpatient department of our hospital by transoesophageal echocardiogram (TOE) because the attending cardiologist suspected mitral valve endocarditis. The patient’s medical history revealed permanent AF, drug-, and hepatitis E-induced liver cirrhosis (CHILD Score B) being on vitamin-K-antagonist (VKA), a biological aortic valve replacement in 2011 and long-standing hypertension. Due to a history of cirrhosis-associated major gastric bleeding complications in February 2014, while being on VKA and rheumatoid arthritis with long-term glucocorticoid therapy, an LAA closure procedure was planned 3 months later in our hospital. At that time, the patient had a CHA2DS2-VASc score of 2 points (age 65–74 years +1 and hypertension +1) and a HAS-BLED score of 5 points (age, hypertension, abnormal liver function, labile International Normalized Ratio (INR), and prior major bleeding; each +1). Despite antihypertensive combination therapy, including a diuretic, the patient’s blood pressure remained increased. Therefore, in combination with the glucocorticoid therapy, the bleeding risk (estimated risk 9–12%) was substantially higher than the risk for ischaemic stroke (estimated at 2.2%). At the time, guidelines did not recommend direct oral anticoagulants as an alternative to VKA use as there was insufficient data. As a result, a percutaneous LAA closure was performed in May 2014 and a 33-mm WATCHMAN device was implanted in the LAA of a chicken wing type and a left atrial (LA) size of 22 cm2. The WATCHMAN device size was chosen based on a maximum LAA ostium size of 30 mm, for which a 33-mm WATCHMAN device is recommended. The manufacturer’s standard guidelines and recommendations were followed and the procedure was performed without any adverse events. Post-interventional TOE assessment showed an appropriate closure of the LAA. The patient was discharged with dual antiplatelet therapy (DAPT) comprising aspirin 100 mg/day and clopidogrel 75 mg/day for 3 months, to which he was compliant.
+In July 2015, the patient was diagnosed with an ischaemic stroke due to the occlusion of the right internal carotid artery and carotid endarterectomy performed. A TOE performed at the time showed no intracardiac thrombus. Systemic lysis was performed, which resulted in intracranial bleeding. As a result, the CHA2DS2-VASc score increased to 4 points (age 65–74 years +1, hypertension +1, and stroke +2; estimated risk 4%) and the HAS-BLED score increased to 6 points [age, hypertension, abnormal liver function, labile INR, prior major bleeding, and (NEW) stroke; each +1 point; estimated risk higher than 9.1%], respectively. After conservative treatment, the patient was discharged to outpatient care with only slight neurological deficits (insecure gait) and his daily life was not impaired. The patient again received DAPT for 3 months, but no oral anticoagulation.
+In April 2016, the patient was invited by the outpatient cardiologist for a routine transthoracic echocardiographic assessment, which included the evaluation of the prosthetic aortic valve function. Examination revealed a mobile mass towards the mitral valve, which was suspected to be potentially endocarditis-related. The size of the left atrium was only slightly larger than in 2014 (25 cm2). A TOE, which was performed shortly after hospital admission, confirmed this mobile mass (∼40 mm × 15 mm in size) arising from a cleft of the LAA and located between the pulmonary vein ridge and the LAA device itself . The structure periodically prolapsed through the mitral valve leaflets and was of dense texture with only minor mobility. Anticoagulation with partial thrombopplastin time (PTT)-controlled heparin (PTT 50–80 s) was initiated. The patient remained completely asymptomatic, without showing any clinical evidence of peripheral embolism or neurological event. Fever and elevation of serological inflammation markers were also absent. Because of the high bleeding risk with a HAS-BLED score of 5 points, surgery was chosen as the therapy of choice instead of long-term anticoagulation.
+The patient was transferred to the cardiac surgery unit of a tertiary hospital and the device together with the thrombus was removed. Surgery was performed by a standard procedure with moderate hypothermia, utilizing a cardiopulmonary bypass manoeuvre, and by surgical closure of the LAA thereafter. In situ analysis showed that the closure did not cover the LAA completely and the device was only partially coated by the endothelium. A gap was identified between the device and the LAA from where the thrombus developed.
+On Day 21 post-extirpation of the thrombus, the patient was discharged in good clinical condition on DAPT for the following 3 months. A TOE 6 weeks later showed no further thrombus formation and a completely closed LAA. In follow-ups at 6 and 12 months after surgery, transthoracic echocardiography was performed in an outpatient setting and did not reveal any clinically relevant findings. At this point, the patient was in a stable clinical condition. Further follow-up is planned on a yearly basis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1216_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1216_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09e126c59c643ec685ae0674d168bbd5c444e7c2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1216_en.txt
@@ -0,0 +1,8 @@
+A 24-year-old Chinese pregnant woman presented to the emergency department with complaints of anemia for 3 mo, gingival bleeding for 1 mo, and hematuria for 2 wk.
+She was 24 wk pregnant and presented to the emergency department complaining of anemia for 3 mo, gingival bleeding for 1 mo, and hematuria for 2 wk.
+Before pregnancy, she had a history of chronic seizures for 22 years that occurred about every 2-3 mo. The patient was on a long-term regimen of levetiracetam tablets (1000 mg per day) but stopped taking antiepileptic drug 1 d before admission.
+The patient had no family medical history of lipid disorders.
+Although she had a normal physique (height: 1.58 m, weight: 61 kg; body mass index: 24.4 kg/m2) with no impaired intelligence, she was anxious with a characteristic round “doll-like” face.
+The biochemistry of this patient was found to be abnormal as indicated by various biochemical tests : hemoglobin: 67 g/L, extremely elevated triglyceride: 5483.5 mg/dL (normal value < 150 mg/dL), cholesterol: 836.6 mg/dL (normal value < 200 mg/dL), elevated lactic acid: 13.3 mmol/L (normal value 0.5-1.7 mmol/L), slightly elevated uric acid: 412 μmol/L (normal value 89-360 μmol/L), albumin: 33.6 g/L, qualitative urine protein: 0.3 (1+) g/L, urinary erythrocyte++++/haptoglobin, and elevated thyroid-stimulating hormone: 8.080 mU/L (the recommended value for pregnant women is less than 2.5 mmol/L). The patient’s enzymes such as amylase and lipase were in the normal range.
+Ultrasound examination showed abnormal enlargement of the liver where the maximum oblique diameter of the right lobe was found to be about 17.2 cm. Two stones smaller than 0.5 cm were found in the left kidney. The patient had been undergoing regular prenatal check-ups after pregnancy and the nuchal translucency thickness, as well as Down’s syndrome screening, were normal. Obstetric ultrasound examination at 24 wk of gestation revealed a live single fetus in the uterus with a thickened and sail-shaped placenta, which needed to be closely monitored during the pregnancy.
+After eating, the patient’s blood glucose returned to normal levels (6-9 mmol/L) after two episodes of intermittent fasting hypoglycemia (minimum 2.66 mmol/L). We highly suspected that she was suffering from GSDI. To confirm this diagnosis, we treated the patient with cornstarch diet therapy and performed genetic testing using samples of her blood and fingernails. The genetic test results showed that there was a gene c.648G>T mutation on chromosome 17q21, indicating that the patient had glucose-6-phosphatase (G6Pase) deficiency.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1229_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1229_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d2fab2fb55088af5f2873b85f0c00307457468f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1229_en.txt
@@ -0,0 +1,7 @@
+A 50-year-old woman presented in the outpatient department with severe abdominal pain, especially in the left iliac region, for the past six months. The pain was dull aching in nature and continuous and used to be relieved with oral analgesics. The patient also complained of shortness of breath, which worsened in the supine position and was eased in the sitting posture. She also stated that she had lost her appetite and lost a large amount of weight. There was no history of vaginal bleeding. There was no previous medical or surgical history.
+On physical examination, the patient looked cachexic with mild degree of pallor with stable vital parameters. Abdomen examination showed a mass of 20 weeks of gestation size with irregular surface, heterogeneous consistency, tender, margins well defined but the lower pole was usually not reached, with restricted mobility. Ascites was present and positive shifting dullness was noted. A vaginal examination showed nodules on the right posterior fornix, tenderness was present. Left fornix was free.
+The patient was advised for contrast-enhanced computed tomography (CECT) of the abdomen and pelvis, which revealed a large cystic lesion with peripheral enhancing solid areas in the pelvis in midline, probably arising from the left ovary, a possibility of malignant ovarian lesion . Another heterogeneously enhancing lesion was seen in the right adnexa. The right ovary was not seen separately from the lesion. There was a large ill-defined heterogeneously enhancing central mesenteric lesion with omental extension showing dense calcification, most likely metastatic deposit. Loculated ascites and left-sided moderate pleural effusion with few peripheral lung parenchymal nodules in the right middle and bilateral lower lobes were suggestive of stage 4A of the International Federation of Gynecology and Obstetrics system 2014.
+CA-125 (cancer antigen 125) value was more than 1000 units/ml. NACT was given to the patient with paclitaxel 175 mg/m2 and carboplatin 675 mg/m2 (area under the curve (AUC)=5-6, calculated by Calvert’s formula). After two cycles of NACT with intervals of three weeks, CA-125 was 452 units/ml. The patient then underwent further four cycles of NACT. CA-125 was repeated, which showed normal values, and CECT was done, which revealed a complex cystic lesion in the pelvis and the infra-umbilical region at midline and para midline locations . A lesion of 2-3 cm thickness and peripherally enhancing solid mass of 8.6 x 5.8 cm in size was displacing the adjacent bowel loop. There was para midline location-significant regression in size of the mass. There was significant regression in ascites.
+USG revealed a solid cystic lesion in the left adnexa measuring 5 x 4.2 x 3.6 cm; the solid component showed vascularity. Left ovary not seen separately. Findings were consistent with left ovarian complex cyst-neoplastic etiology. Omental thickening was seen in midline in the epigastric region.
+The patient was taken for exploratory laparotomy. A vertical incision of 10 cm was made and the abdomen was opened in layers so as to expose the maximum area. In order to assess the extent of the primary tumor and metastatic disease, the peritoneal cavity and retroperitoneum were thoroughly inspected and palpated. All abdominal viscera were palpated and checked, and adhesions between sigmoid and left corn structures were lysed. Ureters were identified and placed away. Dissection of mass, uterus, cervix, bilateral fallopian tube, and ovaries was done by retroperitoneal approach and sent for frozen section according to which it was labeled as bilateral papillary cystadenocarcinoma. Then retroperitoneal resection was done. Bilateral pelvic lymph nodes were removed and an omentectomy was done. No para-aortic lymph nodes were identified. The bowel was inspected for injury. Drain was inserted and hemostasis was achieved. Rectus was closed with prolene 1-0. All laparotomy sponges and instruments were removed from the abdomen and counted. The abdomen was closed in layers with Vicryl 1. Skin closure was done in layers with Ethilon 2-0 mattress sutures. The patient withstood the procedure satisfactorily and was shifted to the postoperative ward. Specimens were sent for histopathology, which confirmed bilateral serous cystadenocarcinoma. The specimen is shown in Figure .
+The patient was discharged on postoperative day 12 after suture removal and advised to follow up every month for the first three months and then every three months for the next one year. On her last follow-up, the patient was better clinically and had no signs of recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1235_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1235_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f658c145deeb35d7a5d125675d5ff85223ddc170
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1235_en.txt
@@ -0,0 +1,11 @@
+A prepubertal, Caucasian 11 years-old girl was admitted to the Pediatric Department of Chieti for evaluation of severe hypertension (200/114 mmHg) in the context of severe obesity [Weight: 86.9 kg, Height: 144 cm, BMI: 41.9 kg/m2 (SDS-BMI: 3.25)]. She had a family history of obesity (both parents and the 17 years-old brother) and both parents were affected by T2D. The girl had a normal weight at birth, developed obesity since the age of 5 years-old. Clinical examination revealed marked acanthosis nigricans and striae rubrae. Essential Hypertension was diagnosed and therapy with amlodipine and bisoprololo was successfully started. The girl presented normal glucose metabolism (fasting glycaemia: 79 mg/dL, HbA1c: 5.4%) with insulin resistance (fasting insulin: 51 mU/mL, HOMA-IR index: 9.9), normal lipid profile (total Cholesterol: 197 mg/dL, HDL: 23 mg/dL, LDL Cholesterol: 137 g/dL, Triglycerides: 185 g/L) and hepatic steatosis with mildly increased transaminases levels (AST: 62 U/L, ALT: 122 U/L). Lifestyle change was recommended including a detailed dietary scheme and physical activity program. Thereafter, during the ambulatory follow-up hypertension was well controlled but the patient was lost after 2 months.
+After six months she was admitted to the emergency department [Weight: 78.5 kg, Height: 146 cm, BMI: 36.8 kg/m2 (SDS-BMI: 2.97)] for lethargy. She had an history of chest pain associated with increasing dyspnoea and progressive drowsiness over the last two days before presentation. Weight lost and intense polyuria over the 4 weeks was reported.
+On admission, Glasgow Coma Scale (GCS) was 13/15, heart rate 120 beats/min, respiratory rate 40 acts/min, blood pressure 140/70 mmHg and pulse oximetry 100% on room air. At clinical evaluation she appeared severely dehydrated. Neurological examination confirmed profound drowsiness although awakeable, with eye opening response to speech and mild confused verbal response. She denied headache and no neurological alterations were reported.
+Kidney function (creatinine: 0.70 mg/dL) and potassium levels were normal. In contrast, on blood gas evaluation severe hyperglycaemia (647 mg/dL), increased sodium levels (corrected Na: 152 mmol/L) associated with high serum osmolality (326 mmol/Kg) were detected. In addition, severe acidosis with low bicarbonates and high ketonemia levels (pH: 7.11, BE: -23.9, HCO3-: 9.2 mmol/L, ketonemia >8 mmol/L) were demonstrated establishing a diagnosis of combined HHS and DKA. Clinical history together with well-known insulin resistance state and long lasting polyuria oriented towards metabolic derangement due to unknown T2D. In this respect therapy was started with the aim to control primarily the hyperosmolar state .
+In fact, rehydration with isotonic saline (0.9% NaCl) infusion was initially started and after four hours continued with 0.45% NaCl together with continuous low-dose insulin administration . Infusion treatment was stopped after 60 hours when normal serum osmolality and pH levels were achieved, although blood ketones were still present. Therefore, subcutaneous basal-bolus insulin administration was started. Over the infusion period general condition progressively ameliorated and no neurological or other complications were developed.
+The suspicion of T2D complicated by combined HHS and DKA, was confirmed by detection of high percentage of HbA1c (11.6%), high levels of C-peptide (3.24 ng/mL) and the undetectable titre of antibodies against pancreatic islets’ antigens (ICA, GAD, IA2) while ZnT8 antibodies were not been performed. She stopped basal-bolus insulin administration after 17 days and continued with degludec therapy once a day and metformin therapy twice daily obtaining normal glucose metabolism after two months (HbA1c: 5.2%). Lifestyle changes were endorsed but after some months the girl was lost for follow-up.
+After 2 years, she presented again to the emergency department with a similar episode characterized by increased dyspnoea, nausea, lack of appetite, sporadic vomiting and a poor glycaemic control over the last seven days [Weight: 95.5 kg, Height: 155 cm, BMI: 39.8 kg/m2 (SDS-BMI: 3.41), Pubertal stage: P5B5]. Parents reported poor compliance over the last months.
+On admission neurological examination was normal (GCS 15/15). She did not complain headache, neither other neurological symptoms. She was severely dehydrated.
+Blood tests performed showed again normal potassium values, while kidney function was borderline (creatinine: 1.26 mg/dL, BUN: 16 mg/dL). Blood gas demonstrated hyperglycaemia (402 mg/dL), increased sodium concentrations (corrected Na: 152 mmol/L), associated with mild increased serum osmolality (316.4 mmol/Kg). Moreover, acidosis and ketonemia (pH: 7.23, BE: -18.8, HCO3-: 26.4 mmol/L and ketonemia: 5.6 mmol/L) were documented.
+Initial combined HHS/DKA was supposed and isotonic saline (0.9% NaCl) infusion was started first and subsequently substituted by 0.45% NaCl for rehydration . After two hours, continuous low dose insulin administration was started and associated thereafter with glucose 5% after 11 hours. Moreover, when osmolality was acceptable but metabolic acidosis with high blood ketone levels persisted after 20 hours, glucose infusion at 10% was started and maintained up to 60 hours post admission with insulin infusion (0.042 U/kg/h). Normal serum osmolality, pH levels and resolution of ketonemia were achieved. General condition ameliorated progressively and no neurological symptoms appeared.
+Poorly controlled T2D (HbA1c: 11.6%) in the presence of detectable levels of C-peptide (1.64 ng/mL, normal range 0.69-2,45 ng/mL) was found and undetectable titre of antibodies against pancreatic islets’ antigens (ICA, GAD, IA2) were confirmed. Degludec therapy once a day and metformin therapy twice daily was confirmed obtaining good metabolic control.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1272_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1272_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..63e9f172f45f8d234b3999966afacd6ea2f2353e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1272_en.txt
@@ -0,0 +1,4 @@
+In May 2005, a 43-year-old man was admitted to the hospital with mitral regurgitation. In 1981, he had been in a car crash and developed a destructive nosocomial Staphylococcus aureus endocarditis of the mitral valve. A bioprosthesis was inserted which failed in 1988 and was replaced. In May 2005, regurgitation through the valve was once again detected and the patient was hospitalized for a further valve replacement. The patient was afebrile and had a systolic murmur over the mitral area. He had no leukocytosis (leukocyte count was 3.63 × 109/l with 50.2% neutrophils). The low neutrophil count corrected itself spontaneously. The erythrocyte sedimentation rate (16/43 mm) and C-reactive protein (<5 mg/l) was normal and hepatic enzymes were elevated (ALT: 69 IU/L; normal ≤ 40 IU/L). Three routine blood cultures were negative (Bactec, Becton Dickinson, Sparus, Maryland) and no rheumatoid factor was detected. Transthoracic echocardiography revealed mitral insufficiency but there were no vegetations and IE was not considered as a possible diagnosis. However, no transesophageal echocardiography was performed. Histology of the prosthetic valve removed at surgery using reported methods [,], revealed an IE with a vegetation containing micro-organisms that stained with Warthin-Starry and Giemsa . Standard cultures of cardiac valve tissue remained sterile, but with cell-cultures (human endothelial cell) a strain of B. henselae was isolated in 3 weeks . Also, DNA of B. henselae was demonstrated to be present in the valve by PCR and sequencing with primers for the eubacterial 16S rRNA gene and Bartonella ITS region Genotyping of the B. henselae strain was carried out using the multi-spacer typing (MST) method as previously described . Sequences obtained from the nine studied spacers classified the strain within MST genotype five, previously described to contain cat isolates from various countries including France, Germany and USA . Serum tested retrospectively was found to contain antibodies to B. henselae and B. quintana at an IgG titer of 1:200 , which is not suggestive of IE. However, western blotting was positive for antibodies to B. henselae and B. quintana and showed a reactivity pattern typical for endocarditis . Immunoblotting with a serum sample adsorbed with B. henselae confirmed the diagnosis of B. henselae IE.
+The diagnosis of IE was made retrospectively based on the combination of histology of the cardiac valve lesions, culture of Bartonella from the valve, presence of a predisposing heart condition, and serological evidence of Bartonella infection. Without the histology of the valve the patient would not have had a positive score using the Duke criteria; he would only have had 2 minor criteria. After surgery, the patient recovered rapidly with routine post-surgical amoxicillin administration for 4 days, followed by gentamycin for 15 days and doxycycline for 1 month .
+Retrospectively, it was found that six months before the patient had had suspected lymphoma of an inguinal lymph node. Histology of the node, however, showed a necrotizing lymphadenitis suggested of CSD. Numerous microabscesses containing fragmented neutrophils were observed in homogenous necrotic areas. These necrotic regions were surrounded by a ring of macrophages and epithelioid histiocytes to form stellate inflammatory granulomas . No bacteria were detected by immunohistochemical examination or Warthin-Starry staining. Unfortunately, the lymph node sample was not available for PCR analysis to confirm the diagnosis of CSD.
+The patient did not own a cat but reported a single contact with a stray cat that scratched him one month before the enlargement of the inguinal lymph node. We report the development of IE after a likely episode of CSD in a patient with a mechanical mitral cardiac valve. In previous studies , B. henselae was described in patients who have regular contact with cats and with pre-existing valvulopathies [,], but to the best of our knowledge the progression of CSD to IE has not previously been reported.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1274_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1274_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3b618253be8815a83976dac111c577c701350d48
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1274_en.txt
@@ -0,0 +1,6 @@
+A 43-year-old Caucasian man on anti-retroviral therapy (lopinavir/ritonavi and emtricitabine/tenofovir) for HIV/AIDS presented in September 2008 with a three-month history of low grade fevers, night sweats, generalized fatigue, lethargy, unintentional weight loss, and bilateral lower extremity swelling. He had a CD4 count of 196 cells/mm3, and a viral load of <50 copies/mL. He had been diagnosed with HIV-infection in 1990; his CD4 nadir was 4 (0.6%) in February 2004 with high viremia, 175,671 copies/mL. After initiation of potent anti-retroviral therapy the HIV viral load has been undetectable since October 2004.
+A physical exam of our patient revealed diffuse lymphadenopathy in his cervical, axillary and inguinal areas, splenomegaly, and pitting edema in both lower extremities. Computed tomography of his chest, abdomen and pelvis demonstrated widespread mediastinal, hilar, axillary, retro-peritoneal and pelvic lymphadenopathy, as well as the splenomegaly. A laboratory workup revealed a hemoglobin level of 8.5 mg/dL, a white blood cell count (WBC) of 4,600 cells/μL, an albumin level of 2.5 mg/dL, and a Westergren sedimentation rate of 90 mm/hr. A lower extremity Doppler was negative for deep venous thrombosis.
+Histological examination of lymph node biopsy material revealed marked plasma cell infiltration, and follicles that were variable in appearance, from marked follicular hyperplasia to involution and dendritic cell hyperplasia . Immunohistochemical studies demonstrated HHV-8 positive , and plasmablastic foci associated with an intense polytypic plasma cell infiltrate. These findings were consistent with the diagnosis of MCD--plasma cell variant. Our patient was discharged from the hospital and was scheduled to start treatment for MCD.
+Three weeks later our patient presented with lower abdominal pain, urinary retention, and lower extremity weakness. Neurological examination revealed bilaterally reduced motor power (4/5) in all major muscle groups in his lower extremities, along with a positive Babinski sign on the right. Deep tendon reflexes were normal bilaterally. An ultrasound of his pelvis demonstrated bladder distention. A Foley catheter was inserted and 2 liters of urine was evacuated, with complete relief of pain.
+A Gadolinium magnetic resonance imaging (MRI) of his spine was done to rule out spinal cord compression; it revealed abnormal spinal cord signal intensity involving several cervical and thoracic segments, associated with expansion of the cord and mild enhancement of the areas of abnormal T2 signal . MRI of the brain revealed a few patchy areas of abnormal T2 signal in the peri-ventricular and pontine white matter.
+A lumbar puncture was performed: cerebrospinal fluid (CSF) contained an elevated WBC of 50 cells/mm3, with 90% lymphocytes, and a high protein level of 243 mg/dL; cytological analysis identified mature reactive lymphocytes with no evidence of lymphoma on flow cytometry. Polymerase chain reaction (PCR) was positive for EBV DNA in the CSF, but negative for HHV-8, cytomegalovirus (CMV), herpes simplex virus (HSV) and Varicella-Zoster virus (VZV). Treatment with high-dose dexamethasone was initiated. Our patient was then transferred to the National Institute of Health (NIH) and started on a treatment protocol of high-dose zidovudine (AZT) and valganciclovir for MCD (ClinicalTrials.gov identifier: NCT00099073). Subsequent laboratory follow-up revealed marked improvement over the first seven days of treatment, including a marked decrease in WBC and protein in his CSF. A follow-up MRI demonstrated resolution of all spinal cord lesions. He is now doing well, his last CD4 was 322 (15%), viral load < 50 copies/mL in August 2010.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1284_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1284_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7bf4de0459e51f2fc5ebbf0c41a95c03d0f6e399
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1284_en.txt
@@ -0,0 +1,3 @@
+A 21-year-old man was diagnosed with B-ALL 5 years ago (August 2015) and received chemotherapy consisting of one cycle of VCDLP (CTX, vindesine, daunorubicin, prednisone, PEG-aspargase) for induction ), and one cycle of MTX plus PEG-aspargase for consolidate . After these two cycles of therapy, minimal residue disease (MRD) was still positive. Therefore, he underwent a second-line therapy with MA (MTX and Arac) , and reached MRD-negative complete remission (CR). In March 2016, he received allo-HSCT (allogenic hematopoietic stem cell transplantation) from an HLA-matched unrelated donor, and all went well with no occurrence of CMV reactivation. Four months later, a disease relapse was suspected, and the patient was admitted to our hospital for further treatment, where he underwent bone marrow (BM) examination. Flow cytometry revealed 18.5% abnormal B lymphoblasts, and immunohistochemistry showed significant hyperplasia of abnormal lymphoblasts with CD34+ TdT+ CD79a+ CD10+ CD19+ CD22+ CD3- BCL2+ MPO- and Ki-67 Li 90%. Gene examination revealed a missense mutation in the NOTCH2 gene and a splice variant of the IKZF1 gene. No evidence of central nervous system (CNS) invasion or any other extramedullary diseases were identified. Serological tests were negative for HBV antigens/antibodies except for HBsAb, but they were not performed for CMV antibodies. No CMV DNA or HBV DNA was detected in the blood. The chest CT scan and hematobiochemical results were consistently normal. He was allergic to ofloxacin and had no history of exposure to HBV, HIV, tuberculosis, or any other infectious diseases. No other clinical history, familiar or psycho-social history of importance.
+Given the relapse after HSCT, we treated the patient with the sequential infusion of anti-CD19 and anti-CD22 CAR-T cells (ChiCTR-OPN-16008526). It took two weeks to manufacture the patient’s own anti-CD19 and anti-CD22 CAR-T cells from collected peripheral blood mononuclear cells (PBMCs). The transfection rates of CD19 CAR and CD22 CAR were 35.6% and 40.9%, respectively . The patient was treated with 3-day conditioning chemotherapy consisting of fludarabine 25 mg/m2 and cyclophosphamide 20 mg/kg per day, and was sequentially transfused with CD19 CAR-T cells and CD22 CAR-T cells at doses of 1.5x106 cells/kg and 1x106 cells/kg, respectively. As shown in , CAR-T cells expanded well in vivo with CD19 and CD22 CAR copy numbers of 1,034,286 and 52,857.14 per µg genomic DNA, respectively, on day 6. Meanwhile, after the infusion of CAR-T cells, the patient developed grade 3 CRS manifested as high fever (max temperature of 41°C), hypotension (lowest at 88/42 mmHg, responsive to fluids therapy), hypoxia (requiring high-flow nasal cannula oxygen), coagulopathy (requiring fresh frozen plasma), pulmonary edema characterized by extensive rales among both lower lobes of the lung, and grade 3 immune effector cell-associated neurotoxicity syndrome (ICANS) with two-side blurred vision. Eye examinations found patchy bleeding around the infratemporal branch of the central retinal vein and scattered exudation in the other parts of the right retina (suspected to be associated with coagulopathy and severe thrombocytopenia), and mild retinal edema (no hemorrhage was observed) in the left eye. Laboratory testing revealed markedly increased levels of IL-6 and ferritin after CAR-T cell infusion, as shown in , with peak values of 1,260 pg/mL and 30,014 µg/L on day 6 and day 8, respectively. The serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), N-terminal B-type natriuretic peptide (NT-proBNP), and hypersensitive troponin were also abnormally elevated. After one session of plasma exchanges [to selectively eliminate inflammatory cytokines ], two 40-mg doses of methylprednisolone, and other supportive treatments, the inflammatory cytokine storm was gradually controlled, with both the levels of IL-6 and ferritin falling to baseline levels 2 weeks after the infusion as well as the levels of AST, ALT, NT-proBNP, and hypersensitive troponin. The blurred vision disappeared spontaneously two days later. In addition, the patient experienced severe myelosuppression but recovered two weeks later, as depicted in . The patient received prophylactic anti-infective treatment (excluding antiviral therapy) after CAR-T cell infusion, and no severe infection was observed during treatment. BM aspiration was performed on day 14, indicative of complete remission by flow cytometry.
+On December 3, three months after CAR-T cell treatment, the patient was hospitalized with a 10-day history of low fever (37-38 °C) and cough, and a 3-day history of palpitations, chest tightness and dyspnea. The primary disease was well controlled, and B cells were still absent . The findings on chest X-ray suggested pulmonary infection and interstitial infiltration . CMV DNA, rather than bacterial DNA or fungal DNA, was detected in the peripheral blood by next-generation sequencing (NGS) sequencing. Given the patient’s previous medical history, clinical manifestations, and laboratory and radiographic evidence, he was diagnosed with suspectable CMV pneumonia (fiberoptic bronchoscopy was contraindicated as the patient was oxygen dependent, and therefore, no pneumonia tissue was available to confirm CMV infection). On December 4, the patient received antiviral (ganciclovir 5mg/kg q12h) therapy, as well as preventive anti-bacteria (tigecycline 50mg q12h, and sequential use of cefoperazone/sulbactam 3g q8h, meropenem 0.5g q6h and imipenem/cilastatin 1g q8h) and anti-fungi (sequential use of voriconazole 0.2g q12h and caspofungin 50mg qd) therapy (all intravenously). However, the symptoms worsened rather than alleviated, with the occurrence of diarrhea (yellow watery stool) and an SpO2 of 90% despite using oxygen mask on December 7. Therefore, we introduced intravenous gamma globulin 20 g/day, methylprednisolone 40 mg/day and bilevel positive airway pressure (BiPAP) ventilation on December 8, after which his pulmonary symptoms gradually improved. Ganciclovir was changed to penciclovir (5mg/kg q12h, intravenous drip) due to the side effects of limb numbness, chills and pain at the infusion site. During treatment with these two antiviral drugs, the patient’s WBC count and platelet count decreased progressively . We stopped penciclovir on December 18 when the clinical symptoms had improved. Meanwhile, CMV DNA was negative in the blood, and a chest X-ray showed reduced inflammatory filtration. However, the side effects of myelosuppression aggravated, and three days after treatment discontinuation with penciclovir, the patient again reported chest tightness and shortness of breath. We reintroduced penciclovir on December 21, but the patient’s symptoms gradually worsened. He died on December 25 from respiratory failure. The key events in this case are summarized in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1330_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1330_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..151974b8ef92d6cd87f23d0e8bcebdc11649f19b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1330_en.txt
@@ -0,0 +1,3 @@
+A 9-year-old female patient arrived at the emergency room because of a 36-h history of intermittent right lower abdominal pain, anorexia, vomit, and quantified high-grade fever. She had no pathological personal or family history of interest. On examination, the right iliac fossa was tender to palpation and no frank peritoneal signs were observed. Initial laboratory evaluation showed leukocytosis, neutrophilia, and an elevated C-reactive protein. Ultrasonography of the abdomen was inconclusive. A heterogeneous lesion of 40 × 37 mm within the colon, no appendix and some swollen mesenteric nodes of at least 10 mm were reported. A complementary abdominal CT scan revealed findings suggestive of ileocolic intussusception with an invagination area of approximately 6.6 × 4.9 cm. After surgical consult, the patient underwent an exploratory laparoscopy that required laparotomy conversion. A well-defined, 5 cm mass at ileo cecal valve and multiple hard pericecal lymph nodes were observed. Preserved permeability between the ileum and colon, complete integrity of the cecum wall and lack of vermiform appendix were also reported. The possibility of an auto-digested appendix and a cecal tumor were discussed. At this time, surgeons decided to resect retrocecal and pericecal lymph nodes and send these samples to pathology before any further intervention. The patient was admitted to the inpatient floor where antibiotic therapy based on ampicillin sulbactam, and metronidazole was initiated. The oncologist department was consulted and complementary laboratory exams including liver and renal function tests, uric acid, electrolytes, lactic dehydrogenase, and quantiferon-TB tests were ordered. Only lactic dehydrogenase was altered. A chest x-ray ruled out mediastinal masses. No alarming findings were reported. However, the patient presented gastric distension, abdominal pain and fever by the second hospitalization day. The content inside the suprapubic JP drain changed from a serohematic aspect to a dense cloudy fluid. A culture and cytochemical analysis of peritoneal fluid was performed without significant results. CBC showed mild leukocytosis and neutrophilia. Reactive C-protein remained elevated. Two blood cultures and an urinalysis were negative. Due to the uncertainty of the etiology of her clinical picture, infectology decided to change antibiotic therapy to piperacillin/tazobactam and amikacin. An abdominal x-ray showed air fluid levels in the small bowel and a colonic distention projected at mesogastrium. Gastroenterology suggested initiating bowel rest and placing a central line for parenteral nutrition.
+After five more days, elevated inflammatory markers, abdominal distension and pain, and the unusual JP drain aspect persisted. A new ultrasound confirmed that the mass and surrounding area had the same aspect as days before. The histopathological description of paracecal-retrocecal lymph nodes and the sample of mesenteric omentum obtained during the first intervention failed to detect neoplastic cells. Macroscopically, three encapsulated lymph nodes from 0.8 to 2 cm were received. Their physiological architecture was preserved; secondary lymphoid follicles with hyperplastic germinal centers containing macrophages with cellular debris were reported. The interfollicular population was polymorphic and contained frequent large cells with prominent immunoblast-like nucleoli. Other areas showed sinusoidal histiocytosis with eosinophils and neutrophils. There was fibrosis with a predominantly neutrophilic mixed inflammatory infiltrate that spread to neighboring adipose tissue in the periphery of the nodes. The immunohistochemical study confirmed the presence of follicular dendritic cells and B lymphocytes in the germinal centers (CD23 + + +/+ + + and CD20 + + +/+ + + respectively), T lymphocytes in the mantle zone (CD3 + + +/+ ++), macrophages in germinal centers and sinusoidal area (CD68 +/+ ++). Frequent CD30 + + +/+ + + immunoblasts and actin + + +/+ + + myofibroblasts within areas of fibrosis were also observed. EBV study using EBER in situ hybridization was negative. Ziehl Neelsen and PAS did not show any pathogen. The 22 × 0.6 cm omentum sample showed fibrous thickening of the septa and the presence of a mainly lymphocytic infiltrate. Fibrino-leukocytic material was also seen in the serosa. Pathologists concluded the possibility of an unspecified acute versus chronic epiploitis, lymphadenitis and serositis. Nevertheless, due to her unfavorable clinical evolution and the elevated inflammatory markers, a second surgical intervention was decided. The patient underwent an omentectomy and resection of approximately 40 cm of terminal ileum, cecum and ascending colon. Pericolonic lymph nodes were resected as well. A sample of a collection observed near the cecum was taken for culture and cytochemical studies before aspiration and drainage. After surgery, the patient remained hemodynamically stable, without abdominal pain or distention. A nasogastric tube was placed and parenteral nutrition continued. The peritoneal fluid analysis was negative. Improvement in inflammatory markers lead to amikacin discontinuation. And by the fifth postoperative day, JP drain, and nasogastric tube were removed. Later, a regular diet was successfully initiated, and the patient was finally discharged.
+The histopathological final report described an 8 cm ileal segment, and a 14 cm ascending colon including the cecum with a diameter that ranged from 1 to 3 cm. The external surface was covered by a pinkish-gray serosa with fibrinopurulent material over the ileocecal area. A completely subserous dilated appendix was identified within the cecum wall. It contained a white-yellowish purulent material at the tip . A well-defined nodular lesion of approximately 1.5 cm was also identified . The mucosa of the cecum was pink while ileal mucosa had a granular appearance. Nine nodules, which measured between 0.3 and 3 cm, were isolated from the surrounding area. The 12 × 4.5 cm omentum sample had no palpable nodes. A second omentum sample showed multiple whitish irregular fragments of bland tissue that measured between 0.8 and 1.5 cm. Microscopically, the histological findings of the fourteen isolated lymph nodes were compatible with follicular hyperplasia. The subserosal cecal appendix showed transmural necrosis and perforation causing leakage of purulent material and an acute inflammatory reaction of the surrounding adipose tissue which extended up to the cecal and ileal serosa. All layers of the appendix were independent and unrelated to the cecum wall . The distal portion of the appendix showed the proliferation of cellular nests that were composed of round uniform nuclei with a “salt and pepper” appearance . No mitotic activity was evidenced. It seemed to infiltrate the muscular layer of the appendix and reach a diameter of 1.5 cm. No lymphovascular or perineural invasion was observed. Disease free margins were reported. Ileum dissection showed Peyer’s patches hyperplasia with wide germinal centers. Tumoral cells’ immunochemical studies showed a Ki67 proliferative index of 2%, a positive (+ + +/+ + +) cytoplasmic granular pan-cytokeratin, a positive (+ + +/+ + +) cytoplasmic chromogranin and a negative synaptophysin reaction . Pathologists concluded the presence of an incidental well differentiated neuroendocrine tumor grade I pT1 pN0 at the tip of the appendix in the middle of a clinical picture caused by an acute necrotizing appendicitis of a complete subserosal appendix. Due to the stage, no further intervention was required. She fully recovered in subsequent controls. Nevertheless, correct management of short bowel syndrome will become a key feature for the preservation of her future quality of life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1343_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1343_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af45aaf39d5ead652a46536552ac1b03a186e57d
--- /dev/null
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@@ -0,0 +1,10 @@
+Here, we report the case of a 63-year-old Japanese man with no medical or psychiatric history, except for type-2 diabetes mellitus and essential hypertension. He had no previous history of psychotropic drug use, including antidepressants and antipsychotics. Additionally, he had no developmental abnormalities or neurodevelopmental disorders. He held a steady job from college graduation until retirement age, and his wife described his premorbid personality as dependable, sociable, and patient. He had no family history of psychiatric disorders, migraine, or epilepsy.
+One year before his first admission to an inpatient psychiatric unit, he started experiencing mild depressive moods and fatigue that did not disrupt his day-to-day functioning. Two months before the first hospital admission, he began complaining about typical AIWS symptoms, including micropsia, altered perception of his body image, and a disturbed sense of the passage of distance and time. All sorts of objects in his environment, such as buildings and cars, looked extremely small to him. He gave up driving because cars looked so small that he lost his sense of speed and distance in relation to the cars around him. Nearby objects also looked very small, with the single exception of pill strips that he had difficulty opening. Moreover, even though he knew it was not possible, he felt as if he could ‘step over’ long distances in a flash, such as the 50 km from his suburban town to the center of Tokyo. Additionally, he felt that days passed extremely quickly, as if in a single moment. He also sometimes felt his body was slightly enlarged or shrunken compared with normal. These AIWS symptoms persisted all day long during the depressive episodes.
+In addition to the typical AIWS symptoms described above, he also complained of disturbances in high-order cognition. For instance, he said, “I cannot sense how important the news is. For example, when I see news about a serial murder on television, I can understand intellectually how sad it is, but I cannot realize it emotionally”. Similarly, he said, “I cannot appreciate the value of money. Even if there were a ¥10,000 bill in front of me, I wouldn’t care about it because I can’t realize how much value it would have”. Although his bowel movements and urination were normal, he complained of a decreased urge to defecate and urinate.
+The depressed mood, loss of interest and pleasure, psychomotor retardation, fatigue, and reduced concentration gradually worsened. He was referred to a neurologist. Organic causes were ruled out as follows: his blood-sugar level and blood pressure were well controlled with insulin injections and oral medications; he was a non-drinker, had no history of head trauma, and took no medications associated with adverse reactions that could mimic depression, such as beta-blockers and cimetidine. Neurological examinations and laboratory tests including endocrine evaluations and an HIV test, electroencephalography, and brain magnetic resonance imaging (MRI) detected no abnormalities. He was then referred to a psychiatrist. After confirming that he was not experiencing a manic episode, was not using illicit drugs, and had not experienced any recent stressful life events, he was diagnosed as having a severe depressive episode with AIWS. His condition worsened to the degree that he could not continue working despite taking paroxetine, and he was hospitalized for the first time.
+At this first admission, he was bed-ridden all day because of severe depressive symptoms. Administration of amitriptyline (75 mg/day) and perphenazine (6 mg/day) induced gradual improvement of depressive and AIWS symptoms. He was discharged on day 47 after he had remitted almost completely from the depressive episode, with the exception of easily becoming fatigued and waking at night. At that time, he was also completely remitted from AIWS. His day-to-day functioning returned to normal, and his work and life continued as they had before the episode began.
+Three years after discharge, he relapsed into another major depressive episode, again simultaneously presenting with AIWS. The symptoms worsened despite the use of amitriptyline (50 mg/day) and aripiprazole (6 mg/day) in the outpatient clinic. The Visual Perception Test for Agnosia detected nothing abnormal. His thoughts became stunted and he became very inactive, lying in bed all day. He continuously refused inpatient treatment because he delusionally believed he was too poor. Upon the strong recommendation from his family, 8 months after this recurrence, he was admitted to the hospital with recurrent severe depressive symptoms and AIWS at the age of 67 years.
+At this second admission, he was alert and oriented, but had prolonged speech latency and spoke in a slow and quiet manner without making eye contact. His face was unshaven and he did not smile. Dementia was ruled out as a plausible cause of his symptoms for the following reasons: 1) his Mini-Mental State Examination (MMSE) score was 28/30 during this depressive episode, 2) he made a complete recovery from the observed reduction in concentration and processing speed after treatment of the first episode, 3) he exhibited no other signs of recognizable cognitive decline such as impaired executive function, learning, memory, language, or social recognition, and 4) he did not exhibit any typical symptoms of common dementia subtypes, such as amnesia, fluctuating cognition, visual hallucinations, extrapyramidal symptoms, or behavioral symptoms. Evidence of depressive symptoms and AIWS was comparable between the first and second episodes. He scored 30/63 on the Beck Depression Inventory-II (BDI-II), indicating severe depression. An ophthalmologist confirmed no eye/visual abnormalities with the exception of bilateral cataracts. Pre-therapy FDG-PET was performed as described below. After 2 weeks of maprotiline (75 mg/day) had no effect, twice-weekly ECT, duloxetine (60 mg/day) and mirtazapine (45 mg/day) were administered. He remitted completely from AIWS and almost completely from the depressive episode after 12 ECT sessions, except for a mild reduction in concentration. He scored 12/63 on the BDI-II, which also indicated significant recovery from depression. He was discharged after 75 days, just after post-therapeutic FDG-PET was performed.
+We obtained the pre- and post-treatment FDG-PET images of the brain during the second admission. The patient was kept at rest in supine posture with a blinder in a quiet and dim room from 10 min before each PET examination until the end of the scan. Scans were recorded with a PET scanner (Advance NXi; GE Medical Systems, Milwaukee, WI, USA) 45 min after the injection of 296 MBq FDG.
+Upon visual inspection, the pre-treatment FDG-PET images depicted moderate hypometabolism in the frontal cortex and relative hypermetabolism in the occipital and parietal cortices . These abnormalities improved slightly after treatment .
+Statistical analysis was performed in the following steps: (1) morphological co-registration between pre-and post-treatment FDG-PET; (2) normalization of voxel values to the global mean voxel counts using proportional scaling; (3) subtraction of pre-treatment from post-treatment images to obtain pre-post difference images; (4) mean and standard deviations of voxel values were calculated for the difference images; and (5) identification of area with statistically significant difference, using a cutoff value of z > 2 and extent threshold k > 200. These methods are part of the standard process for subtracting ictal single photon emission computed tomography (SPECT) coregistered to MRI (SISCOM), which is generally used for comparing ictal and interictal SPECT images in epileptic patients . The statistical analysis showed that metabolism decreased after treatment in the posterior half of the cerebral cortex, including the posterior part of the bilateral temporal cortex, the occipital cortex, the inferior part of parietal cortex, precuneus, and posterior cingulate cortex . No area showed statistically significant increases in metabolism after treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_135_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_135_en.txt
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index 0000000000000000000000000000000000000000..da44e4efa38ee0f653209184f43759c5b1582526
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_135_en.txt
@@ -0,0 +1,8 @@
+A 48-year-old Japanese woman had a sudden onset of severe headaches early in the morning during work and was transported to a local hospital. She was alert-oriented and had no neurologic deficits. She had a medical history of atopic dermatitis and metal allergy that had discouraged her from wearing any jewels.
+A head computed tomography (CT) scan demonstrated a subarachnoid hemorrhage (SAH) around the basal cistern with predominant SAH in the left sylvian cistern. A three-dimensional-CT angiography revealed a left internal carotid artery (ICA)-posterior communicating artery (Pcom) aneurysm. Although an emergent aneurysm clipping surgery was scheduled, the patient preferred a coil embolization rather than an open surgery so that she was referred to us for a coil embolization.
+On the next day after the onset, a coil embolization was performed using a simple technique under the general anesthesia. The left ICA angiogram confirmed an irregular-shaped aneurysm measuring 7.7 mm in the maximum diameter at the left ICA-Pcom junction. Besides the ICAPcom aneurysm, aneurysms at the bilateral middle cerebral artery (MCA) bifurcations and at the top of the right ICA were also revealed. Given the distribution of SAH as well as the size and the shape of the aneurysm, the left ICA-Pcom aneurysm was believed to be the cause of the SAH.
+A guiding sheath (Flexor shuttle 7F × 90 cm ST 0.100”/2.54 mm) was advanced to the pre-petrous portion of the left ICA. A microcatheter (Excelsior SL-10 pre-shaped 90°) was placed in the aneurysm using a manual-shaped intermediate catheter (TACTICS 120 cm STR). Seven coils were used for the complete obliteration of the aneurysm (Raymond-Roy occlusion classification class I) and are listed in . The patient recovered well without any neurologic deficits. The head CT scan right after the embolization showed no abnormal findings, as shown in
+Despite no neurologic deficits after the surgery and no abnormal findings on a MRI 7 days after the coil embolization, an MRI study performed 24 days after the embolization demonstrated a round lesion beside the posterior horn of the left lateral ventricle, as shown in . The lesion showed homogeneously moderately high intensity on the T2-weighted image (T2WI) and the fluid-attenuated inversion recovery (FLAIR) sequence, mildly high intensity on the apparent diffusion coefficient (ADC) map but isointensity on diffusion-weighted imaging (DWI). An MRI taken 44 days after the surgery showed multiple patchy lesions at separate locations of the left frontal and parietal lobes. The lesions demonstrated high intensity on FLAIR as the previous one. An MRI obtained 70 days after the surgery still demonstrated an even larger high intense lesion on T2WI, FLAIR, and ADC map and an isointensity on DWI in the left frontal lobe, though the previous lesion had disappeared. An MRI taken 146 days after the surgery showed complete disappearance of the abnormal high intense lesions finally.
+Meanwhile, the ratio of eosinophils (EOS) among the leukocytes was 3.0% (0.0–7.0%) before the surgery, and it elevated up to 9.7% 16 days after the coil embolization and got back to 2.6% 147 days after the surgery, as shown in .
+Despite the MRI findings, the patient showed no neurologic deficits and complained of only mild headaches throughout the course. No specific treatments were performed, and the headaches gradually subsided and finally resolved completely.
+The patient subsequently underwent a metal skin patch test that showed positive against only zinc though the patch test covered neither titanium, tungsten, nor molybdenum, as shown in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1364_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1364_en.txt
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index 0000000000000000000000000000000000000000..15026fe5628f0257907fd5350033b1748810112d
--- /dev/null
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@@ -0,0 +1,2 @@
+A 3-week-old girl, with a family history of maternal unilateral retinoblastoma, presented for evaluation of leukocoria right eye (OD). On examination, visual acuity was fix and follow in both eyes (OU) and intraocular pressures were normal OU. External examination documented obvious leukocoria OD. Fundus evaluation OD revealed a white macular tumor measuring 16.0 mm in largest basal dimension and 6.1 mm in thickness, and with overlying mild vitreous seeding and surrounding extensive serous retinal detachment. Fundus evaluation of the left eye (OS) detected a solitary mass measuring 2.0 mm in basal dimension and 1.0 mm in thickness, located within 2.0 mm from the foveola. A diagnosis of bilateral familial retinoblastoma, group D OD and group B OS, was rendered and treatment with intravenous chemoreduction (CRD) using vincristine, etoposide, and carboplatin was initiated. Following therapy with individual tumor consolidation, all retinoblastomas were regressed.
+At 6-months follow-up, the right eye remained under control, but the left eye revealed a subtle recurrence of the juxtafoveal tumor and HH-OCT (iVue Optovue, Fremont, CA) revealed an intact macula with adjacent tumor recurrence , measuring 2750 µm in diameter and 792 µm in thickness. The recurrence was 615 µm from the foveola. Treatment with intraarterial chemotherapy (IAC) using Melphalan 5 mg was performed and complete tumor control was achieved with 1 cycle , leaving a concave scar of 2750 µm in diameter and 120 µm in thickness, located 663 µm from the foveola. In addition, there was underlying choroidal thinning and preservation of the foveal microanatomy documented by HH-OCT OS . The findings remained stable on last follow-up at 2 years following IAC.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1375_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1375_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..380e89f1bc6aa6e9dc34eea1b2d4a5f720f29fb1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1375_en.txt
@@ -0,0 +1,3 @@
+A 45-year-old man was referred to our center due to Wolff-Parkinson-White (WPW) syndrome for radiofrequency ablation. General physical examination was normal. Electrocardiography (ECG) showed pre-excitation in favor of left posterior accessory pathway (AP). Echocardiography was also normal.
+Guided by fluoroscopy, right atrium (RA), right ventricle, and coronary sinus catheters were introduced into the corresponding heart chambers. Basic electrophysiology study confirmed that AP was located in the posterior part of mitral valve ring; so we decided for TSP. This was the first time we used HeartSpan Steerable (Merit Medical Systems, South Jordan, UT, United States) sheath and the needle for TSP; in the previous TSP procedures, we used the AgilisTM sheath (Abbott, Saint Paul, MN, United States). Withdrawal of trans-septal sheath from superior vena cava into RA after 2 jumps usually places the introducer system in the fossa ovalis; but in this patient, this maneuver did not work despite several attempts. Finally, we could place the sheath into lower part of the interatrial septum, just above coronary sinus catheter in left anterior oblique projection. Jerky puncture with the needle was done and small amount of contrast injection showed that the needle has traversed the interatrial septum. So, we advanced the steerable sheath over the needle to the left side, and then the needle was withdrawn. However, to our surprise, contrast injection into the side branch of the sheath showed that it was in the left ventricle (LV) rather than the left atrium (-A). We advanced the 0.032” guidewire through the sheath to LV, and retracted the sheath to RA. Continuous arterial blood pressure monitoring did not show hemodynamic compromise, nor did echocardiography show pericardial effusion; so we decided to perform radiofrequency ablation of AP via the retrograde trans-aortic approach that was successful (-B).
+We transferred the patient to coronary care unit (CCU) for better hemodynamic monitoring. On the next day, transthoracic and trans-esophageal echocardiography showed LV outflow tract to RA jet (-C and -D respectively). The patient was discharged uneventfully. Follow-up echocardiography showed that the tract was present for up to 18 months without any evidence of cardiac enlargement . Since the patient was asymptomatic, endovascular or surgical closure was not attempted.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1380_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1380_en.txt
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index 0000000000000000000000000000000000000000..5b161aa24fe7e2d8e4cdefe65246dd60cb17c41d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1380_en.txt
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+An 82-y-old woman, gravida 2 para 2, suffering from right vulvar swelling and pus drainage for 1 week was transferred to our hospital. She presented with a remarkable swelling of her vulva as well as her right leg. Computed tomography scan and magnetic resonance imaging showed a 75 mm irregular mass in her right vulva; additionally, her pelvic and inguinal lymph nodes were markedly swollen. However, we did not detect any instance of distant metastases, and neither did the patient have a family history. Incidentally, the patient had been diagnosed with endometrial cancer stage IA, and she had undergone a total abdominal hysterectomy and bilateral salpingo-oophorectomy 3 y ago. Histological diagnosis of the hysterectomy specimen had confirmed endometrioid carcinoma (grade1, pT1a cN0 cM0) (shown in Fig. a). However, lymphovascular space invasion was observed over the uterine wall (shown in Fig. b). No adjuvant therapy had been administered post-surgery. The current vulvar biopsy revealed small atypical cells with necrosis, a high nucleo-cytoplasmic ratio, and a proliferating solid mass (shown in Fig. c, d). The patient’s tumor marker levels were as follows: cancer antigen 125 – 20.2 U/mL (normal value: ≤ 35.0 U/mL), cancer antigen 19–9 < 2.0 U/mL (normal value: ≤ 37.0 U/mL), squamous cell carcinoma antigen – 1.0 ng/mL (normal value: ≤ 1.5 ng/mL), neuron-specific enolase > 370 mg/mL (normal value: ≤ 16.3 mg/mL), and pro-gastrin releasing peptide – 53.4 pg/mL (normal value: ≤ 80.00 pg/mL). The vulvar SCNEC was thought to be a primary or secondary SCNEC. The tumors grew daily. However, owing to the patient’s age and poor prognosis, only palliative care was provided for the pain management. Unfortunately, the patient died of the disease within 1 month.
+Immunohistochemical staining of the vulvar mass revealed that most of the vulvar tumor cells were positive for AE1/AE3, CAM5.2, neuron-specific enolase, CD56, and chromogranin A (shown in Fig. a). On the contrary, the tumor cells tested negative for MCPyV (shown in Fig. b), CK20, synaptophysin, c-kit, estrogen receptor, progesterone receptor, p16, and adrenocorticotropic hormone. Retrospectively, immunohistochemical and virological analyses had been performed for the initial endometrial endometrioid carcinoma. Immunohistochemical staining had revealed that the tumor cells were positive for CD56 and chromogranin A (shown in Fig. c). Notably, endometrial cancer cells infiltrated into lymphatic vessels are also positive for chromogranin A. Additionally, the tumor cells were negative for MCPyV and CK20. Furthermore, the HPV DNA typing analysis (types 6, 11, 16, 18, 30, 31, 33, 35, 39, 45, 51, 52, 56, 58, 59, and 66) of the formalin-fixed, paraffin-embedded specimens of the vulvar tumor was negative (PapiPlex™, GeneticLab Co., Hokkaido, Japan) (shown in Fig. ). Therefore, the vulvar tumor was suggested to be a recurrence of the endometrial cancer rather than a primary vulvar HGNEC (shown in Table ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1440_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1440_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0741e056027d006f3b1847252f5f13d7c4147a87
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1440_en.txt
@@ -0,0 +1 @@
+A 42-year-old man with no previous medical history presented with mild dyspnea on exertion and abdominal distension that lasted for a week. Computed tomography (CT) revealed a huge homogeneous mass completely obstructing the right ventricle and extending into the pulmonary trunk . CT findings showed little evidence of blood clots and moderate amounts of pericardial effusion . The patient was admitted via the emergency room for further evaluation and scheduled for echocardiography the next day. However, he suddenly collapsed the next day while on his way to an echocardiography. Cardiopulmonary resuscitation (CPR) was performed immediately by medical staffs, but heart rhythm did not recover. Accordingly, an extracorporeal membrane oxygenation (ECMO) device was inserted percutaneously via the left femoral artery and right femoral vein and ECMO support was urgently initiated. Subsequently, a pericardial window was created at bedside, and about 350 cc of dark blood colored effusion was drained. Soon afterward, blood pressure stabilized but consciousness was not confirmed. But his light reflexes remained intact. Based on consideration of right ventricular outflow tract (RVOT) obstruction in the initial CT scan, we decided to remove the mass from the right ventricle immediately. Surgery was performed using a median-sternotomy approach. Initially, an arterial cannula was placed in the distal aspect of the ascending aorta, and the superior and inferior venae cavae were cannulated to establish cardiopulmonary bypass (CPB). After aortic cross-clamping, the pulmonary trunk and RVOT were incised. By intra-operative gross visualization, the tumor was located in the RVOT and protruded from endocardium of the right ventricle out of epicardium of the right ventricle and also extended toward and was attached to the right leaflet of the pulmonary valve . The tumor was fragile and considered highly likely to be malignant and impossible to completely control, and thus, we planned chemotherapy after surgery. The main mass was resected to relieve the RVOT obstruction, and after the operation, the ECMO was removed from the operation room. However, the patient failed to regain consciousness and electroencephalography (EEG) and subsequent magnetic resonance imaging (MRI) indicated severe hypoxic brain damage. We assume CPR was unsuccessful because the mass completely blocked the RVOT. Pathology revealed the mass was an undifferentiated spindle cell sarcoma .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1452_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1452_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c538e43d02d9d592544a202ebf0a25910ed49b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1452_en.txt
@@ -0,0 +1,8 @@
+A 4-year-old girl visited her local hospital due to abdominal pain and vomiting for one day. Then, she was admitted to our department for a giant retroperitoneal lesion, which was considered an NB.
+The girl’s abdominal computed tomography (CT) scan showed a giant retroperitoneal lesion, which was considered an NB. For further diagnosis and treatment, she visited our department. Her symptoms such as abdominal pain and vomiting had disappeared spontaneously without treatment after admission.
+Previously, she did not have a specific past medical history.
+The girl did not have any significant family history. Both her father and mother were healthy.
+On physical examination, a mass was found on palpation of abdomen, mainly in the left upper and left lower quadrants, extending to the right lower quadrant, of about 10 cm × 7 cm in size. It was firm mass without tenderness, and had an unclear boundary and limited mobility.
+Tumor markers revealed a neuron-specific enolase level of 42.45 ng/mL. All other blood test findings, including other tumor markers, coagulation, liver and renal function tests, were within normal values.
+Ultrasonography showed a giant hypoechoic mass in the left retroperitoneal space, and the mass had a patchy strong echogenicity and no obvious cystic area. The lesion size was 12.4 cm × 10.5 cm × 6.3 cm with irregular morphology, and the mass crossed the midline. A tumor blood supply vessel with a diameter of 0.3 cm branched from the abdominal aorta . Contrast-enhanced CT showed that the huge lesion appeared well defined and was 123 mm × 85 mm in maximum cross-section, while the inferior mesenteric artery was fully encased 360°. Mixed density and patchy calcification were seen within the mass, the solid component was significantly enhanced, and adjacent structures were pushed out. The radiologists considered it to be a tumor (NB?) .
+To clarify the diagnosis and decide the next treatment, ultrasound-guided abdominal mass aspiration biopsy was performed. Pathology revealed a retroperitoneal neoplastic lesion, and some cells were spindle-shaped and considered Schwann stroma. As a whole, the tumor was differentiated, while some of the cells were suspected to have undergone ganglion cell differentiation. Some areas appeared to be immature, but no definite NB nesting mass was observed. Immunohistochemical results showed calretinin (+-), Syn (+-), NF (+-), and SOX10 (+-). Therefore, the pathologists first considered it to be a GN .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1479_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1479_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd1aadea581d0c88ef19c313f09e426aab843b73
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1479_en.txt
@@ -0,0 +1,2 @@
+A 47-year-old Caucasian man with a past medical history significant for noninsulin-dependent diabetes mellitus, hepatitis C, past alcohol abuse and cirrhosis was admitted to our medical intensive care unit with an upper gastrointestinal bleed. On presentation, his blood pressure was 104/70mmHg, heart rate 137 beats per minute, temperature 37.2°C and respiratory rate 24 breaths per minute. On examination, he was pale and icteric, and had a mildly distended abdomen with no discernable organomegaly. Cardio-respiratory examination was normal. He was confused and agitated with no focal neurological signs. His white blood count was elevated at 23.7 × 109//L with 24% bands, with a hemoglobin of 78g/L and platelets of 83 × 109/L. Albumin was 19g/dl (normal 32 to 49g/L), total bilirubin 83.3μmol/L (normal 3.4 to 20.4μmol/L), aspartate aminotransferase (AST) 32 IU/L (normal 7 to 42 IU/L), alanine aminotransferase (ALT) 35 IU/L (normal 1 to 45 IU/L), alkaline phosphatase (ALP) 32 IU/L (normal 25 to 120 IU/L), international normalized ratio (INR) of 1.84, arterial ammonia 151μmol/L (normal 11 to 35μmol/L) and lactate of 6.1mmol/L (normal 0.6 to 1.7mmol/L). His blood urea nitrogen (BUN) and creatinine were 9mmol/L and 124μmol/L, respectively.
+The patient was electively intubated for airway protection and to facilitate endoscopy. He was resuscitated with crystalloids, 5% albumin, packed cells and fresh frozen plasma and treated with vancomycin and piperacillin/tazobactam for presumed sepsis. Ultrasound and Doppler of his upper quadrants was consistent with cirrhosis with normal blood flow and splenomegaly. An upper endoscopy revealed grade 4 esophageal varices with no active bleed. Over the next few days, the patient became progressively unresponsive (off sedation) with his ammonia level rising above 200μmol/L despite aggressive treatment with lactulose and rifaximin. Neurologic assessment revealed posturing to painful stimuli with a poorly reactive pupillary reflex. Computed tomography of the head revealed diffuse white matter edema prominent in the posterior temporal, parietal and occipital lobes. Brain MRI confirmed diffuse white matter edema with temporal and occipital lobe predominance consistent with the diagnostic pattern for PRES . His course was complicated by the development of tonic-clonic seizures which were controlled with intravenous levetiracetam. His pupils became fixed and non-responsive. Transcranial Dopplers (TCD) of the middle and posterior cerebral arteries demonstrated a marked reduction in cerebral blood velocity consistent with severely increased intracerebral pressure (ICP). As an extraordinary salvage method to control the patient's severe ICP, we lowered his core body temperature to 32°C with the addition of propofol and mannitol, titrated to keep serum osmolarity < 310mmol/L. Induced hypothermia was maintained for 48 hours during which time he regained normal pupillary reflexes with marked improvement in TCD velocities. During the passive rewarming phase, the patient developed massive hematemesis. He required massive transfusion and Minnesota tube placement as attempted banding via endoscopy was unsuccessful. The patient underwent an emergency transjugular intrahepatic portocaval shunt (TIPS) placement followed by repeat induced hypothermia (32 to 34°C). Due to the anticipated increase in the serum ammonia level following the massive gastrointestinal hemorrhage, we initiated high-flow continuous venovenous hemodiafiltration (CVVHD) to facilitate ammonia removal. The CVVHD was associated with a fall in the ammonia level . At this time, the patient was again passively rewarmed and the propofol discontinued. His neurological status improved slowly over the following week becoming more alert and responsive and allowing extubation. A repeat MRI of the brain showed interval improvement in extensive white matter signal abnormality most consistent with resolving PRES. He was discharged home with no neurological sequela apart from amnesia for the entire hospital stay. The patient has returned to work part-time and is currently listed for liver transplantation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_147_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_147_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a9c79dc6ce7257af965332980cfabec2eeba0d2b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_147_en.txt
@@ -0,0 +1,9 @@
+A 67 year-old male presented to his local hospital with six weeks of extreme lethargy. He complained of non-radiating chest and epigastric pain with associated breathlessness and anorexia. On further questioning he admitted to 25 kg weight loss over the previous six months. He reported a past history of empyema occurring decades previously.
+Examination revealed normal heart sounds, an irregular tachycardia with a pulse of 100 beats/min, raised jugular venous pulse, widespread peripheral edema, vesicular air entry to lungs, no abdominal signs, and no lymphadenopathy.
+Vital signs revealed a pyrexia of 39 °C, relative hypotension of 110/67 mmHg, pulse oximetry 95 % on air, a tachypnea of 26 breaths/min and normal urine output.
+Laboratory investigations showed hemoglobin 57 g/L (125–160 g/L), MCV 71 fL (80–100 fL), white cell count 33.6 × 109/L (4-11 × 109/L), CRP 218 mg/L (<5 mg/L), sodium 127 mmol/L (135–145 mmol/L), potassium 5.9 mmol/L (3.5–5.5 mmol/L), creatinine 111 mmol/L (60–110 mmol/L), albumin 17 g/L (35–55 g/L), bilirubin 9 mg/L (0–17 mg/L), ALT 182 U/L (7–56 U/L), ALP 203 (44–107 U/L). Blood film demonstrated neutrophilia with left shift consistent with severe bacterial infection, and evidence of anemia including microcytosis, polychromasia, target cells and pencil red blood cells.
+Initial treatment included transfusion of 4 units of packed red blood cells, treatment of heart failure with diuresis and of sepsis with intravenous broad-spectrum antibiotics (tazobactam/piperacillin).
+Serial electrocardiograms showed sinus tachycardia with paroxysmal atrial fibrillation and widespread ST elevation of about 2 mm in leads II, III, aVF, V3-V6 , which later normalized. Serial troponin I ultra over a 24 h period after presentation were 695, 538, 491 ng/L (<20 ng/L) respectively. It was thought this represented cardiac stress secondary to persistent tachycardia and profound anemia. Thoracic radiogram showed a small left-sided pleural effusion .
+Echocardiography was obtained and showed mild left ventricular dilatation with severe dysfunction and an ejection fraction of 25 %. There was also a 0.9 cm apical, 1.4 cm anterior and 1.3 cm posterior simple pericardial effusion without hemodynamic compromise or tamponade. For this reason, pericardiocentesis was not performed.
+Computed tomogram of chest abdomen and pelvis demonstrated right lower lobe pulmonary artery embolus with infarction of lung parenchyma, pneumopericardium and pericardial effusion , fixed large hiatus hernia with a mass , enlarged 18 mm celiac node and unremarkable appearances elsewhere. Subsequent gastroscopy confirmed a large hiatus hernia with a bleeding ulcerated gastroesophageal junction tumor . Serosal breaching by this mass led to fistulation into the adjacent pericardium. Histological diagnosis was subsequently confirmed as poorly differentiated adenocarcinoma.
+After an initial improvement with antibacterial therapy and hemodynamic stabilization, drainage of his contaminated pericardial cavity was considered, but the patient rapidly deteriorated with uncontrolled sepsis and multi-organ failure. Management of a complex case such as this requires multidisciplinary team discussion. It was felt that aggressive management of a cachectic man with a poor cancer prognosis and a multiple serious clinical conditions arising from this was not in his best interest as he was unlikely to survive intervention or surgery. These discussions included the patient and his family, and led to a palliative management approach.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1482_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1482_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2ebdc82007d173d87337dcb1363de4e51e536afe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1482_en.txt
@@ -0,0 +1,4 @@
+Our patient was a 48-year-old woman with a history of two previous cervical surgeries, the first one in 1987 and the second in 2003, with placement of titanium plates and screws at C4-C5 and C5-C6. She was seen at the clinic in 2005 with a 2-month history of fatigue, chills, headache, nausea, and asymmetric arthralgia. She also had episodes of malar rash after sun exposure and cutaneous fluctuating rash in the trunk. Physical examination revealed arthritis of the left shoulder and left ankle, livedo reticularis, and erythematous cutaneous rash in the thorax. No infection foci were detected. Laboratory studies revealed thrombocytosis 485,000 cells/mm3 (normal range 130,000–400,000 cells/mm3), elevated C-reactive protein (CRP) 75 mg/dl (normal range 0.1–1.0 mg/dl), and erythrocyte sedimentation rate (ESR) 40 mm/h (normal range 0–20 mm/h). Autoantibodies were negative, and complement levels were within normal range.
+From 2005 to 2007, she had no treatment, and her symptoms had a fluctuating course. In 2007, fatigue, rash, and arthralgia appeared again, and she developed edema in her hands and feet. Rheumatology started prednisone and methotrexate without improvement. Six months later, dysphagia, halitosis, and “sputum” production of purulent aspect were added to the patient’s symptoms. She consulted an ear, nose, and throat specialist, who did not find any abnormality.
+She continued with elevated CRP, ESR, and thrombocytosis. Labeled leukocyte single-photon emission computed tomography (SPECT) suggested spondylitis in the cervical spine (C4-C6) and revealed an inflammatory process in the nasopharynx, an increase in the prevertebral space of > 2 cm, and free air in this area . An esophagogram with hydrosoluble contrast revealed a posterior pharyngoesophageal diverticulum with a fistula to C6 . The patient’s x-rays of the lateral column after the cervical spine anterior fixation in 2003 showed preserved prevertebral space, and intersomatic C4-C5 box and plate were 5 mm anterior to the vertebral bodies, pressing the esophagus .
+The patient was taken to surgery; screws and plates were removed from C4 to C6; surgical debridement was performed; and the fistula and diverticulum were removed with cricopharyngeal myotomy and esophageal repair. Esophagography with water-soluble contrast showed no leak after surgery, but the lumen of the esophagus at C4–C6 was increased in diameter with diminished compliance. Removed plates, screws, and tissue were cultured and grew Streptococcus milleri. The patient was treated with oral amoxicillin 1 g every 8 h and probenecid for 4 months, until a gammagram was negative. Her fatigue, arthralgia, rash, and livedo reticularis as well as dysphagia disappeared. Her acute-phase reactants normalized.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1497_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1497_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9152c2a954061ffbf4887958b641beba715687f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1497_en.txt
@@ -0,0 +1 @@
+A 49-year-old man was hospitalized due to pleuropneumonia. Transthoracic echocardiography in parasternal and modified apical view showed a markedly dilated coronary sinus . There was no evidence of valvular heart disease and diameters of cardiac chambers were within normal limits. Systolic and diastolic function of the left ventricle and estimated pulmonary systolic pressure were in normal range. All pulmonary veins drained into the left atrium. In order to reveal the cause of coronary sinus dilation an agitated saline injection was given into the left antecubital vein. The contrast entered first into the coronary sinus and subsequently appeared in the right atrium. Similarly, when the saline injection was given into the right antecubital vein, the contrast agent appeared first in the dilated coronary sinus and thereafter entered into the right atrium . Transesophageal echocardiography showed absence of right SVC, presence of left SVC at lateral border of left atrium and no evidence of any other structural abnormalities of the heart and great thoracic vessels . An upper venous digital subtraction cavography confirmed the absence of the right SVC and the presence of persistent left SVC . Surface electrocardiogram and laboratory exams were within normal limits. Abdominal sonography verified normal position and structure of visceral organs.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_149_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_149_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c08b54892a7e306a10118dce73520afe49e88884
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_149_en.txt
@@ -0,0 +1,5 @@
+We report the case of a 46-year-old female non-smoker without medical history of interest, who had been working in a cosmetics packaging company for 20 years. She had undergone daily exposure to several substances including a red azo dye known as Sudan red.
+Over the past 15 years, the patient had experienced dyspnea, dry cough, occasional wheezing, facial edema, rhinitis and conjunctivitis. These symptoms had worsened in the last 3 years; she had frequently required emergency-room assistance for acute episodes of bronchospasm and had been admitted to hospital on four times. The patient’s symptoms responded to inhaled long acting beta-2 agonist and inhaled corticosteroids, and were clearly work-related since they improved on weekends, during vacations, and after she finally left her job.
+Physical examination and chest radiograph were normal. Blood tests showed eosinophilia (500 cells/mm3) and increased total serum IgE (846 KU/L). Lung function study revealed an obstructive ventilatory pattern with a forced vital capacity (FVC) of 3.14 L (91%), a forced expiratory volume in one second (FEV1) of 2.12 L (76%) and FEV1/FVC of 67%. Methacholine challenge test was positive, with a PC20 of 0.85 mg/mL and a fractional exhaled nitric oxide test (FENO) of 47.2 ppb.
+With a suspected diagnosis of OA, the patient underwent a specific inhalation challenge (SIC) with the azoic dye, in accordance with the recommendations in the European Respiratory Society guidelines . The patient was exposed to a mixture of 2 g of “Sudan Red” and 100 g of lactose powder, tipped from one tray to another 30 cm away from her face for 10 min; she continued treatment with inhaled long acting beta-2 agonist and inhaled corticosteroids due to the persistence of bronchospasm. During the procedure, she suffered dyspnea and cough, and experienced a dual positive response with a fall in FEV1 of 22% in the first 20 min and another of 33% approximately 10 h after the exposure. No significant changes in FEV1 were observed in response to a control challenge of lactose powder alone conducted on a separate day .
+Induced sputum samples were obtained previously and in the 24 h following the procedure, with a rise in the percentage of eosinophils from 10 to 65%. Methacholine and FENO tests did not present significant variations from the results obtained prior to the SIC. The diagnosis of OA due to Sudan Red was established, and the patient was advised to avoid the causal agent.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1521_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1521_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4184df22117900fb66cbb529d5a8d7342d97e652
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1521_en.txt
@@ -0,0 +1,2 @@
+A 56-year old woman presented with chronic back pain. No history of trauma and no other associated symptoms. Patient’s personal and family medical histories did not show positive signs and symptoms of any splenic pathology. Physical examination likewise did not show any palpable splenic mass or splenomegaly. Laboratory workup was within the normal limits. She underwent thoracolumbar MRI to investigate her chronic back pain which incidentally showed 5 cm splenic mass which appeared hyperintense on T1-weighted images .
+She was admitted in our institution and was subsequently prepared for laparoscopic splenectomy. Preoperative cardiopulmonary screening did not reveal any significant comorbidities. She had previous immunization as per established protocols for elective splenectomy. On surgery under general anesthesia, she was positioned in right lateral semi-decubitus position. A 10 mm Hasson trocar was inserted through the left periumbilical area followed by CO2 insufflation. Three more trocars (10 mm, two 5 mm trocars) were inserted at the left subcostal area. Abdominal inspection was done. Splenic artery and vein were identified and doubly ligated and clipped. Afterwards, splenocolic, lienorenal and phrenicosplenic ligaments were dissected and proceeded with ligation of the short gastric vessels. The spleen was then extracted. Grossly, the spleen was enlarged to 6 × 4 × 10 cm (A and 2B) and weighed 380 g with well-defined 3.8 × 3.2 × 4.2 cm mass predominantly cysts measuring less than 5 mm in diameters and containing serous and mucinous fluid. No solid or complex areas were identified. The rest of the splenic parenchyma is normal. Perioperative course was uneventful and the chronic back pain resolved. Final histopathological result was splenic lymphangioma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1549_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1549_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9e0c0ae67de432b6fa0192007c8e2307e4d03091
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1549_en.txt
@@ -0,0 +1,16 @@
+On July 24, 2022, a 4-year-old pregnant Simmental beef cow (approximately 600 kg, 268 days gestation) stopped eating and had not drunk water for 8 days. The cow was not producing any feces despite being given 1 kg of sodium sulfate and 8 l of vegetable oil twice.
+Primary symptoms
+The affected cow had an increased abdominal circumference , was dehydrated (as evident by the recession of the eyes in the orbits and skin tent duration >2 seconds), and transabdominal palpation revealed a large accumulation of fluid in the rumen. The cow had a body temperature of 39.4°C, respiration rate of 42 breaths/minute, and heart rate of 74 beats/minute. The left 1–3 ribs had high-pitched “pinging” based on auscult ation and percussion. The right abomasum area was enlarged , which was hard and clearly defined on palpation. On rectal examination, the intestine was found to be empty, the intestinal wall was dry, and a small amount of black sticky feces was attached to the rectum . The fetus was confirmed to be alive by the rectal touch of the uterus.
+Laboratory examination
+Blood routine examination showed an elevated white blood cell count of 18.4 × 109/l (reference range: 4.9–12.0 × 109/l) and neutrophil count of 9.6 × 109/l (reference range: 1.8–6.3 × 109/l). There were also marked increases in the number of red blood cells (10.8 × 1012/l; reference range: 5.1–7.6 × 1012/l), hemoglobin content (154 g/l; reference range: 85–122 g/l), and hematocrit (0.75 l/l; reference range: 0.22–0.33 l/l).
+Biochemical results showed reduced potassium ions (3.2 mmol/l; reference range: 3.9–5.8 mmol/l), chloride ions (88 mmol/l; reference range: 95–110 mmol/l), and calcium ions (2.0 mmol/l; reference range: 2.43–3.10 mmol/l), with elevated creatinine (384.46 μmol/l; reference range: 88–175 μmol/l), urea nitrogen (28.2 mmol/l; reference range: 2.0–9.6 mmol/l), total bilirubin (19.23 μmol/l; reference range: 0.17–8.55 μmol/l), and γ-glutamyltransferase (29.7 U/l; reference range: 6.1–17.4 U/l).
+X-ray examination revealed a metallic foreign body in the reticulum . The rumen fluid pH was approximately 8.5. Based on the above results, the cow was diagnosed with TR and AI. Based on previous reports , the diagnosis of TR can be confirmed by foreign body tests and X-ray examination. However, the differential diagnoses include forestomach atony (FA), rumen obstruction (RO), omasal obstruction (OO), left displaced abomasum (LDA), abomasal torsion (AT), and intestinal obstruction (IO) .
+Treatment plan
+Both TR and AI were treated surgically. To save the fetus, a cesarean section was performed on the cow before the two operations were carried out. Medication was administered 3 hours before surgery to correct the dehydration, electrolyte disturbances (hypokalemia, hypocalcemia, and hypochloremia), and acid-base disturbances (metabolic alkalosis). describes the specific treatment plan in the present case.
+Antibiotics and anti-inflammatory agents were administered in the following preoperative injections: (i) 500 ml Ringer’s solution, 5 mg vitamin C, and 50 ml of 10% potassium chloride; (ii) 100 ml of 10% glucose and 500 ml of 10% calcium gluconate; and (iii) 500 ml of 5% glucose and 5 g ampicillin, each as a one-time intravenous injection; and (iv) 0.3 g meloxicam as a one-time intramuscular injection.
+Before surgery, the accumulated fluid in the rumen was extracted by inserting a gastric tube via the oral cavity, further relieving the abdominal pressure. After local-infiltration anesthesia with a 0.5% procaine solution, an incision was made in the middle of the paralumbar fossa in the lef t flank to open the abdominal cavity. Intraperitoneal exploration rev ealed that the wall of the reticulum had adhered to the diaphragm, although no inflammatory purulent exudate from the abdomen. The omasum was found to be approximately 0.5 times larger than normal and located in a more ventral position than normal. The volume of the abomasum was approximately 5–7 times normal and was very firm on palpation. The bowel was empty and the fetu s was active. The cesarean section was then performed. Part of the uterus was pulled out at the incision, the uterus was cut open, and the fetus was removed. The uterus was then sutured. Subsequently, the rumen was cut open and the wire attached to the wall of the reticulum was removed. The rumen was then sutured.
+The abomasum was cut open to eva cuate its contents. Xylazine hydrochloride (60 mg) w as injected intramuscularly to sedate the cow while lying down on the left side. After administering local-infilt ration anesthesia using a 0.5% procaine solution around the right lower abdominal wall in the abomasum region, the surgical incision was sele cted at the location where the AI was the hardest and made contact with the body surface. The feed material was removed a nd the abomasum was sutured. It is worth noting that we apply a slightly different approach for suturing the rumen, abomasum, and uterus from the traditional method. In particular, continuous spiral sutures were made on the mucosa of the uterus, and on the mucosa and submucosa of the rumen and abomasum with thinner polyglycolic acid (PGA) sutures (USP: 2–0), followed by continuous spiral sutures throughout the layer with thicker PGA sutures (USP: 0). Finally, cushing sutures were made with the same thicker PGA suture.
+Postoperative treatment was provided for 5 days, including (i) 2 l Ringer’s solution, 5 g vitamin C, and 50 ml 10% potassium chloride; (ii) 1 l 10% glucose and 300 ml 10% calcium gluconate; (iii) 500 ml 10% concentrated sodium chloride; (iv) 500 ml 5% glucose and 5 g ampicillin; (v) 500 ml normal saline and 600 mg ranitidine, each as a single intravenous injection once per day; (vi) 20 mg neostigmine methylsulfate as a single subcutaneous injection twice a day; (vii) 20 ml compound vitamin B as a single intramuscular injection twice a day; and (viii) 100 IU of oxytocin as a single intramuscular injection once a day.
+On the seco nd day after the surgery, the cow began to ruminate, had an appetite, was in good spirits, and passed a large amount of black mucous feces. The cow fed on 3 kg hay and 2 kg concentrate. On the third and fourth days after surgery, feed intake increased, with 7 kg hay and approximately 5 kg concentrate consumed. On the fifth day, the fetal coat was completely excreted, but the feed intake decreased, the number of ruminations was reduced, the rumen peristalsis was weakened, and only a small amount of feces was excreted. On the sixth day after surgery, the cow began to drink a substantial amount of water, the abdominal circumference increased, rumination stopped, only a small amount of hay was eaten, and no excrement was observed. With rumen effusion, the high-pitched “pinging” could be heard by auscultation of the left side of ribs 1–3 with percussion, and palpation of the genuine stomach area was slightly hard. Therefore, we suspected that the abomasum had become obstructed again.
+Routine blood examination showed an elevated white blood cell count of 14.5 × 109 and neutrophil count of 7.2 × 109/l, whereas no obvious abnormalities were found in biochemical parameters. On the eighth and ninth days after the operation, Zeng Ye Cheng Qi Tang (a traditional Chinese medicine powder consisting of 300 g rhubarb, 600 g mirabilite, 60 g Magnolia officinalis, 80 g Fructus aurantii immaturus, 120 g Scrophularia ningpoensis, 120 g Ophiopogon japonicus, 120 g Rehmannia glutinosa, 150 g areca nut, 60 g Aucklandia, and 200 g Raphanus seed) was administered, which is often used to treat ruminal impaction and IO, along with 1 l of vegetable oil. The abomasum area was massaged at the same time as the administration of the formulation (1 hour each time, three times/day). Furthermore, a subcutaneous injection of 10 mg neostigmine was administered four times/day. The cow was fed hay only (2 kg a day) and concentrate feed was stopped. As of the 11th day, the ruminant returned to normal, feed intake gradually increased, the rumen and abomasum peristaltic sound was enhanced as detected by auscultation, and normal defecation was observed. The amount of hay fed daily was gradually increased (but not more than 10 kg). After continued observation for 5 days, all indices of the diseased cow returned to normal . After 120 days, the cow made a full recovery and became pregnant again. The calf born by cesarean section is in good health .
+The animal study was reviewed and approved by the College of Animal Science and Technology, Chongqing Three Gorges Vocational College. Written informed consent was obtained from the owners for the participation of their animals in this study.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1575_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1575_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18dfa0b1678a7161997288d3eead52ab03afe1c6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1575_en.txt
@@ -0,0 +1 @@
+An 81-year-old Lithuanian woman was tested for faecal occult blood during preventive colorectal cancer screening. Test results were positive and she underwent a colonoscopy. The colonoscopy revealed a tumour in her caecum. Abdominal and thoracic computed tomography (CT) scanning revealed no metastasis. She then underwent elective surgery. During the operation, a 6×5cm tumour was found in her caecum. Her MD was found 40cm from the hepatoduodenal ligament . A right hemicolectomy was performed to excise the MD from her jejunal loop. After the operation, she underwent chemotherapy. There were no complications related to the surgery. Histological results showed a poorly differentiated G3 adenocarcinoma of the caecum. In her small intestine a muscular layer of excised MD and mesenteric adipose tissue was found, which was pancreatic tissue morphologically. Microscopic analysis revealed pancreatic tissue without islets of Langerhans in the small intestine and mesenteric adipose tissue. Moreover, in the HP tissue, dilatation of the pancreatic ducts was observed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1594_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1594_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d028ec8cbde44741ec8aeb5b23fe63d258400ff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1594_en.txt
@@ -0,0 +1,3 @@
+A 53-year-old Caucasian man with FD presented to our cardiology department for regular follow-up. He reported symptomatic ventricular extrasystoles with palpitations for over ten years while he has been in good physical shape. Moreover, he complained of pain and cramps in the lower limbs. In the past, he had two operations (retractile testicles, operation of his knee), but denied further comorbidities. The family history for FD was negative. The physical examination revealed an arrhythmic pulse and a mild atrial hypertension. The ECG showed a shortened PendQ interval, i. e. PQ interval minus P-wave, of 40 ms and negative T-waves . The echocardiographic examination presented LVH about 15 mm and a mildly reduced global longitudinal strain (, Video 1). The left ventricular ejection fraction was in a normal range and no valvular damage was observed. N-terminal prohormone of brain natriuretic peptide (NT-proBNP) was mildly elevated (160 ng/L, normal range <121 ng/L).
+FD was suspected in 2018 after performing a CMR. The CMR presented LVH [left ventricular mass (LVM) 146 g] and short T1 relaxation time, which is indicative of sphingolipid storage in an early FD. Moreover, it showed prolonged T1 time with an intramural hyperenhancement in the inferolateral wall in late enhancement sequences as a sign for fibrosis (, Video 2). Biochemical testing revealed a reduced GLA activity [<2.8 µmol/L/h (limit of quantification), normal range ≥15.3 µmol/L/h] and an increased concentration of lyso-globotriaosylceramide (lyso-Gb3, 20.0 ng/mL, normal range ≤1.8 ng/mL). The diagnosis was confirmed by a hemizygous pathogenetic mutation in exon 6 of the GLA gene [c.902G>A, p.(Arg301Gln)]. Afterwards, the patient was admitted to the Department of Nephrology to evaluate organ involvement in a multidisciplinary approach. Arterial hypertension was treated with an angiotensin receptor blocker. Kidney biopsy was performed due to unclear aetiology of proteinuria in the presence of arterial hypertension. It showed ‘zebra bodies’ and vacuoles in podocytes as a renal involvement of FD. Neurological examination detected bilateral carpal tunnel syndrome and cerebrovascular magnetic resonance showed microbleeds and white matter lesions. According to the detected mutation, an ERT with Agalsidase Beta was started in 2018. The patient presented regularly for follow-up examinations in our Fabry Centrum (CeRKiD). In 2019, CMR detected increased T1 relaxation time (1079 ms in 2019 vs. 1060 ms in 2018) and reduced LVM (−14 g) and, in 2020, lyso-Gb3 concentration decreased to a level of 9 ng/mL.
+In retrospective analysis, ECG characteristics of FD have already been present in 2008 and progressed over time . In particular, the first ECG (2008) showed a sinus rhythm with a PendQ interval of 40 ms, a PQ interval of 160 ms, a QT interval of 360 ms, and negative T-waves in II, III, aVF, V5, and V6. ST elevations were present in V1-V4 with a maximum of 0.2 mV in V2 and V3. Seven years later, the ECG showed additional negative T-waves in I and V4. The duration of the PQ interval remained stable over time while PendQ decreased. The ECG findings correlated well with echocardiographic measurements. While the diameter of the interventricular septum was constant with 15-16mm, the posterior wall exhibited an increasing thickness from 11 mm (2008) to 14 mm (2018, before ERT) and up to 15 mm (2020, two years after ERT was started). In addition, in 2020, lateral and posterior longitudinal left ventricular function was reduced.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_163_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_163_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2cae06bb4d7f3825b8853d89436f9135be81e07a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_163_en.txt
@@ -0,0 +1 @@
+A 43-year-old man, who had undergone hemodialysis therapy for chronic renal failure owing to diabetic nephropathy for 6 years and whose blood pressure had been under control (<140/80 mmHg), developed mild elevation of blood pressure (150/100 mmHg) for 2 weeks. He has not been treated with immunosuppressant agents. He suddenly showed weakness in both of his legs, and he realized that he had postural instability and that he could not walk. Subsequently, his consciousness level deteriorated. On admission, his blood pressure was 156/96 mmHg. Neurological examination showed a Glasgow Coma Scale of 14(E3V5M6). His facial expression was flat and his voice was barely audible. He had paraparesis in both lower limbs. Brain MRI demonstrated hyperintense lesions in the bilateral basal ganglia, bilateral frontal cortices, and left cerebellum on FLAIR images, and those lesions were hyperintensity on DWI and ADC maps . No arterial stenosis on MR angiography was found . He was treated with anti-hypertensive agents and continued hemodialysis therapy, and his blood pressure were controlled to 130/70 mmHg within 2 weeks. On the 7th day after admission, disturbance of consciousness and paraparesis improved, and he could walk by himself. However, we noticed that he showed parkinsonian signs including FOG, bradykinesia, and postural instability. His FOG fulfilled the criteria of “brief, episodic absence or marked reduction of forward progression of the feet despite the intention to walk” based on the 2010 workshop of clinicians and scientists interested in FOG . The score from part III of the Unified Parkinson’s Disease Rating Scale (UPDRS) was 28 points. He did not show cerebellar ataxia. Concurrently, MRI showed hyperintense basal ganglionic lesions on FLAIR images, DWI, and ADC maps persisted, although lesions on bilateral frontal cortices were diminished . His FOG and postural instability gradually improved, and UPDRS part III scores were 22 and 5 points at 2 and 4 weeks after admission, respectively. Follow-up MRI at 4 weeks after admission showed significant alleviation of the bilateral basal ganglionic lesions on FLAIR . Thus, he was diagnosed as PRES based on the acute transient neurological symptoms and MRI findings. He was treated with 150 mg of amantadine, and a combination of 300 mg of levodopa and 30 mg of carbidopa at 15th and 22st day after admission for 7 days, respectively, but he did not show dramatic improvement of FOG. Thereafter, those anti-parkinsonian drugs were discontinued.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1686_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1686_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f42b9d9ee1b1ce33f5fdd22b324de2bbe0fe30f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1686_en.txt
@@ -0,0 +1,3 @@
+A healthy, nonimmunocompromised 43-year-old female with bilateral lower extremity radiculopathy had a fluoroscopically guided percutaneous ozone treatment for degenerative lumbar disc disease . Three months later, she presented with severe back pain (VAS 9/10), bilateral lower extremity radiculopathy (leg VAS-7/10), and a partial right-sided foot drop. The C-reactive protein (CRP 27 mg/dl) and erythrocyte sedimentation rate (ESR 58 mm/h) rates were both elevated, the leukocyte count was at 7.03 thous/ul with 2100 lymphocytes; and she was also anemic (hemoglobin 11.7g/dl).
+The repeat MR of the lumbar spine demonstrated L4–L5 spondylodiscitis with paradiscal erosion consistent with a tubercular type of infection [ and ]. The patient underwent a L4–L5 transforaminal lumbar interbody fusion , with soft-tissue debridement; the purulent/ infected epidural tissues were sent for bacterial, fungal, and tubercular cultures. The rapid AFB cultures showed MA.
+The patient was discharged on intravenous cefoperazone- sulbactam 1.5 g twice daily. She, however, returned after 6 weeks with a fluid collection in the wound, and the CRP and ESR studies remained elevated. The wound was debrided and then she was discharged on intravenous amikacin 500 mg (intravenously) twice daily for 6 weeks, supplemented with oral clarithromycin 500 mg twice daily. Subsequently, she was continued on oral clarithromycin for another 6 weeks following resolution of the primary infection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1689_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1689_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..145c2fe5a68e55e16be70a84ece699b508efcdb8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1689_en.txt
@@ -0,0 +1,4 @@
+A 23-year-old male patient came to the emergency department at Universitas Airlangga Hospital presenting fever, anosmia, headache, and nausea 5 days before. He was diagnosed with COVID-19, confirmed by the RT-PCR amplification of SARS-CoV-2 virus nucleic acid on a nasopharyngeal swab. The patient had abnormal laboratory findings, such as lymphopenia, neutrophilia, thrombocytopenia, and high CRP, with a normal chest X-ray . The patient was treated with Favipiravir at 1600 mg per 12 h on day 1, then 600 mg per 12 h on day 2-day 5, intravenous drip of paracetamol 1000 mg every 8 h, oral vitamin C 500 mg per 8 h, and oral vitamin D 1000 IU per day according to Indonesian national COVID-19 treatment guidelines. After 10 days of treatment, the patient was still PCR positive despite no complaints. He was then discharged to continue self-quarantine at home.
+He returned to the hospital two weeks later with general weakness and fever. The fever did not resolve during his self-quarantine, was raised intermittently every 2 days, and was marked by a chilling-fever-sweating cycle. The fever temperature measured was around 39.7°–40 °C. The fever improved when the patient took paracetamol, but the fever returned 6 h later. The fever was accompanied by malaise and muscle pain. The next day the patient was fever-free and able to carry out his daily activities. The physical examination revealed a body temperature of 38 °C, a blood pressure of 112/72 mmHg, a heart rate of 93 bpm, a respiratory rate of 20 breaths/minute, and oxygen saturation of 98% under ambient air. The patient weighs 65 kg with a height of 170 cm (BMI 22.5 kg/m2). Other physical examinations were normal.
+The laboratory results reflected a white blood cell count of 8750/µL with 76.3% neutrophils, 13.5% lymphocytes, and 0.6% eosinophils. Haemoglobin level and platelet counts were 12.2 g/dL and 231,000/µL, respectively. CRP and D-dimer levels were 41.51 mg/L and 9.52 mg/L, respectively. Serum electrolytes and renal function tests were normal, with urea and creatinine serum 6 mg/dL and 0.4 mg/dL, respectively. The liver enzymes test was normal, with ALT being 14 IU/L and AST being 25 IU/L. Electrocardiography showed normal sinus rhythm and axis. The chest X-ray was unremarkable . The RT-PCR amplification of the SARS-CoV-2 virus nucleic acid test from the nasopharyngeal swab was still positive.
+From the previous history, he said that he traveled to Timika District, Papua, for office work for the last 2 years. In May 2021, the patient was infected with P vivax, with initial symptoms including fever, dizziness, nausea, and muscle pain. The patient was treated until declared fully cured. A laboratory test for malaria was performed. The rapid malaria test was positive for PAN antigen, and microscopic diagnosis on blood smear revealed Plasmodium vivax on ring form, trophozoite, and gametocyte stage . Based on anamnesis, physical examination, and laboratory results, the patient was diagnosed with confirmed COVID-19 with hypercoagulopathy and malaria vivax relapse . According to Indonesian National Guidelines for Antimalarial Treatment , he was treated with dihydroartemisinin-piperaquine (DHP) 4 tablets per day for 3 days and primaquine 2 tablets per day for 14 days. The G6PD status was not tested. The patient was given an intravenous drip of paracetamol 1000 mg every 8 h and a subcutaneous injection of heparin 5000 IU every 12 h during treatment. After six days of treatment, the patient had no complaints, and the results of laboratory tests had improved. The patient was discharged from the hospital, continued self-isolation at home, and followed up with the internal medicine outpatient clinic two weeks later. Furthermore, the patient was called later and reported feeling healthy with no complaints.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1691_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1691_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..50549a8e493080be8230244707d44eaa5733c42a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1691_en.txt
@@ -0,0 +1,4 @@
+A 75-year old Caucasian man with a long-standing history of tophaceous gout and several recurrent episodes of arthritis during the past five years presented with a large, painful, ulcerated tophus located on the first metatarsophalangeal joint of his left foot to our emergency department. He had intentionally interrupted treatment with allopurinol four months previously; however, he did not report any recent deviations from his standard diet, any alcohol abuse or diuretic treatment. Five days before presenting to the emergency department, a tophus on the first toe of his left foot had become painful, red and swollen. He tried a course of non-steroidal anti-inflammatory drugs (NSAIDs) without improvement. Ten hours before seeking medical assistance, the tophus burst releasing a viscous, chalk-like material.
+On physical examination he had a mild fever of 37.8°C. A greyish, voluminous and ulcerated nodule containing chalky material was located on the first metatarsophalangeal joint of his left foot . Further examination revealed multiple other tophi overlying the first and second metacarpophalangeal joints of his left hand and the interphalangeal joints of his right hand , wrists, elbows , ankles, interphalangeal and metatarsophalangeal joints of the feet and heels . Two smaller ulcerated tophi were also seen on the fingertip of the left thumb and over the first interphalangeal joint of the right foot. Many joints were also deformed. The first metatarsophalangeal joint of his left foot was totally nonfunctional.
+Laboratory workup revealed leukocytosis (14.524/mm3), elevated C-reactive protein (7.21 mg/dl) and elevated serum uric acid (14 mg/dl). Radiographs of the foot showed soft tissue swelling and total destruction of the first metatarsophalangeal joint . Moderate periarticular alterations were also observed in the other joints of the foot. Cultures from the ulcerated tophus were negative. Antibiotic treatment with ciprofloxacin (800 mg/day) and intravenous administration of NSAIDs (lornoxicam 16 mg/day) was initiated.
+Due to the extraordinary size of the ulcer and the complete destruction of the underlying joint, amputation of the left foot was considered. However, before resorting to this solution, a surgical debridement with lavage of the joint was performed. Debridement was also performed on the minor ulcers. Five days after admission treatment with allopurinol (300 mg/day) was initiated. The patient improved clinically and was discharged two days later. For the next 33 days foam silver-containing wound dressing (CELLOSORB® Ag) and heterologous lyophilized collagen (BIOPAD®, equine collagen) were used on the largest of the three ulcers, on an outpatient basis, while efforts were made to keep serum uric acid levels within normal limits. All three ulcers healed completely within eight, 10 and 40 days after initial presentation, respectively . Six months after treatment, he remains symptom free, although he still refuses to comply with the prescribed uric acid lowering regimen and rejects any further surgical intervention.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1696_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1696_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3d778399798aa71b9be94f9887120179774799c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1696_en.txt
@@ -0,0 +1,7 @@
+A 52-year-old female developed mandibular sensory paresthesia and pain after 3 mo of lurasidone administration, without orofacial dyskinesia, hands tremor, limbs rigidity, bradykinesia, axial dystonia, retrocollis, torticollis, or blepharospasm.
+A 52-year-old female had been diagnosed with schizophrenia since April 2001, and was treated with various antipsychotics, including risperidone 1 mg/d, amisulpride 200 mg/d, quetiapine 200 mg/d, ziprasidone 40 mg/d, and clozapine 125 mg/d, with a duration of a few months, respectively. The most long duration of main regimen was olanzapine 10-25 mg daily (June 2013-March 2021), which was fully effective, but was discontinued due to the adverse side effect of weight gain. Consequently, the main regimen was shifted to lurasidone, initiate dose 40 mg/d then up titration to 120 mg/d since March 2021. However, she developed mandibular sensory paresthesia and pain after 3 mo of lurasidone administration, without orofacial dyskinesia, hands tremor, limbs rigidity, bradykinesia, axial dystonia, retrocollis, torticollis, or blepharospasm.
+A 52-year-old female with no history of medical disease, movement disorders or sensory paresthesia had been diagnosed with schizophrenia since April 2001.
+The patient had no developmental delay, and had elementary school education level with poor academic performance. She had introverted personality as premorbid personality and poor interpersonal relationship. She could keep her occupational function as a cleaner since young adult until now. She got married at her 20’s and divorced at her 32’ while she was diagnosed of schizophrenia. The patient denied psychiatric family history.
+We also consulted a dentist to rule out oral infection or other lesions. Both the aforementioned laboratory tests and dental consultation showed negative findings. Due to the defining features, TSS was suspected. Severity was evaluated on the basis of an Extrapyramidal Symptom Rating Scale (ESRS) score of 18 points before we changed antipsychotics to quetiapine monotherapy.
+A series of laboratory tests including complete blood count, liver function, renal function, diabetes mellitus lipid profile, copper, ceruloplasmin, thyroid function, rheumatoid factor, antinuclear antibody, immunoglobulin (Ig)A, IgG, anti-2 glycoprotein 1Ab, anticardiolipin Ab IgG, anticardiolipin Ab IgM. Anti-ENA, a venereal disease research laboratory test, HBs antigen, hepatitis C virus antibody, cryoglobulin identification, a homocysteine test and brain computed tomography (CT), were performed to rule out a secondary organic etiology. We also consulted a dentist to rule out oral infection or other lesion. The aforementioned laboratory tests and dental consultation both showed negative findings.
+The brain CT image and report are demonstrated in Figure . Technique of examination: Axial brain CT with 5 mm section from vertex to skull base without contrast enhancement; normal ventricular size; normal appearance of cerebral fissures, cisterns & sulci; no evidence of intracranial hemorrhage; no midline deviation; no abnormal parenchymal attenuation change; no definite bony fracture; well pneumatization of bilateral mastoid cells; unremarkable of paranasal sinus; symmetrical and smooth contours of nasopharynx; and left frontal scalp swelling. There is no evidence of intracranial hemorrhage.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1700_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1700_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..48491e64ce38c221e598bb812c89882e342d4a9c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1700_en.txt
@@ -0,0 +1,3 @@
+The patient was a 66-year-old Chinese man with a past medical history significant for AF, not on anticoagulation per the patient’s preference, and coronary artery disease (CAD) status post-percutaneous coronary intervention to left anterior descending artery about 1 year ago, currently on aspirin, clopidogrel, and rosuvastatin. He initially presented with 2 days of chest tightness, and acute coronary syndrome was ruled out. He then suddenly developed intermittent and sharp left-sided abdominal pain. Systemic review was negative for fever, chills, nausea, vomiting, diarrhea, or hematuria. He lives in a rural town working as a farmer, and is a current smoker with about 30 pack year smoking history. He denies any alcohol abuse or illicit drug use, and has no known drug allergies. Family history is non-contributory. Current home medications include aspirin (100 mg), clopidogrel (75 mg), rosuvastatin (10 mg), furosemide (20 mg), spironolactone (20 mg), and isosorbide mononitrate (10 mg). No known drug allergies were documented.
+On admission, his vitals were normal, with blood pressure of 100/70 mmHg, heart rate of 68 beats/minute, and oral temperature of 36.3 °C. On examination, his heart rate was irregularly irregular without heart murmurs, jugular venous pressure (JVP) was normal, with no pitting edema in lower extremities. Lungs were clear on auscultation. His abdominal examination was notable for mild tenderness to palpation over the left quadrant without rebound or guarding. Bowel sounds were normal. The rest of the examination was unremarkable.
+Routine laboratory tests showed normal complete blood count, liver function tests, amylase, lipase, and thyroid function tests. Creatinine was normal at 56 μmol/L (normal range, 40–130 μmol/L) with mildly elevated blood urea nitrogen (7.29 mmol/L [normal range, 2.3–7.1 mmol/L]). Urinalysis was negative for proteinuria, infection, and hematuria. Fecal occult blood test was negative. Both lactate dehydrogenase (LDH) and alpha-hydroxybutyrate dehydrogenase (α-HBDH) were elevated (283 U/l [normal range, 135–225 U/l] and 239 U/l [normal range, 76–195 U/l], respectively). Bedside abdominal and renal vascular Doppler ultrasound were normal. Due to persistent abdominal pain of unclear etiology, a contrast-enhanced CT scan was then performed, revealing renal infarction of the left kidney . Coronary (data not shown) and aortic angiograms were negative for coronary stenosis and aortic dissection. Given the CT findings and unresolved abdominal pain, a renal angiogram was performed and showed distal occlusion of both superior and inferior segments of the left renal artery . Next, attention was paid to the left renal artery. Two guide wires were introduced into the left renal superior and inferior segments , and the Pt wire was then passed through the distal end of the occluded superior artery. A 5 × 4 mm thrombus was aspirated by a suction catheter and locally inflated using a Maverick 1.5 × 15 mm balloon, and 0.1 mg nitroglycerin and 1 mg diltiazem were injected through the microcatheter . Blood flow restoration to both superior and inferior segments of the renal artery and vessel potencies were confirmed by angiography after the aforementioned interventions , which is more clearly observed in the amplification of the images for renal angiograms after the surgery compared with before the surgery . Abdominal symptoms resolved 6 hours after the operation. LDH (230 U/L) and α-HBDH (216 U/L) decreased and eventually normalized by postoperative day 5. He was continued on all home medications and started on warfarin post-procedure with an international normalized ratio (INR) goal of 2–3. The patient was discharged on triple therapy with aspirin (100 mg), clopidogrel (75 mg), and warfarin (3.125 mg) for 1 month, followed by clopidogrel and warfarin for a further 6 months. At 6 months follow-up, the patient was symptom-free and renal function remained normal (creatinine 74 μmol/L [normal range, 57–111 μmol/L]). Repeat angiography was not performed at follow-up to avoid additional radiation exposure given low suspicion for persistent or recurrent renal infarction.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1701_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1701_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c39a7a55d1bf8aaf1c16c048caac756288d194d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1701_en.txt
@@ -0,0 +1,4 @@
+A 13-year-old male presented with complaints of painless swelling which was insidious in onset and gradually progressive over the right distal forearm for 3 years. He had multiple bony swelling all over the body which was asymptomatic.
+On examination of the right wrist, there was an ulnar deviation of the wrist, which was passively correctable. The distal radioulnar joint (DRUJ) was unstable. There was a palpable, non-tender, osseous prominence in the distal aspect of the ulna . He had pain on the wrist range of motion and was unable to lift heavy objects. The skin over the affected site was normal with no distal neurovascular deficit. The examination of the ipsilateral elbow and other joints was normal.
+Anteroposterior and lateral radiographs of the right forearm show distal ulnar exostosis approximately 5*2 cm in size which was Type I according to Masada classification ( and ). At the wrist, a negative ulnar variance of 15 mm was observed. There was substantial radial bowing compared to the contralateral side and the length of the ulna was 3 cm shorter.
+The patient was planned for excision of distal ulna osteochondroma through the Volar approach of the ulna . The osteotomy was done at proximal one-third of the ulna and was stabilized with LRS (two-pin above and two-pin below) and gradual ulnar lengthening was done . Deformity of the radius was not corrected as it will itself get remodeled with time ( and ). Postoperatively, the full range of motion of wrist and elbow is present . DRUJ is stable at subsequent follow-up, no additional procedure was done for DRUJ. We are still following up on the patient until skeletal maturity.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1821_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1821_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a74ac94f44e2c78e3fbe904f88d9e2bd09d01559
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1821_en.txt
@@ -0,0 +1,2 @@
+An Asian male, aged 63 years, presented with sudden severe bilateral leg edema. His past medical history included hypertension that was made stable by medication for over 10 years. Abdominal CT showed various lymph node swellings, including in the left subclavian, para-aortic, and intrapelvic regions . Biopsy of the para-aortic lymph node was performed; histopathological findings revealed a poorly differentiated adenocarcinoma . Immunohistochemical staining was positive for AE1/3 , PSA , and negative staining for TTF1 , synaptophysin , and chromogranin A . The patient was referred to our department since such results indicated the primary tumor occurred in the prostate. The serum PSA level of the patient was 20.3 ng/mL. Various serum tumor markers were within normal range, including NSE. MRI of the prostate showed an indistinct hypo-intensity in the left peripheral zone on T2-weighted images with a focal area of diffusion restriction (apparent diffusion co-efficient 0.63 × 10−3 mm2/s; Fig. ), diagnosed as prostate cancer of PI-RADS-v.2 category 4. MRI-fusion ultrasound-guided prostate biopsy showed PCa with a Gleason score of 4 + 3 . The final diagnosis was prostate cancer of stage IV (T2N1M1a) with aggravation in the short term. After informed consent, the patient agreed to be treated with a combination of surgical castration and abiraterone acetate. As a result, his serum PSA quickly decreased to 1.34 ng/mL and adverse events did not occur; all lymph node swellings gradually reduced on CT by 4 months after the initiation of treatment.
+However, 10 months after the initiation of treatment, serum NSE was elevated to 27.4 ng/mL (normal range: 0–10 ng/mL), without elevation of serum PSA. Furthermore, CT revealed multiple liver nodules and bone metastasis in the fourth lumbar vertebra. Pathological findings of the specimen obtained by biopsy of liver tumor, on HE staining, nests of round to polygonal cells with scant cytoplasm and infiltrated necrosis were observed as shown in Figure . The cells were immunohistochemically positive for PSMA , CD56 , synaptophysin , and negative for chromogranin A . Consequently, the patient was diagnosed with t-SNPC, and combination chemotherapy of etoposide and cisplatin was administered. The serum NSE levels quickly decreased to a nadir level of 7.9 ng/mL and metastatic sites uniformly reduced at 3 months after the initiation of chemotherapy; however, those increased after seven cycles of treatment. After informed consent, second-line amrubicin treatment was administered but the reduction in tumor growth was insufficient. FoundationOne® CDx (Foundation Medicine Inc, Cambridge, MA, USA) was used for cancer-related gene profiling of a formalin-fixed paraffin-embedded liver tumor specimen that identified a BRCA2 mutation at H1223fs*9. Considering this result, a PARP inhibitor was promising drug, however, progression of the tumor was very rapid, and finally, the patient died because of cancer-related disseminated intravascular coagulation 10 months after the initiation of first-line chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1838_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1838_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..644d0bca167b5f3cea770dc953141d0707116900
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1838_en.txt
@@ -0,0 +1 @@
+A 29-year-old man was taken to our hospital by ambulance, suffering from severe headache. He had no past medical history and did not take any medication. Head computed tomography (CT) revealed an extensive subarachnoid hemorrhage (SAH) filling basal cisterns, especially the thick hemorrhage in the interhemispheric fissure . CT angiography showed an Acom with fenestration, but no evidence of aneurysm . Three-dimensional-digital subtraction angiography (3D-DSA) demonstrated the fenestration of Acom with a small saccular aneurysm (2 mm) [Figure –]. The aneurysm arose from the inferior limb of the fenestrated segment, and it projected posteriorly [Figure –]. In addition, an accessory ACA arose from the upper limb of the fenestrated segment [Figure and ]. This patient underwent a clipping surgery via an interhemispheric approach. At the operation, we had difficulty in getting a good surgical view for an aneurysm existing behind the Acom, because we could not mobilize the Acom complex enough. Additionally, the surgical dissection behind the Acom complex was interfered by an accessory ACA . The intraoperative premature rupture occurred, and a fenestrated clip was applied to be able to preserve an accessory ACA . Immediately after the clip application, the bleeding from the ruptured aneurysm stopped. The remnant of aneurysm was not identified in the visible range, and then we finished off the operation. Postoperatively, we performed the management of brain swelling and cerebral vasospasm. Unfortunately, the re-rupture from an Acom aneurysm occurred on Day 13 [Figure –]. 3D-DSA demonstrated the recurrence of an aneurysm next to the clip . Cerebral vasospasm became progressively worse under the influence of re-rupture, and the patient died on the same day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_184_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_184_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7f5bd02ab85c954662cc76c07bd22ce8fd3c7a74
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_184_en.txt
@@ -0,0 +1,3 @@
+A 43-year-old male patient presented to the emergency department with a 20-day history of fever, predominantly at nights and headaches. His previous medical history is unremarkable; he only referred to a 20-year history of smoking and denied use of intravenous or recreational drugs, any prior sexually transmitted diseases, or blood transfusions. At presentation, the patient had a blood pressure of 109/75 mmHg, heart rate 87 bpm, respiration rate 24 breaths/minute, temperature 38.5°C, and oxygen saturation of 70% at atmospheric pressure. Physical examination revealed pale skin and mucosa; tongue and soft palate had lesions consistent with oral candidiasis and congestive pharynx. Pulmonary fields revealed decreased sounds without crackles or wheezing and painful hepatomegaly and extremities with hyperchromic nodular lesions on both ankles, suggestive of Kaposi sarcoma. Due to these findings, initial blood tests included HIV serology that came out positive; CBC: Hb 11.1 g/dL, hematocrit 33.8%, WBC 7,100/mm3, lymphocytes 3%, and neutrophils 95%; IgE 788.2 UI/ml; VSG 77 mm/hr; TGO 91 UI/L; TGP 66 UI/L; and DHL 2250 UI/L. Chest X-ray revealed disseminated infiltrates in both lungs. Medical management was initiated with omeprazole, metamizole, and oxygen with nasal prongs 3 L/min. On day 2 of hospitalization, the bronchoscopy fluid examination resulted positive for C. albicans and negative for other pathogenic bacteria and fungi. However, we decided to start dexamethasone 6 mg IV, trimethoprim/sulfamethoxazole 160/800 mg, nebulization with ipratropium, and budesonide due to high suspicion of P. jirovecii infection. On day 3 of hospitalization, HIV infection was confirmed with a viral load of 531,000 copies/ml and CD4+ T-cell count of 11 cells/mm3. Other studies were performed including a PPD (negative test 0 mm) and anticytomegalovirus serology (IgG positive). On day 4 of hospitalization, the infectious disease division started ART with ritonavir/lopinavir, tenofovir, and emtricitabine. During the subsequent days, the patient showed clinical improvement. However, on day 13, his clinical condition declined with progressive dyspnea, severe dysphagia, and abdominal pain. Auscultation showed basal rales in both lungs; a new chest X-ray demonstrated no changes compared with the previous one. New blood tests included CBC: Hb 14.5 g/dl, hematocrit 44%, VCM 90 fL, platelets 284,000 × 103, WBC 18,400/mm3, neutrophils 89%, and lymphocytes 5%. Serum electrolytes, glucose, BUN, and creatinine had no alterations. He developed dysphagia and episodes of oxygen desaturation partially corrected with nasal prongs. On day 19 of hospitalization, due to continuous episodes of low oxygen saturation, a chest CT-scan was ordered , showing generalized lung involvement and mediastinal adenopathy (Video 1 in Supplementary Material ).
+Supplementary Video 1 showed digitalized CT-scan of the thorax in coronal sectioning.
+Later that day, an endoscopy showed chronic reflux esophagitis (Grade D of the Los Angeles Classification System), with ulceration . On day 23 of hospitalization, dyspnea worsened; oxygen supply was administered with continuous positive airway pressure (CPAP). A pulmonary biopsy was performed on day 24, which reported CMV pneumonia ; the patient was transferred to the intensive care unit (ICU) due to persistent hypoxemia and was started on methylprednisolone 500 mg IV (maintained for 2 days) and ganciclovir 500 mg IV, and ART was changed to efavirenz, emtricitabine, and tenofovir, to decrease pill intake (1 pill/day). Intravenous sedation was initiated and oxygen supply was maintained with CPAP. The patient had 2 episodes of heart failure that required management with furosemide and nitroglycerin. He developed fever and respiratory distress with episodes of delirium treated with antipsychotics; we suspected the development of IRIS due to a paradoxical worsening of his condition despite being treated with ART and ganciclovir. Therefore, we started methylprednisolone and thalidomide 100 mg/day for immunosuppression and immunomodulation, respectively. After 17 days in the ICU, the oxygen requirements began to drop and the mental status improved. He remained hemodynamically stable with clinical and radiological improvemt. A new viral load reported 12,800 copies/ml. A new CBC reported hemoglobin 8 g/dL, hematocrit 26.4%, MCV 29 pg., platelets 366,000, WBC 7,400 mm3, neutrophils 86%, and lymphocytes 6%. Patient was discharged from the hospital after 45 days of treatment .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1908_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1908_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6be9b66e0a865886fe2a103512841388f90628b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1908_en.txt
@@ -0,0 +1,2 @@
+A multigravid 31-year-old white woman and her 35-year-old white husband were admitted for pre-pregnancy consulting for their fourth pregnancy. In their first pregnancy, no fetal movement was detected by sonography at the 18th gestational week. Subsequently, three-dimensional ultrasound imaging showed a fetus with cystic kidneys and fusion of the lower limbs, so the pregnancy was terminated by induced abortion. The woman later gave birth to a normal baby at gravida 2, but at 32 weeks of her gravida 3, vaginal delivery following intrauterine fetal death (IUFD) occurred. The physical examination of the stillborn baby showed typical Potter facies and normal upper part of the body with fused lower limbs and two feet. The two feet were fused, and the femur and tibiae with four toes were discriminable. The external genitalia and anal opening were absent, as shown in Fig. . Although the exact type of anomaly cannot be identified in the absence of radiographic findings, it may be classified as type II or III based on the Stocker and Heifetz classification, since the fusion somewhat affects superficial tissue. There was no report of diabetes mellitus (DM) or other anomalies in the mother’s medical history or familial medical history. Moreover, their marriage was non-consanguineous, and the mother had not had exposure to any intrinsic or extrinsic factors (such as teratogenic drug intake) associated with sirenomelia during her pregnancy. Further investigation could not be conducted because the parents refused autopsy.
+Eventually, the follow-up to her fourth pregnancy indicated that she gave birth to a normal baby.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1926_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1926_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8b8ee6ced341f193b4daa908f2046bb64a393eb1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1926_en.txt
@@ -0,0 +1,7 @@
+A 71-year-old man presented with a lengthy history of benign prostatic hypertrophy.
+He was asymptomatic without any hematuria, pain, or other urinary symptoms. The ECOG performance status was 1.
+He had a lengthy history of benign prostatic hypertrophy.
+Height: 6 feet (1.83 m); Weight: 225 lbs (102 kg); Body mass index: 30.5 kg/m2.
+A computed tomography (CT) scan of the abdomen and pelvis showed a 1.8 cm left retroperitoneal lymph node which was concerning for malignancy . There was no evidence of renal pathology. A positron emission tomography/CT revealed intense fluorine-18-deoxyglucose activity in the left retroperitoneal soft tissue nodule adjacent to the medial limb of the left adrenal gland . The standard uptake volume was 12.4.
+A core biopsy was performed under CT guidance of the left para-aortic lymph node. The immunohistochemical stains were strong and diffusely positive for PAX8 and cytokeratin (CK) AE1 and AE3 and negative for prostate-specific antigen (PSA), prostate specific acid phosphatase, Inhibin, and melanocyte antigen related to T-cells-1. Although the primary tumor site was unknown, the morphological and immunohistochemical features were most consistent with CCRCC.
+Restaging studies by bone scan 6 wk later were negative for skeletal metastasis. An abdominal and pelvic CT scan with and without Gadolinium contrast demonstrated a significant increase in size of the hypoenhancing retroperitoneal lymph node (4.3 cm × 4.4 cm compared to 1.8 cm × 2.8 cm 8 mo earlier). A primary lesion in the renal collecting system or ureters was not observed, although the prostate was markedly enlarged and there was diffuse bladder wall thickening.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1965_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1965_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f51c82973507cf28f3ea90c0664a5a8953bee53
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1965_en.txt
@@ -0,0 +1,3 @@
+A 68-year-old man was scheduled for elective coronary artery bypass graft surgery. He had a past history of hypertension, bronchial asthma, cerebral infarction, and myelodysplastic syndrome and has been on hemodialysis because of autosomal dominant polycystic kidney disease. He was alert and preoperative laboratory data were unremarkable except white blood cell count 2.24 × 103/μL, red blood cell count 3.83 × 103/μL, platelet count 9.1× 104/μL, creatinine 4.15 mg/dL, and B-type natriuretic peptide 161.9 pg/mL. Echocardiography demonstrated left ventricular ejection fraction 34%, mild aortic regurgitation, mild aortic stenosis, and mild mitral regurgitation. An IABP catheter (TRANS-RAY®, 7.5 Fr, 34 mL, Getinge AB, Lindholmspiren, Göteborg, Sweden) was inserted via the right femoral artery and connected to the console (Cardiosave® IABP Hybrid, Getinge AB), and circulatory support was started before surgery.
+In the operating room, a radial arterial catheter was inserted and an electrode for monitoring PSI was placed on the forehead in addition to routine monitors. General anesthesia was induced with midazolam 3 mg and remifentanil 0.3 μg/kg/min and was maintained using sevoflurane in an air–oxygen mix after tracheal intubation. PSI value prior to CPB was between 30 and 50. Propofol was continuously infused with a target concentration of 3 μg/mL using an infusion pump (TERUMO TE-371, Diprifuser™, TERUMO, Tokyo, Japan), and heart rate was approximately 60 bpm during CPB. IABP was continuously operated using electrocardiogram-triggered mode (1:1) in order to provide pulsatile flow.
+PSI value was increased from 30 to 50 immediately after starting CPB and remarkably decreased after stopping IABP before partial clamping of the ascending aorta for anastomosis with the saphenous vein . PSI was increased to approximately 70 abruptly after resuming IABP, which did not respond to an increase of infusion rate of propofol and remifentanil and to a bolus administration of fentanyl 100 μg or midazolam 10 mg. PSI values varied between 6 and 88 in accordance with the stopping and restarting of IABP. It decreased to 14 after stopping IABP for hemostasis around the anastomosis and again rapidly increased to 80 corresponding to restart of IABP before weaning from CPB . EEG remained almost electrically silent, mean arterial blood pressure was around 40 mmHg, and rectal temperature was 35.3 °C during CPB with a flow rate of 2.5 L/min. Based on the EEG findings, we were certain that the patient was adequately anesthetized. After weaning the patient from CPB, the PSI value and EEG pattern spontaneously showed sedative status. Postoperatively, there was no evidence of intraoperative awareness, anesthetic drug delivery, or instrument trouble.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1969_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1969_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3d7b4d756d742efa56ace92eb1fe959cc7eebb6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1969_en.txt
@@ -0,0 +1 @@
+An asymptomatic 40-year-old woman presented with gastric wall thickening detected by screening with an upper gastrointestinal series and underwent contrast-enhanced computed tomography (CT), which also revealed an anterior mediastinal mass. She had been diagnosed with asymptomatic SjS at the age of 35, which was overlooked during the initial work-up. She had no medication or smoking history. She had a family history of breast cancer in her mother’s side and rheumatoid arthritis in her father’s side. The laboratory data showed nothing but hypergammaglobulinemia (IgG, 2750 mg/dL; IgA, 625 mg/dL; IgM, 241 mg/dL), and the serum soluble interleukin-2 receptor level was also within the normal limits (362 U/mL). A chest radiograph revealed no abnormalities. An abdominal CT revealed a localized wall thickness measuring 22 mm with enhancement in the middle part of the gastric body on the greater curvature. A well-circumscribed mass with a heterogenous concentration measuring 49 × 22 mm in the anterior mediastinum without any distant metastases and multiple cysts in both lungs were also demonstrated. Magnetic resonance imaging revealed a multilocular mediastinal mass without invasion to the surrounding parenchyma . 18Fluoro-2-deoxyglucose positron emission tomography (FDG-PET) was not performed before the surgery. Suspecting the gastric wall thickness suggested a gastrointestinal stromal tumor or MALT lymphoma, we performed an endoscopic incisional biopsy. The pathological findings showed lymphocytic infiltration without any atypical cells or a light chain restriction between the kappa and lambda chains on immunostaining, consistent with inflammatory changes. We successfully performed a total thymectomy, due to suspecting an anterior mediastinal mass as a thymoma, by a bilateral approach via video-assisted thoracoscopic surgery with carbon dioxide insufflation in a supine position. There were no adhesions around the mass, and it was removed from the surrounding organs without any surgical difficulty . We also performed a wedge resection of the right upper lobe of the lung as a surgical biopsy to rule out lymphangioleiomyomatosis (LAM). The operation time was 187 min with 2 g of total blood loss. The cut surface of the mediastinal tumor exhibited a grayish-white solid mass with multiple cysts. Histopathologically, there was an infiltration of numerous lymphoid cells with lymphoid follicles. Small- to medium-sized atypical lymphoid cells were observed, and some of them exhibited plasmacytoid differentiation . Cytokeratin immunostaining revealed a lymphoepithelial lesion, consistent with infiltration of lymphoid cells into the epithelium. These cells were positive for CD20 and negative for CD3, CD5, and CD10. A light chain restriction positive for kappa and negative for lambda chains was demonstrated. From these findings, we diagnosed the mediastinal mass as a MALT lymphoma. A lung cyst was found to be an emphysematous bulla without any specific histological findings suggesting LAM. The postoperative course was uneventful, and she was discharged home on postoperative day 2. FDG-PET revealed no abnormal FDG uptakes in any organs 1 month later, and she is currently disease-free at 9 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1986_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1986_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..37e314ec887f514d21767d736e3e151a90e3fa27
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1986_en.txt
@@ -0,0 +1,8 @@
+A 46-year-old female patient was admitted to our department on December 12, 2019 due to the presence of abdominal and back pain for 2 d and aggravation of these symptoms for 1 d.
+The patient had no obvious inducement for upper abdominal pain or back pain 2 d before admission. Her discomfort was mainly located in the middle and upper left abdomen, and she exhibited persistent, paroxysmal aggravation; no nausea and vomiting; and no fever and chills. At the outpatient department of our hospital one day prior, after first ruling out angina pectoris, the patient was sent to the Department of Cardiology, where cardiac enzyme analyses, electrocardiograms, and other tests were performed to rule out ischemic heart diseases; next, she went to the emergency department of our hospital to undergo laboratory analyses. Amylase levels were normal and routine blood tests showed normal white blood cells and a haemoglobin (Hb) level of 125 g/L. After symptomatic treatment, the patient’s abdominal pain worsened, and she was admitted to the Department of Gastroenterology.
+The patient reported no history of chronic abdominal pain, upper abdominal murmur, or weight loss during the disease course. She reported a history of “arrhythmia” for 3 years, and no history of hypertension, diabetes, coronary heart disease, etc.; additionally, she had no history of pancreatitis or abdominal trauma and no family history of genetic diseases.
+N/A.
+The patient’s body temperature was 36.8 °C, blood pressure was 120/80 mmHg (1 mmHg = 0.133 kPa), and heart rate was 100 beats/min. She had a face of acute ill, painful expression, clear consciousness, mild pallid eyelid conjunctiva, flat abdomen, tenderness and rebound pain throughout the abdomen, no obvious mass, and no muscle tension. No murmurs were heard in the upper abdomen on inhalation or exhalation.
+The blood test showed that Hb was 88 g/L, liver and kidney function was normal, C-reactive protein was 12 mg/L, and blood and urinary amylase levels were normal.
+Computed tomography (CT) of the abdomen revealed haematomas around the head of the pancreas and retroperitoneum. To further determine the cause of the haematoma, CT and CT angiography (CTA) examinations of the whole abdomen were performed, suggesting a superior mesenteric artery (SMA) mural thrombus , with stenosis of the lumen, local pancreaticoduodenal artery dilation, 1.2 cm wide diameter , uneven thickness , and a haematoma around the head of the pancreas and retroperitoneum. Moreover, an abnormal collateral vessel was formed between the gastroduodenal artery and the SMA. The preliminary diagnosis was “retroperitoneal haemorrhage, PDAA, and SMA mural thrombus”. The cause of bleeding was considered to be PDAA rupture. The blood examination showed an Hb level of 69 g/L, and the red blood cell suspension was used to correct anaemia. Because the patient was critically ill and our hospital has not yet performed coil vascular embolism and interventional therapy, surgical exploration was performed in combination with the above conditions.
+After layer-by-layer laparotomy, the omentum and gastrocolic ligament were dissociated along the greater curvature of the stomach to expose the retroperitoneal hematoma and remove the hematoma adjacent to the duodenum and above the pancreas. The hepatoduodenal ligament was dissected and the gastroduodenal artery isolated. There was active bleeding approximately 1 cm below the branch of the gastroduodenal artery. PDAA rupture was ruled out due to the location of the bleeding. We read the enhanced CT and the CTA films in detail, and found that the initial segments of the celiac artery and SMA were narrow and that the celiac artery origin was V-shaped . In addition, abnormal collateral blood vessels were formed between the arteria gastroduodenalis and the SMA.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1994_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1994_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8e8693782092cd5effc2cda9e2fd795bb248512c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1994_en.txt
@@ -0,0 +1,9 @@
+A 55-year-old man was hospitalized after he discovered a painless perianal mass.
+The patient’s symptoms started 10 d prior to presentation.
+The patient had no relevant previous medical history.
+The patient’s family history was unremarkable.
+A lump approximately 3 cm × 4 cm could be felt in the 7 to 8 o’clock direction of the perianal area.
+After admission to the inpatient ward, laboratory examinations were carried out, which included routine blood tests , routine tests for stool plus occult blood, and tests for liver and kidney function, electrolytes, blood coagulation function, and tumor biomarkers. Preoperative examinations ruled out hepatitis B, hepatitis C, syphilis, and human immunodeficiency virus. All results were within normal ranges.
+Postoperative pathology showed that a lump approximately 8 cm × 6.5 cm × 5 cm with a clear boundary, regional capsule, surface color of gray or taupe, interior color of gray, likely nodules, and mucoid changes in some areas was observed .
+Immunohistochemistry showed that the tumor cells were diffusely and strongly positive for CD34 and vimentin, but negative for CD31, S100, desmin, EMA, SMA, CD117, Dog-1, CK-P, INI1, CD68, CD99, STAT6, β-catenin, HMB45, and ALK (D5F3) . The Ki-67 index was < 1%.
+Ultrasound showed a 7.9 cm × 7.6 cm cystic mass in the 1 to 5 o’clock direction in the knee-chest position. The border was clear with poor entrant sound and rear echo enhancement. Many vascular signals could be detected around the mass .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2002_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2002_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..efeea092fd167c808ed7703aa6cbb3816bc8a3a6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2002_en.txt
@@ -0,0 +1,3 @@
+An 18-year-old man (175 cm, 81 kg) with right hemifacial microsomia was scheduled for double-jaw surgery, correction with distraction osteogenesis, and mandibular anglectomy. Although he had no underlying medical history, he had undergone correction with distraction osteogenesis in 2006. At that time, the patient was classified as Cormack-Lehane grade 4, and oral intubation was performed with FOB. The patient reported a history of sleep apnea and heavy snoring, during the preoperative interview. His mouth opening was about 2.5-finger-breadth and neck extension was normal, during the preoperative physical examination. However, he had severe retrognathia and a class III Mallampati score. The thyromental distance was less than 6 cm. Moreover, an oral panoramic view X-ray showed narrowing of the nasopharyngeal airway, due to severe retrognathia . According to El-Anwar et al. , the mean depth (anteroposterior diameter) of the nasopharynx in normal adults is 21.8 ± 4.6 mm. However, the depth of nasopharynx in our patient was 15.5 mm, which was narrower than usual. We explained the possibility of a difficult airway and informed the patient about the special risks and procedures pertaining to performing an awake intubation procedure. Other preoperative laboratory examinations, chest X-ray, and electrocardiography revealed no abnormalities.
+On the day of surgery, we prepared a Glidescope®; LMA, fiberoptic bronchoscope (Olympus Optical, Japan); a 0.035-inch-thick, 145-cm-long straight-tipped Angio Guidewire (Lunderquist-ring, Cook Critical Care, ); and a high-flow nasal cannula (Optiflow™). Nasotracheal intubation was required to secure space in the oral cavity for surgery; thus, we prepared nasotracheal tubes of various sizes. Non-invasive blood pressure monitoring, electrocardiogram, pulse oximetry, and bispectral index (BIS) measurement were performed in the operating room. The monitor showed an initial blood pressure of 140/84 mmHg, a heart rate of 58 beats/min and room air saturation of 98%. Lidocaine 4% was sprayed onto the tongue and oropharynx for topical anesthesia. Sufficient preoxygenation was provided with Optiflow™, at a flow rate of 20 L/min, to achieve an SpO2 of 100%. We started total intravenous anesthesia (TIVA) with 2% propofol and remifentanil administered at effect-site concentrations of 2.5 µg/ml and 1.5 ng/ml, respectively, with a target-controlled infusion pump. The SpO2 decreased to 96%, soon after the BIS was 42 and the patient fell asleep, but there was no further desaturation, after we raised the flow rate of Optiflow™ to 40 L/min. Since the left nostril was larger than the right nostril, owing to right-sided hemifacial microsomia, we decided to insert the FOB into the left nostril. After guiding the FOB into the left nostril of the patient, it passed into the trachea through the glottis, without any issue. We inserted the 145-cm-long, straight-tipped Angio Guidewire (Lunderquist-ring, Cook Critical Care) into the working channel of the FOB, till we could visualize the entrance of the guidewire into the carina . We carefully removed the FOB and the guidewire remained in position. We also used the Glidescope® to confirm that the guidewire was still within the oral cavity and had passed through the vocal cord, and into the trachea . The exchange catheter (1.6-mm internal diameter [ID], 2.7-mm outer diameter, CAEC, Cook Critical Care) was inserted over the Angio Guidewire and the Angio Guidewire was pulled out. A nasotracheal tube with 6.5 mm ID was advanced carefully over the exchange catheter into the airway without incidence. After removing the exchange catheter, the tracheal tube cuff was inflated, and proper positioning of the ETT was confirmed by auscultating both lungs and by confirming continuous positive end-tidal CO2. The monitor showed a blood pressure of 133/86 mmHg, heart rate of 95 beats/min, an SpO2 of 97%, and a BIS of 50 after intubation. An oxygenation level of 97% or higher was maintained throughout the procedure. After confirming proper intubation, we adjusted the effect-site concentration of propofol and remifentanil to 4.0 µg/ml and 2.5 µg/ml, respectively, and administered 80 mg of rocuronium intravenously. The time required for the administration of intubation to its confirmation was 16 min. The intra and postoperative periods were uneventful.
+After the procedure, we provided a full explanation regarding this case report to the patient and obtained permission for the same.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2005_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2005_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c0a385e879480e4e9561d6c4a65757f10055e5d1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2005_en.txt
@@ -0,0 +1,5 @@
+A 42-year-old Native American female presented to University of South Dakota Sanford Medical Center in December of 2020 after developing numbness, tingling, and a sharp shooting pain in both arms immediately following parathyroidectomy for parathyroid adenoma (S = 0). The numbness, tingling, and pain were worse in the right arm and radiated across the upper back and chest. Medical history was significant for a traumatic SCI caused by a motor vehicle collision at the age of 15. Following her injury, she experienced paralysis of her bilateral lower extremities, classified by the American Spinal Injury Association (ASIA) as an ASIA B injury. Her injury required thoracolumbar stabilization with Harrington rods. She had resulting chronic foot drop and was only able to ambulate with a walker. The patient did not report any history of upper extremity symptoms prior to parathyroidectomy. Examination of the patient was significant for morbid obesity with a body mass index (BMI) of 51. She had decreased temperature and light touch sensation in the upper extremities and neck in dermatomes C3 through T10 with preserved proprioception and vibration sense. Hypocalcemia was suspected as a cause of her paresthesias considering her recent parathyroidectomy, but calcium levels were normal. Cervical magnetic resonance imaging (MRI) 2 days after symptoms onset (S+2 days) demonstrated a T2 signal hyperintense area, just to the right of midline, that extended throughout the length of the central cervical spinal cord, consistent with an expanding syrinx . Thoracic MRI showed the syrinx extended throughout the thoracic spinal cord as well . The reading radiologist initially misread this MRI as longitudinally extensive transverse myelitis. The radiologist specifically reported that they did not believe this was a syrinx because it was located in the lateral aspect of the spinal cord rather than in the central spinal cord canal. There was mild peripheral contrast-enhancement around the syrinx. The patient was hospitalized, and an extensive infectious, autoimmune, and metabolic workup was negative. A working diagnosis of longitudinal extensive transverse myelitis was made, and the patient was treated unsuccessfully with 5 days of intravenous methylprednisolone. Repeat cervical MRI 2 weeks after symptom onset revealed no changes from the previous MRI. Her paresthesias and pain persisted.
+Six months after discharge (S+7 months), the patient presented to our neurology clinic for increasing weakness in the lower extremities, worsening dexterity of her right hand, and more frequent falls. These symptoms had progressed to the point of requiring her to move to an assisted living facility as she was unable to complete her activities of daily livings (ADLs) independently. On examination, there was new pronator drift, decreased right hip flexion strength, and decreased reflexes in the right upper extremity. Based on the patient’s current and previous symptoms along with the previous imaging, we were able to arrive at a diagnosis of PTS, which had previously been missed. Cervical MRI was repeated and showed rostral expansion of the syrinx into the brain stem [ and ]. With the advancement of her symptoms and growth of the syrinx into the brainstem, the patient received an urgent referral to an outside facility for neurosurgical evaluation.
+The consulting neurosurgeon at the outside facility did not believe her condition warranted hospital admission and requested that she be seen on an outpatient basis. Due to a combination of difficulty finding temporary housing for the patient that could provide skilled nursing care, and difficulty working the patient into the neurosurgeon’s schedule, the patient’s care was delayed. She was not seen by the neurosurgeon for another 6 weeks (S+9.5 months). During that time period, the patient became progressively weaker, and had more frequent falls. She also developed a hoarse voice, concerning for vocal cord paralysis, and dysphagia with several episodes of choking.
+On evaluation at the outside facility the evaluating neurosurgeon concluded that the patient’s symptom severity and rapid progression were indications for surgical drainage of the syrinx. The patient was taken to the operating room, and a C7-T2 laminectomy was performed. After removing the C7 through T2 lamina and entering the dura, the cord was noted to be quite dilated, nearly filling the entire dural tube, and was rotated 90° within the dura. A 2 mm hole was made in the dorsal root entry zone of the cord below the C8 nerve root to insert the shunt. The syrinx cavity was encountered at a depth of <1 mm, and the cord immediately deflated after penetration of the syrinx. A syringo-subarachnoid shunt was placed to allow the syrinx to continuously drain. The surgery and immediate postsurgical period were uncomplicated.
+She was discharged back to her previous nursing home 9 days following the operation. The patient was ambulating back at her baseline with a walker. Follow-up 2 months after surgery (S+12 months) noted subjective persistent but not worsened right arm and leg weakness, as well as weakened voice. At this point, the patient was able to complete her ADLs independently although she had assistance at home. It was determined that the surgery stabilized as well as halted the progression of her neurological symptoms but did not reverse them. Cervical MRI 4 months after surgery (S+14 months) showed dramatic reduction in syrinx size, with only a small residual fluid collection, which confirmed that the shunt was patent and functioning . However, thoracic MRI showed possible persistent syringomyelia with slight enlargement compared to previous, which was significantly limited due to hardware artifact . The patient continues to live in a nursing home with assistance with her ADLs and frequent physical therapy. Patient consent and hospital approval were obtained before the writing of this report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2009_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2009_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5c06c2227cc46820c772986408e50342408eb267
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2009_en.txt
@@ -0,0 +1 @@
+A 50-year-old housewife presented in the emergency department of our level 1 trauma center with complaints of pain and immobility of the left hip joint and inability to bear weight forthe past 20 days. She gave a history of bilateral anterior groin pain (left > right) for thepast 4 months. She also had a history of limping, difficulty in sitting cross-legged, and squatting for the same period. The pain was insidious in onset and progressed over time to make her bedridden. On examination, there was tenderness over bilateral hip joints (left > right), external rotation deformity, and 1cm shortening of the left lower limb. Movement of the left hip joint was extremely painful and was not encouraged. There was pain at extremes of motion of the right hip joint. The patient was able to do straight leg raise on the right side but not on the left side. Neurovascular examination was bilaterally unremarkable. The patient had no comorbidities and was not on any long-term medication. There was no history of trauma (trivial or overt), excessive physical activity, or fragility fractures in the past. The patient was postmenopausal for2 years. The patient was actively mobile before the onset of symptoms. She consulted a local practitioner during initial stages of her discomfort who had prescribed her NSAIDs. However, there was no relief and pain progressed to such an extent that she was not able to bear weight. A 20 days earlier anteroposterior pelvis with bilateral hip radiograph showed sclerosis over bilateral inferomedial femoral neck with cortical breach in the right side and an undisplaced complete fracture line over the left side. The neck shaft angle was 130° on the right side and 114° on the left side. Plain radiographs were orderedon presentation which showed a displaced fracture neck of femur on the left side collapsed in varus and sclerosis over inferomedial aspect of the right femoral neck with cortical breach. A computed tomography scan confirmed the X-ray diagnosis . Blood investigations showed a normal calcium profile, Vitamin D, and serum parathyroid hormone levels. DEXA scan showed normal t- and z-scores in hip and spine. Whole spine radiographs revealed no abnormalities. Thus, a diagnosis of bilateral FNSFs was made and the patient was admitted for surgical stabilization. She underwent osteosynthesis with three cannulated screws on the right side and 2 days later underwent total hip arthroplasty for displaced fracture on the left side . Postoperatively, she was allowed full weight-bearing mobilization on the left side and toe touch on the right side. There were no post-operative complications. Radiographs were repeated at 3 weeks, 6 weeks, 3 months, 6 months, and 1 year postoperatively which showed union at the right side with no further varus collapse or implant failure . The left side with hip prosthesis was also normal. At 1-year follow-up, the patient was pain free, able to walk full weight-bearing without support and carry out her daily activities comfortably.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2026_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2026_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..60cdb72d5a982f657eed30d97724a87287367d91
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2026_en.txt
@@ -0,0 +1,2 @@
+We report the case of a 40-year-old Serbian woman who presented after surgery of cleft lip, primary and secondary palate. She was born with palate shisis, lip shisis and nose deformity. She had more surgical interventions in order to take care of cleft palate.
+Patient was admitted to the Aesthetic Education Center Medica Aesthetica in Belgrade, Serbia for aesthetic treatment after surgery. After clinical examination and specifying the desired look with a patient, correcting the application is accessed hyaluronic fillers. Preparing patients included the provision of short-term local infiltrative 2% lidocaine - epinephrine (lidocaine 40 mg/2 ml + epinephrine 0.025 mg/2 ml) plexus anesthesia, local anesthesia terminal branches of the mandibular nerve and disinfection of the operating field. We used a cross-linked hyaluronic acid (sodium hyaluronate) in the form of a gel concentration of 18.5 mg/g with the addition of antioxidants (mannitol) STYLAGE Special Lips, VIVACY laboratories, originating in France. Hyaluronic Filer is a non-animal origin, sterile and non-pyrogenic, physiological pH and osmolality. For injection is used needle 30G thickness, length 13 mm factory packed with hyaluronic fillers. When patients were done soft tissue reconstruction of the oral region, the application of hyaluronic acid injection was administered retrograde linear and bolus technique. We performed a biphasic therapy in the first stage in the zone semimucosis lips is initially carried incision scar tissue. We applied incision fibrous tissue release adhesions. The second stage is placed hyaluronan implant linear retrograde technique and bolus technique whereby the injected 0.33 ml of material. In order to achieve the most natural-looking lips in accordance with the accepted average proportions lips were drawn contours and minimum compensation amount of lip volume of 0.5 ml hyaluronic fillers .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2077_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2077_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..53a4df15f20443b90d126ae1865cfbac0b65a43b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2077_en.txt
@@ -0,0 +1,77 @@
+A seventy-eight year-old man, without previous skin lesions or skin scars
+consistent with tegumentary leishmaniasis (TL), evolved during the last
+year with volume increase in the nasal pyramid to the right side, nasal obstruction,
+epistaxis to manipulation of nasal cavities, crusting and occasional cacosmia. He
+also had 117 mg/dL glucose; 48 mg/dL urea; 1.5 mg/dL creatinine; 78
+mg/dL amylase; 22 U/L AST; 30 U/L ALT; 74 U/L ALP. Systemic
+arterial hypertension was treated with 25 mg/day hydrochlorothiazide 20
+mg/day nifedipine, 2 mg/day doxazosin mesylate, besides 50 mg SOS sodium
+diclofenac, due to chronic muscle pain. He reported bilateral hearing loss for the
+last seven years, but he denied tinnitus, dizziness, noise exposure or family
+history of auditory and/or vestibular symptoms. Otoscopy was normal and the
+endoscopic examination of the upper aero-digestive tract presented infiltration of
+the right nasal wing and the entire mucosa of the right nasal cavity, preventing
+progression of optics. There was also infiltration of the vestibular region,
+anterior nasal septum and head of the left inferior turbinate, with discrete crusts,
+as well as absence of mucosal lesions in the pharynx and larynx. Syphilis and fungal
+serologies were negative. TL serologies performed were: 1:40 indirect
+immunofluorescence technique and ELISA reactor. A nasal biopsy was performed.
+Fragment cultures were negative to Leishmania, mycobacteria and
+fungus. The histopathological examination revealed chronic granulomatous
+inflammation with necrosis. The immunohistochemistry with
+anti-Leishmania serum showed occasional amastigote forms and
+polymerase chain reaction was positive to Leishmania. A
+pre-treatment audiometric study showed mild to severe sensorineural hearing loss,
+tritone mean at 500-1000-2000 Hz of 53dB and 62dB, in the right and left ears,
+respectively. Additionally, he presented bilateral type A tympanogram and
+bilaterally absent distortion product otoacoustic emissions (DPOAE).
+Treatment with meglumine antimoniate (MA) (Glucantime® from
+Sanofi Aventis) was initiated at a maximum daily dose of three ampoules
+(weight 72 kg; dose 16.9 mgSb+5/kg/day) for 30
+days.
+On the twelfth day of treatment, the patient returned with herpes zoster
+in the buttock (dermatome S1) and myalgia, and acyclovir cream, urea cream
+and 50 mg of sodium diclofenac if pain were prescribed. He was asymptomatic from the
+cochlea-vestibular point of view, but presented a 10 dB increase of the auditory
+threshold at 6 kHz and a 15 dB increase at 8 kHz in the left ear (LE). On
+the twenty-sixth day, treatment was discontinued due to cutaneous rash, scaling of
+lower limbs, difficulty in walking, arthralgia, myalgia, hand tremor, dry oral
+mucosa, anorexia and loss of weight (-3 kg). He also presented frequent
+severe rotatory dizziness lasting some minutes with no associated vagal symptoms,
+without worsening of hearing complaints previously reported. VENG was normal and the
+audiometry showed a 20 dB increase at 6 KHz and a 25 dB increase at 8 KHz in the LE.
+He also had 153 mg/dL glucose; 83 mg/dL urea; 322 mg/dL amylase; 181
+U/L AST; 174 U/L ALT; 112 U/L ALP; 175 U/L GGT) and QTc
+0.46. Sixteen days after the treatment was discontinued, he maintained rare
+non-rotatory dizziness lasting seconds, without objective worsening of hearing
+complaints, but with tinnitus, and he had fallen two days before. Pure tone
+audiometry presented severe worsening of LE auditory thresholds (10 dB increase
+at 250 Hz; 10 dB increase at 500 Hz; 15 dB increase at 1 KHz; 25 dB increase at 2
+KHz; 30 dB increase at 3 KHz; 15 dB increase at 6 KHz; and 45 dB increase at 8
+KHz) and VENG was within the normal range, although with reduction of more than
+50% of the previous value of Angular Velocity of the Slow Component of
+Nystagmus in degrees per second (AVSC°/s) at 18 °C. He had
+118 mg/dL glucose; 30 mg/dL urea; 90 mg/dL amylase; 41 U/L AST;
+71 U/L ALT; 155 U/L ALP; 128 U/L GGT) and QTc 0.33. Twenty-eight
+days after treatment interruption, he no longer had tinnitus and dizziness remained
+of mild intensity and lasting seconds. He walked adequately and myalgia and tremors
+had improved. Pure audiometry showed no more increments consistent with ototoxicity
+criterion. He had 110 mg/dL glucose; 1.4 mg/dL creatinine; 105 mg/dL
+amylase; 371 mg/dL lypase; 34 U/L AST; 43 U/L ALT; 115 U/L ALP;
+80 U/L GGT) and QTc 0.33. As the patient still presented mucosa lesions 90
+days after treatment interruption, he was successfully treated with 150 mg/day
+(2.2 mg/kg/day) liposomal amphotericin B, up to an accumulated
+dose of 1800 mg, when it was discontinued due to serum creatinine value of 1.6
+mg/dL, without worsening of hearing and/or dizziness complaints. A year
+and four months later, he did not present worsening of hearing complaints when
+compared to the beginning of treatment with MA, neither tinnitus nor dizziness, and
+the audiometry was not consistent with ototoxicity criterion and VENG was within the
+normal range, with AVSC in the LE at 18 °C returning to values similar to the
+beginning of symptomatology. The DPOAE examination remained absent during the entire
+monitoring. (Pure tone audiometry through air conduction of the left ear of
+a patient during the monitoring process, IPEC, FioCruz, Rio de Janeiro, 2011)
+and 2 (Variations of Angular Velocity of the Slow Component of Nystagmus in
+degrees per second (AVSC °/s) of the patient during the
+monitoring process - IPEC, FioCruz, Rio de Janeiro, 2011) show the variations
+in pure tone audiometry and of the angular velocity of the slow component of
+nystagmus, during the patient's follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2115_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2115_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1011a8bf3c445b72289defc1b3d54db7f757312e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2115_en.txt
@@ -0,0 +1,9 @@
+A 31-year-old Chinese woman was hospitalized because of premature contractions at 27 + 6 wk of gestation.
+The patient had conceived spontaneously, her blood pressure during pregnancy was normal but her serum glucose was found high at 24 wk of gestation. She had been controlling her blood sugar by injecting insulin subcutaneously, along with diet and exercise. She came to our hospital because of the frequent contraction at 27 + 6 wk of gestation.
+The patient (gravida 4, para 2) had no history of coronary heart disease, hypertension, hepatitis or tuberculosis, or food and drug allergies.
+The patient had no history of drug abuse, smoking, or drinking. There was no family history of genetic disease or cancer.
+Body temperature 36.7 °C, pulse rate 86 bpm, blood pressure 121/78 mmHg, respiratory rate 18 per minute, indoor oxygen saturation 99%. Fetal heart rate was 147 bpm.
+Laboratory examinations revealed a white blood cell count of 6.34 × 109/1 (70.1% neutrophils), and an elevated C-reactive protein level of 29.3 mg/L. Liver and kidney function, electrolytes, creatinine, and cholestatic liver enzymes were all within normal limits. Extensive serological tests such as Epstein-Barr virus, cytomegalovirus, rubella, and Coxsackie proved to be negative. Tests for hepatitis B, chlamydial antigens and human immunodeficiency virus were negative, as well as the bacterial culture of skin, blood, urine, and genital lesions.
+Ultrasound: The heart, liver, and kidneys showed no obvious abnormalities.
+Fetal ultrasound: Ultrasound examination at 30 wk of gestation showed a single live fetus of 29 wk and the amniotic fluid was normal.
+Continuous ritodrine (for 5 wk until her skin issues appeared) and indomethacin rectally (6 times) were used to suppress premature labor whereas dexamethasone (twice, 2 d every time) was given to reduce the severity of respiratory distress syndrome and offspring mortality. The patient began to complain of itching and abdominal rash at 32 + 3 wk of gestation, which spread fast to her back and all extremities . After 3 d, a fine maculopapular rash resembling erythema multiforme cover the whole body but over the face, neck, and chest. Her skin condition was diagnosed as allergic dermatitis; therefore, calamine lotion and mometasone furoate cream were topically applied when she was 32 + 6 wk pregnant. She started taking prednisone (20 mg/d) and was advised to terminate the pregnancy if contractions could not be suppressed when she was 33 + 1 wk pregnant. At 33 + 3 wk of pregnancy, erythema and bullous rashes had spread throughout the body and was particularly prominent on the upper limbs, the dorsum of the hands, back, and breech. As the lesions became confluent, hydrocortisone (200 mg/d i.v.) was used. Since starting with the rash, indomethacin and dexamethasone had been no longer used. Due to increased uterine contraction and the patient's refusal to terminate the pregnancy, intravenous ritodrine to prevent preterm delivery was not stopped and the dose of ritodrine had been increased despite the skin rash. At 34 wk of pregnancy, she had been on treatment for 10 d but her condition was progressing; her skin rash on the upper extremities turned dark and gray with small blisters, and the skin of the patient’s elbows became broken, blisters enlarged, and the whole body rashes were accompanied by blisters ; several white spots were seen on the tip of the tongue, and there was obvious pain when eating. After a multidisciplinary team discussion, involving a dermatologist, intensivist, pharmacist, obstetrician, nutritionist, and pediatrician, we considered these phenomena likely to be a severe drug eruption. Intravenous methylprednisolone (60 mg) and immunoglobulin were administered immediately. After a comprehensive analysis of the history of medication, clinical symptoms, and auxiliary inspection, we suspected TEN induced by the ritodrine (Symptoms and treatment of the patient during different periods is listed in Table ).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2117_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2117_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d9a756ee94bf2899406c0972b6a490c5020c1333
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2117_en.txt
@@ -0,0 +1,4 @@
+A 22-year-old Brahmin man presented with complaints of gradual, painless, progressive loss of vision in both eyes for 1 month. It was associated with complaints of headache and dizziness for 1 month. He had a history of multiple painless swellings over his body for the past 1 year. Multiple swellings were present on his face, mandibular area, elbow, arm, and abdomen. His headache was intense on awakening and bending down position. He had a history of fever for 2 days after intake of anti-filariasis medication 1 month back. There was no history of vomiting, unconsciousness, seizures, or change in behavior. He had a history of using tablet amitriptyline 75 mg before sleep for headache for the past 15 days. He was a plumber by occupation. He did not smoke tobacco or drink alcohol; he was not a vegetarian by diet and had a history of eating wild pork meat. There was no significant history of similar illness in his family. There was no significant social and environmental history. On examination he was healthy and well oriented to time, place, and person. His visual acuity was 6/12 in both eyes. Intraocular pressure was 12 mmHg in both eyes. He had multiple small pea-sized nodules which were soft, mobile, non-tender, and well defined; each nodule was approximately 2 × 2 cm. There were no signs of inflammation on his face, mandibular area, elbow, arm, and abdomen .
+His vital signs and systemic examination were normal. He had no neurological deficit. Pupillary reaction was sluggish in both eyes, otherwise the anterior segment was unremarkable. Posterior segment revealed papilledema in both eyes in the form of blurred, elevated disc margin and tortuous dilated vessels. Parapapillary hemorrhage was present in his left eye. The macula was healthy with good foveal reflex .
+Blood reports were hemoglobin 11.5 gm%, neutrophils (N) 55%, lymphocytes (L) 22%, eosinophils (E) 12%, monocytes (M) 1%, erythrocyte sedimentation rate (ESR) 30 mm/first hour, total leukocyte count (TLC) 7800 cells/mm3, and random blood sugar (RBS) 80 mg%. His serology was negative. His urine routine microscopy was normal. Stool routine microscopy showed absence of parasites. A CT scan showed multiple calcified lesions with scolex in cerebellum and brain parenchyma, with multiple sites of edema on left side of parietal area suggestive of neurocysticercosis .
+A physician consultation was done and he was treated with intravenous injection of dexamethasone and the dose was tapered every 3 days: 4 mg dexamethasone intravenously administered thrice daily for 3 days, 2 mg intravenously administered bi-daily for 3 days, and 2 mg intravenously administered once daily for 3 days. Tablet albendazole 400 mg was prescribed bi-daily for 1 month and tablet valproic acid was prescribed 300 mg bi-daily for 1 month. Unfortunately we lost the follow-up of our patient.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2126_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2126_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ee931125d443c3cff7118ec99ef7f139fed6abd8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2126_en.txt
@@ -0,0 +1 @@
+A 23-year-old female presented to our eye clinic with chief complaint of mild blurring of vision in the right eye and inquired about refractive surgery. The patient denied any previous history of ocular inflammation, trauma, surgery, or use of topical or systemic medications. Snellen’s visual acuity in the right eye was 0.05, which was corrected to 0.5 with −3.00 to 2.00 × 15 and from 0.5 in the left eye to 0.8 with plano −0.75 × 170. Intraocular pressure was 14 mm Hg in the right and 14 mm Hg the in left eye. Slit-lamp examination of the right eye anterior segment showed clear cornea, deep and quiet anterior chamber without iris transillumination defects, whereas crystalline lens anterior capsular showed confluent pigment deposits stellate in shape over the pupillary axis. Dilation the of right eye pupil showed no pigment deposits in the peripheral capsule, zonules, or on the posterior lens capsule or anterior hyaloid face (a, c). The examination of the left eye anterior segment was within normal limit before and after dilation. Gonioscopy revealed open angle with mild pigmentation and prominent iris processes of the right eye, whereas left eye showed open angle without remarkable findings . Ophthalmic examination of the posterior segment was normal in both eyes. The patient was reassured and prescribed glasses, and booked for regular follow-up. Following discussion with the patient, she opted to have transepithelial photorefractive keratectomy for the right eye myopic astigmatism which improved her unaided vision to 0.8. Based on her previous ophthalmic history and slit-lamp examination of the right eye, a diagnosis of unilateral congenital lenticular pigmentation was made.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2138_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2138_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9a077fff1f78679e9af26dabb7d659a7cdf5f2e2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2138_en.txt
@@ -0,0 +1,3 @@
+A 69-year-old female referred to the clinic with a painful lump in her left breast 3 months ago. She also complained of bloody discharge from left nipple four years ago.
+Despite recommendations for diagnostic procedure, the patient decided not to follow-up. On physical examination, an erythematous tender mass, owning hard consistency on palpation was detected around the nipple led to further radiological investigations. Sonography showed lobulated hypoecho mass with microcyctic areas measuring 20×17 mm at 3o’clock beside areol . Mammography also showed a hyperdense mass in retroareolar site. The patient was admitted and underwent surgery. According to the intraoperative pathology consultation based on multiple frozen sections from the mass, left modified radical mastectomy and lymph node dissection done.
+The specimen was received in formalin. On serial sectioning, there were tan-brown firm mass with multiple cystic areas. On gross examination, the surgical margins are free from tumoral cells and nipple was retracted . Sections were taken and stained by hematoxylin and eosin. Microscopically, neoplastic tissue was seen, composed of dilated ducts, filling by papillary projections, cribriform and fused glands, lined by mild to moderate atypical cells with scattered mitoses and without distinct, myoepithelial layer mostly floating in mucinous lakes with invasion to surrounding stroma . Foci of ductal carcinoma in situ including cribriform, papillary and micropapillary pattern were present in about 30% of tumor bulk. All surgical margins were free of tumor. Insitu component with papillary feature was seen in nipple. Nearby skin-deep dermis was involved by tumor. All of 16 lymph nodes showed reactive changes. There was no perineural or lymphovascular invasion. Immunohistochemistry profile showed positive estrogen and progesterone receptors and negative for HER2 . The patient was finally discharged with regular follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2145_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2145_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..94a2330805f18fcaa84aebe518b222c46a811727
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2145_en.txt
@@ -0,0 +1 @@
+The patient is a previously healthy 44-year-old man who presented with a painless enlarging mass in his left groin. He was observed initially for three months and eventually was referred for an excisional lymph node biopsy. Histologic examination showed a high-grade malignant neoplasm that was diagnosed as BPDCN. He was then referred to our institution. BM evaluation included a trephine biopsy and aspiration. There was no evidence of BPDCN in BM by morphology or immunohistochemistry. Flow cytometry was also negative for BPDCN in BM. However, conventional cytogenetic analysis performed on the BM aspirate sample showed karyotypic aberrations involving chromosomes 12 and 22, which were further characterized by fluorescence in situ hybridization (FISH) analysis (see details below). The patient was treated with a hyper-CVAD-Bortezomib regimen (hyperfractioned cyclophosphamide, vincristine, doxorubicin, dexamethasone alternating with high dose of methotrexate and cytarabine, plus bortezomib) regimen. He also received prophylactic intrathecal chemotherapy with methotrexate for 3 cycles and achieved a complete remission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_214_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_214_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..004e2552809de3f41a365a7c1ef6e313e601909e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_214_en.txt
@@ -0,0 +1,7 @@
+A 67-year-old male patient was admitted in our department due to a mass in front of the ankle joint for 23 years.
+In 1998, his right foot was accidentally injured by a brick that fell from a height. He developed pain and swelling in the front of his right foot and calf. He went to a local hospital and was diagnosed with a soft tissue infection. The patient developed a hard mass on the right ankle 3 mo after the injury, about the size of an egg, with no limited ankle joint movement. He then went to the local hospital for treatment and surgery was suggested. The patient did not undergo surgery as the mass did not cause obvious pain and did not affect his joint function.
+Three years ago, the patient experienced an accidental sprain of the right ankle with ankle immobility, and was admitted to our department for surgical treatment.
+The patient had no remarkable medical history, no history of hypertension, diabetes, hepatitis, tuberculosis, drugs, or food allergies.
+A lump was seen in front of the dorsum of the right foot and the middle and lower part of the calf, which was obvious on the right dorsum; the right calf was slightly swollen, the skin was slightly translucent, there was no obvious tenderness, and the skin temperature was not elevated. The mass on the right dorsum was approximately 6 cm × 7 cmin size and non-movable, with a hard texture, unclear boundary, unsmooth surface, no obvious tenderness, no obvious boundary with surrounding tissues, and there was no right ankle joint movement. The blood supply, sensation and movement of the extremity were good.
+Routine blood tests showed that C-reactive protein, erythrocyte sedimentation rate, alkaline phosphatase, blood sugar, and blood trioxypurine were normal.
+X-ray showed a bone mass in front of the right tibia. Computed tomography (CT) showed multiple patchy bone masses with uneven bone density in front of the upper segment of the right tibia and the dorsum of the right foot. The edge of the right ankle joint was osteosclerotic with adequate joint space.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2152_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2152_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..092fe777aa2038a860b01448ba4a50a7f1a42d29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2152_en.txt
@@ -0,0 +1,2 @@
+A 27-year-old woman, who had never smoked, presented with a fever persisting for the past two days. The patient had no relevant past medical history or family history. A physical examination revealed left costovertebral angle tenderness and a urinalysis revealed the presence of pyuria. There were no other indications suggestive of an obvious fever source. The diagnosis was pyelonephritis, and intravenous ceftriaxone was administered. An incidental finding on screening chest computed tomography (CT) revealed a 9 mm pulmonary nodule with a round shape and smooth margin in the left upper lobe (A). She reported no weight loss, hemoptysis, or shortness of breath. A three-dimensional CT scan obtained at a 0.63 mm thickness with volume rendering showed that the nodule volume was 425 mm3 (B). Volume rendering was obtained on Aquarius iNtuition 3D workstation (TeraRecon Inc., San Mateo, CA). Based on its radiological features, a benign pulmonary nodule was suspected and a radiographic follow-up was planned. One year later, the nodule enlarged to a maximum diameter of 14 mm (A) with an estimated volume of 1050 mm3 (B). No other pulmonary lesions or lymphadenopathies were observed. Due to the health insurance limitations, positron emission tomography was not accessible. A rapid growth pattern, with an estimated VDT of 249 days calculated using the Schwartz formula, prompted us to consider a malignancy . Transbronchial biopsy was considered non-diagnostic because of the absence of a bronchial connection to the lesion, based on the thin-section CT. A surgical resection was planned for both diagnostic therapeutic purposes. The patient underwent a thoracoscopic lingulectomy successfully and was discharged uneventfully on the fifth postoperative day.
+A histopathological examination revealed that the tumor was composed of a mixture of papillary, sclerotic, and solid patterns. The papillary area showed cores of fibrovascular sclerotic stroma and epithelioid cells lined by cuboidal epithelium. The solid area exhibited sheets of round to oval cells with pale eosinophilic cytoplasm . Additionally, there was chronic infiltration of inflammatory cells, predominantly lymphocytes and plasma cells . Immunohistochemical staining showed that the epithelial cells tested positive for cytokeratin (CKAE1/AE3) and thyroid transcription factor 1 (TTF1) (A and B), while the stromal cells were positive for TTF1 but negative for CKAE1/AE3 (C). No mitotic activity was not observed. Those results were consistent with a diagnosis of a PSP. She is currently disease free at 2 months since surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2156_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2156_en.txt
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index 0000000000000000000000000000000000000000..6f10c62f08a73cb649d96440ecdfa40b54f71077
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+A 47-year-old male, who hospitalized due to a giant scrotal tumor. He has a history of chronic alcoholism, developed numerous soft masses in the anterior neck, supraclavicular fossa, nape, bilateral arms, and shoulders 10 years ago. The tumors were painless and gradually enlarged in size. Five years ago, the patient developed a soft mass in the scrotum. The scrotal mass rapidly increased in size, he complained that hindering his ability to have sexual activity. Furthermore, the patient found it difficult to perform his daily activities. A physical examination revealed masses in the anterior neck, nape, shoulder, upper back, and scrotum. The mass was soft and poorly defined. The largest one was the scrotal swelling, causing expansion of the scrotal skin and buried penis . The penis could not be palpated if it was not erect; a short portion of the penis protruding to the surface could be manipulated during an erection, the prepuce and meatus were not abnormal. Normal-sized testicles were palpable in addition to the tumor, which moved independent of the tumor. His BMI was 26. Magnetic resonance imaging (MRI) revealed non-encapsulated adipose tissue on either side of the scrotum . An excision biopsy revealed a benign lipomatous tissue. Thyroid ultrasound image and thyroid hormones was normal. The levels of lipid in the blood, including cholesterol and triglycerides were within normal range. Liver function test results were abnormal. The levels of factors II, V, and VII were decreased, which in turn reduced the thrombocyte count and PTT levels. Thus, the patient was treated preoperatively with infusions of fresh frozen plasma and vitamin K.
+An incision was made at the midline of the scrotal skin, and the tumor was dissected from the scrotal skin and surrounding tissues. The bilateral epididymis, spermatic cord, and testes were preserved. The lower part of the tumor could be easily dissected from the scrotal subcutaneous tissue. However, it was firmly attached to the scrotal skin. The resected fatty tumor was pale yellow, multi-lobed, and weighed 1650 g. The excess skin was excised in a wedge shape between the anterior and posterior scrotal regions to preserve the flap supplied by the anterior and posterior scrotal arteries . The patient was advised for quitting alcohol, weight loss after operation. At 3 months postoperatively, the patient confessed that he was able to perform normal sexual activity and his quality of life was improved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2187_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2187_en.txt
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index 0000000000000000000000000000000000000000..248a922743d3ae961e97ac3cdb684f519c4d5cfd
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+A 28-year-old man presented with a relapsing–remitting course of distal-predominant limb weakness and numbness for 10 years. Ten years earlier, he had gradually progressive weakness and numbness in the distal limbs. He was unable to write, button his clothes, or open jars, but had no difficulty in climbing stairs or rising from a seated position. He was treated with intravenous dexamethasone and subsequent oral prednisolone for 1 month in another hospital, although the specific dosage was unknown. His symptoms disappeared after treatment. However, 7 years ago, the same symptoms relapsed and were gradually progressive. He presented at our hospital because of persistence of the aforementioned symptoms. He was treated with intravenous immunoglobulin at 0.4 g/kg/day for 5 days, and intravenous methylprednisolone at 500 mg per day for 3 days, followed by 240 mg per day for 1 day and 120 mg per day for 1 day. Subsequently, he received 55 mg of oral prednisolone for 1 month, after which it was gradually tapered off. He also took cyclosporine at 50 mg twice per day. In addition, he was subjected to another two 5-day courses of intravenous immunoglobulin, at 6 years ago and 5 years ago. He began to gradually recover after treatment and achieved remission, and he stopped all treatment 5 years ago. However, his symptoms relapsed 10 months ago, with gradually progressive asymmetrical weakness and numbness in his distal arms and legs. His left upper limb was most affected. He had no known comorbid conditions and no relatives with a similar condition.
+On neurological examination, the patient had mild bilateral facial paresis, asymmetric atrophy of the tongue muscle, and tongue fasciculations . No dysarthria or dysphagia was observed. Pinprick and vibration sensations under the wrists and ankles were significantly decreased, while sensation of the trunk was normal. No marked atrophy of the limb muscles was observed. The arms and legs were asymmetrically weak, with a Medical Research Council scale strength of 1–4, and predominant involvement of the upper distal extremities (Supplementary Materials Table ). Tendon reflexes including bilateral biceps, triceps, brachioradialis, knee and ankle tendon reflexes were absent, and the Babinski sign was negative. An inverted Beevor's sign was also observed, characterized by a downward movement of the patient’s umbilicus while attempting to stand from a recumbent position .
+Laboratory evaluations, including a complete blood count, erythrocyte sedimentation rate, C-reactive protein, antinuclear antibodies, anti-neutrophil cytoplasmic antibody, fasting serum glucose, thyroid function studies, serum and urine protein electrophoresis and immunofixation, and angiotensin-converting enzyme, were all unremarkable. Anti-ganglioside antibodies, myelin-associated glycoprotein, neurofascin 155 and 186, and contactin 1 were all negative. In addition, cerebrospinal fluid analysis revealed a normal protein content, cell count, and glucose level. Electrodiagnostic testing revealed severe, diffuse, asymmetric sensorimotor polyneuropathy that fulfilled the criteria for primary demyelination in CIDP. This included prolonged distal motor latencies, delay and disappearance of F waves, and conduction block in the radial and ulnar nerves . The nerve ultrasonography showed segmental hypertrophy in the bilateral median and ulnar nerves (Supplementary Materials Table ). Magnetic resonance imaging of the lumbosacral plexus revealed that the L5 and S1 spinal roots were mildly enlarged (Supplementary Materials Fig. ). A biopsy of the left sural nerve was almost normal and vasculitis was excluded.
+The patient was diagnosed with CIDP, and was again treated with intravenous immunoglobulin at 0.4 g/kg/day for 5 days, intravenous methylprednisolone at 500 mg per day for 3 days, and then oral prednisolone at 60 mg/day for 1 month before it was gradually tapered off. The patient was followed up by telephone. After 3 months of treatment, his numbness was completely relieved, his limb strength was recovered about 70%, he had no difficulty in daily life, and he returned to work.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_21_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_21_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a09aa99a4cb1190d5b025e45f44671ef08e0ff3a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_21_en.txt
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+A male, 71 years old, a retired teacher, did not have previous history of diseases, including hypertension, diabetes, coronary heart disease, chronic lung disease, kidney disease, and liver disease. He had a long history of smoking with 20 cigarettes per day. On August 24 2018, he got a fever with the heat peak at 40.0 °C without known causes and heat type, accompanied by chills, dizziness, abdominal pain, cough, and by a lot of yellow purulent sputum which was occasionally bloody. These symptoms appeared mainly in the morning and night, accompanied by right chest pain, aggravating when coughing, and difficulty in breathing. After an ineffective antibiotic treatment in the local hospital, he was then transferred to our hospital on September 2nd, 2018. The Computed Tomography (CT) results showed a large consolidation, grinding glass shadow, honeycomb changes, lung balloon formation in the right lung, and a newly-discovered solid patch and grinding glass shadow in the left, as well as bilateral pleural effusion . These indicate: 1. Double lung infection, interstitial pneumonia (mainly right lung), left emphysema, pneumatocele in the upper lobe of left lung; 2. Bilateral pleural effusion, mainly in the right lung; Laboratory analysis and display: Blood analysis: white blood cells 17.34 × 109 / L, neutrophil count 15.52 × 109 / L, neutrophil ratio 89.5%, lymphocyte count 0.83 × 109 / L, lymphocyte ratio 4.8%, platelets 102 × 109 / L. Abnormal test results in liver function: Alanine aminotransferase (ALT) 709 U/L, Aspartate aminotransferase (AST) 474 U/L, Cholinesterase (CHE) 2789 U/L, Total bilirubin (TB) 25.6umol/L, Direct Bilirubin (DB) 23.3umol/L, Lactate dehydrogenase (LDH) 758 U / L; Abnormal test results in renal function: Blood urine nitrogen (BUN) 10.10 mmol / L, Creatinine (Cr) 122umol / L; Hypersensitivity C reactive protein (Hs-CRP) 17.49 mg / dl. Abnormal test results in coagulation function: Prothrombin time (PT) 17.40, international normalized ratio (PT-INR) 1.52, D-dimer (DD) 2.37 mg/L; sputum anti-acid staining (−), T-SPOT (−), HIV antibody (HIV-Ab) (−); The patient was diagnosed to be severe pneumonia with multiple organ dysfunction. According to the initial experience, caspofungin (CAS) combined with imipenem, moxifloxacin and oseltamivir were given to resist infection; At 7 days later, the re-examination of chest CT plain scan showed that the pulmonary lesion did not change much in comparison with the previous symptom, showing that the treatment was ineffective, and the clinical symptoms did not improve.
+Mycelia and spores were found frequently in the sputum samples of the lower respiratory tract by Gram staining and methylenol lactate microscopic examination. Colonies could be observed in fungal culture: the Sabourauds Agar (SDA) and Potato Dextrose Agar (PDA) showed rapid growth at 25 °C, 35 °C and 42 °C, especially on the SDA, with colonies of a gray front and a black reversed. It was dark grayish brown on the PDA. The characteristics of colonies on various substrate were shown in Fig. . Microscope: the hyphae was light brown, 1.5–3.5 μm wide, straight, separated, and unbranched. Erected or slightly curved conidiophores stretch out from the top or side of the hyphae. The tip was tapered; the base was slightly enlarged with a bottle-shaped stalk; the long and narrow neck was similar to the tubular of the Paecilomyces, appearing transparent, and smooth. An array of oval or round conidium was produced from the top of or directly from the end or side of conidiophores arranged in chain. Elliptical conidial was a unicellular microorgnism, which was straight or slightly curved, tapered to the top, transparent, smooth, 4–9 μm long, 2–6 wide micron with a smooth fine spiral strip pattern. The various staining and morphological features under microscopy were shown in Fig. .
+For further identification, a single colony on the SDA purification plate was selected, and the general primers for ITS1 and ITS4 of fungi were used. By amplying the region of the internal transcriptional interval region, the sequencing results were analyzed by BLAST comparison. The homology to the Acrophialophora levis sequence in the gene bank was 99%, and the NCBI number referenced was KM995879. We have also submitted the sequence data to GenBank (Accession number is MN461541).
+After that, sensitivity to antifungal drugs was further tested by colorimetric microdilution method recommended by CLSI M61 version 2018. The tested antifungal drugs were amphotericin B (AMB), 5-flucytosine (5-FC), anidulafungin (AND), CAS, micafungin (MF), fluconazole (FLU), itraconazole (ITR), posaconazole (PSC), and voriconazole (VRC). Until now, the in vitro sensitivity information of Acrophialophora had not been reported. Among them, AMB (≤0.12 μg/ml) had the best anti-fungal activity against A. levis in vitro, following by the activity of VRC (0.12 μg/ml), ITR (0.12 μg/ml), and PSC (0.25 μg/ml) in vitro. The activity of 5-FC (≥64 μg/ml), AND (≥8 μg/ml), CAS (≥8 μg/ml), MF (≥8 μg/ml), and FLU (16 μg/ml) were poor. Drug sensitivity results confirmed that the original drug, CAS, was not effective. Then liposomal amphotericin B was used for suppressing infection. After that, the fever of patient declined with fluctuations from 36.5 to 37.8 °C. He had reduced sputum volume, cough, sputum blood in phlegm, but still had the white phlegm, with oxygen 5 L/min and blood oxygen saturation by more than 95%. The re-examination of chest CT plain scan at 17 days after the change of anti-infection program indicated that the upper left pneumonia sites were more reduced than before, and the pleural effusion was less severe than before. The next day, the patient was asked to go back to the local hospital for treatment. The treatment was discontinued because liposomal amphotericin B was not available in the local hospital, and this patient died of respiratory failure at 2 days later. The imaging data were shown in Fig. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2206_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2206_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..64d3dfa484e80137baff6bee55a64d761eef0306
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2206_en.txt
@@ -0,0 +1,5 @@
+A 69-year-old man presented with upper abdominal pain that radiated to his back and was accompanied by nausea and vomiting. The patient had no history of underlying diseases and did not smoke or drink alcohol. He reported using no medications within one month of the onset of pain. Upon presentation, the patient’s blood amylase and lipase concentrations were 916 U/L and 53 U/L, respectively. The patient’s myocardial enzyme concentrations and electrocardiographic results were normal. Abdominal computed tomography (CT) revealed mild swelling and thickening of the pancreas, blurring of the lipid spaces around the pancreas, and no gallbladder or extrahepatic bile duct expansion . A diagnosis of acute pancreatitis was considered. The patient fasted and was administered symptomatic and supportive therapies, including analgesics, hydration, and antibiotic treatment with levofloxacin (500 mg qd) intravenously. However, his abdominal pain did not subside, and the patient was admitted to the gastroenterology department for further diagnosis and treatment.
+Upon admission, the patient’s temperature was 36.9°C, heart rate was 82 beats/min, respiratory rate was 26 breaths/min, blood pressure was 113/70 mmHg, and oxygen saturation was 94%. The patient was fully conscious and had no enlarged superficial lymph nodes. Upon auscultation, he had mild shortness of breath, bilateral coarse breath sounds, and no dry or wet rales, and his heart rhythm was normal, with no pathological murmurs. The patient’s abdomen was soft, with tenderness below the xiphoid process and in the left upper quadrant, with no rebound tenderness. He did not exhibit oedema in his lower extremities.
+Once admitted, the patient was administered octreotide to inhibit pancreatic enzyme secretion and an esomeprazole injection to suppress gastric acid secretion, upon which his abdominal pain was slightly alleviated. However, on hospital day 2, he developed pyrexia (39.5°C) with chills, fatigue, headache, and muscle aches. The patient experienced dyspnea upon physical exertion, and a chest CT revealed patchy consolidation in the superior lobe of the left lung . A blood gas analysis revealed a fraction of inspired oxygen of 33%, pH of 7.49, partial pressure of oxygen of 65.0 mmHg, partial pressure of carbon dioxide of 26.4 mmHg, and bicarbonate concentration of 18.7 mmol/L. The patient’s total blood cholesterol concentration was 4.21 mmol/L, triglyceride concentration was 1.72 mmol/L, and serum calcium concentration was 2.15 mmol/L. Other laboratory test results are summarized in . The patient was diagnosed with severe community-acquired pneumonia complicated by acute pancreatitis.
+On hospital day 2, the patient was transferred to the Department of Respiratory and Critical Care Medicine. He was administered meropenem (1.0 q8h) intravenously and moxifloxacin (400 mg qd) intravenously as anti-infective therapy, umifenovir (200 mg tid) as antiviral therapy, and nasal high-flow oxygen therapy for acute pancreatitis. However, the patient continued to have severe pyrexia and his abdominal pain did not considerably resolve. CT pulmonary angiography revealed increased consolidation in the left lung and a small degree of bilateral pleural effusion . The patient’s blood amylase concentration was 1,150 U/L, blood lipase concentration was 324 U/L, urinary amylase concentration was 1,742 U/L, white blood cell count was 6.7 × 109/L, lymphocyte count was 0.28 × 109/L, neutrophil percentage was 97.6%, C-reactive protein concentration was 280 mg/L, and procalcitonin concentration was 11.3 ng/mL. As the patient did not respond to conventional antibiotic treatment, the possibility of infection with a special pathogen was suspected. On hospital day 4, fibreoptic bronchoscopic examination revealed no obvious abnormalities. Alveolar lavage fluid (10 mL) was obtained for microbe identification via mNGS. The patient’s serum antinuclear antibody, antineutrophil antibody, and immunoglobulin (Ig) concentrations were within the normal ranges. The patient was negative for severe acute respiratory syndrome coronavirus 2 nucleic acid, influenza virus nucleic acid, serum 1,3-β-D-glucan, galactomannan, and IgM antibodies against respiratory pathogens (Legionella pneumophila, Mycoplasma pneumoniae, Rickettsia spp., Chlamydia pneumoniae, adenoviruses, respiratory syncytial virus, influenza A virus, influenza B virus, and parainfluenza viruses). His blood and sputum cultures were also negative.
+On hospital day 6, the mNGS results indicated the presence of C. psittaci (number of sequences: 512, relative abundance: 90.3%, coverage: 91%) and Candida albicans (number of sequences: 698, relative abundance: 57.8%, coverage: 98%). At that time, the patient divulged that he had found and buried several dead chickens in his vegetable field 10 days prior to the onset of symptoms. Therefore, he was diagnosed with severe C. psittaci pneumonia, and his treatment regimen was changed to a combination of moxifloxacin (400 mg qd) intravenously and doxycycline (100 mg q12h) on hospital day 6. On hospital day 9, the patient’s body temperature returned to normal, and his abdominal pain and dyspnea were substantially resolved. His oxygenation index and markers of inflammation and organ functions were also improved . Abdominal CT revealed a reduction in the pancreatic swelling and in the patchy, blurred, low-density shadows around the pancreas . On hospital day 11, the patient’s abdominal pain was relieved, and his blood amylase concentration was normal. The patient was started on a bland liquid food diet, which was tolerated. On hospital day 14, chest CT revealed marked resorption of the consolidation in the left lung and a slight bilateral increase in pleural effusion . The nasal high-flow oxygen therapy was replaced with oxygen inhalation via a nasal cannula. On hospital day 26, chest CT revealed no exudative lesion of the left lung and no pleural effusion . Markers of inflammation and various organ functions had generally returned to normal . The patient was discharged on hospital day 27. Doxycycline (100 mg q12h) was continued for one week. At a one-month follow-up visit, the patient was in a generally good condition with an occasional cough without dyspnea, abdominal pain, or diarrhea.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2222_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2222_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..531820f275abf64677ee55ca0ff22e5bbe9d6ec1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2222_en.txt
@@ -0,0 +1,7 @@
+Ms. B is an 86-year-old woman who presented with a four-day history of obstipation, anorexia, nausea, and vomiting associated with worsening colicky abdominal pain and postprandial reflux. Her past medical history included Kaposi sarcoma, hypertension, osteoarthritis, and vitamin D deficiency. Although she had acute cholecystitis in the past, cholecystectomy had not been performed. Her surgical history included caesarean section through a lower abdominal midline incision and tonsillectomy. She lived alone and was independent with her daily activities of living.
+On examination, all the vital signs were within the normal range. Her abdomen was distended and tender on palpation as well as percussion, particularly in the lower abdomen. There was also guarding in the same region. Bowel sounds were present. On initial laboratory evaluation, she had mildly elevated inflammatory markers with white cell count of 15.6 [4.0–11.0 × 109/L], C-reactive protein (CRP) of 67 [<6.0 mg/L]. Her liver function tests showed bilirubin of 25 [2-20 μmol], alanine aminotransferase (ALT) of 18 [<33 U/L], alkaline phosphatase (ALP) of 135 [30-110 U/L], and gamma-glutamyl transpeptidase (GGT) of 56 [<56 U/L], indicating an obstructive pattern of the liver enzyme derangements. Other laboratory abnormalities were creatinine of 99 [45-90 μmol/L] and urea of 8.6 [2.5-7.5 mmol/L], indicating mild acute kidney injury in the context of her reduced food intake and dehydration. Her other serum electrolytes were normal. The urinalysis was unremarkable.
+On her computed tomography (CT) scan of her abdomen and pelvis, there were two gall stones of 3 cm and 3.3 cm lodged in the proximal duodenum and distal colon, respectively . It also showed a contracted and inflamed gallbladder with gas in the biliary tree. Along with the gallstones, the presence of pneumobilia was consistent with the presence of fistula originating from the gallbladder. The common bile duct (CBD) was dilated, measuring 17 mm. The diagnosis of Bouveret syndrome with gallstone coleus was made.
+While resuscitating with intravenous fluids, a nasogastric tube was inserted. Intravenous antibiotics (Ampicillin, Gentamicin, and Metronidazole) were commenced. The patient was consented for a laparotomy for removal of the gall stones and a potential bowel resection with stoma formation. Laparoscopic approach was not considered due to its technical difficulty with manoeuvring the gallstones and the likely presence of intra-abdominal adhesions.
+The laparotomy revealed two points of obstruction at the first part of the duodenum and at the distal sigmoid colon . An attempt was made to manually move the stone in the duodenum into the distended stomach but was unsuccessful. Following a duodenotomy, the duodenal stone was extracted. The sigmoid colon was distended proximal to the second stone. An indurated segment of the sigmoid colon was found distal to the stone. The cholecystocolonic fistula was not found. Similarly, a colotomy was made to remove the stone. There were no intraluminal pathology including strictures and masses identified. Both of the gallstones were removed via longitudinal incisions. The duodenotomy and colotomy were primarily closed transversely using PDS in a single layer. Duodenal repair was reinforced with an omental patch. There were severe inflammatory changes in the right upper quadrant involving the gall bladder and the second part of the duodenum, which were more in favour of a cholecystoduodenal fistula over a choledocoduodenal fistula.
+On examination of the rest of the bowel, it was grossly normal except for multiple diverticulae in the left-sided large bowel. They were relatively small and uncomplicated diverticulae. The cause of the dilated CBD was not found. The cholecystectomy, resection of the fistula, and CBD exploration were not performed due to the unclear anatomy intraoperatively as well as patient comorbidities, making the risk of complications high.
+Her immediate postoperative recovery was uncomplicated. She did not require inotropic or ventilator support. Her diet was slowly progressed. The patient was subsequently discharged to the care of her family and followed up in the general surgery clinic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2252_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2252_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7339ae6fe77c9d1292a182577915a9879aa6b67b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2252_en.txt
@@ -0,0 +1,10 @@
+A 20-month-old Japanese boy presented with pectus carinatum with no relevant past or family medical history (including no history of metabolic/storage disorders) and as the second child in the family. He had presented to his family physician at 6 months of age with left rib protrusion, and at 18 months of age with left torticollis. At this time, chest X-ray showed deformity and protrusion of ribs (pectus carinatum), but there were no other symptoms suggestive of Morquio A syndrome; for example, joint contracture and peculiar facies were not present and there were no problems with sleep or respiration. The patient was referred to our department (Department of Pediatrics, Jikei University School of Medicine, Tokyo, Japan).
+At the time of initial consultation in our department, the patient presented with normal growth for his age (height 83.3 cm, body weight 11.0 kg; 0.4 and 0.2 standard deviations, respectively, relative to growth standards for Japanese children ). On physical examination, we observed genu valgum, kyphosis, and pectus carinatum. Clear contracture of the elbow and knee joints was not observed. As part of our differential diagnosis based on these physical findings, and to rule out possible storage/metabolic diseases, we initiated a workup and measured urine GAG levels. We performed a quantitative urine mucopolysaccharide test and detected an elevation in GAGs: 97.7 µg/mL compared with a normal range of 5.3–34.0 µg/mL. The patient was admitted to the hospital for further examination.
+On admission at 22 months of age, the patient presented with similar height and body weight and normal vital signs (body temperature 36.6 °C, blood pressure 94/- mmHg, heart rate 90 beats per minute, respiratory rate 35 breaths/minute). As at the initial consultation, genu valgum, kyphosis, and pectus carinatum were present . Detailed clinical examination did not reveal adventitious lung sounds or heart murmur, hepatosplenomegaly, neurological abnormalities, coarse facial features, macroglossia, tonsillar hypertrophy, or umbilical hernia. Ophthalmic examination did not reveal any corneal opacity. Blood tests did not reveal any abnormalities. Chest X-ray showed the flattening of ribs , thoracolumbar X-ray showed kyphoscoliosis and ovalization of the thoracolumbar vertebral body , and carpus X-ray showed short and stubby phalangeal bones with mild metaphyseal cupping and strikingly short metacarpals with proximal coning . Echocardiography revealed very slight tricuspid, pulmonary, and mitral valve regurgitation. Brain magnetic resonance imaging (MRI) did not reveal any clear abnormalities in the parenchyma.
+Given these findings, blood enzyme activity for MPS I, MPS II, MPS IVA, and MPS VI was measured (Advanced Clinical Research Centre & Asian LSD Centre, Institute of Neurological Disorders, Tokyo, Japan). GALNS enzyme activity, indicative of MPS IVA, was found to be at very low levels (0.05 pmol/punch/hour) compared with normal levels (1.21–1.87 pmol/punch/hour). The enzyme activity levels for MPS I, MPS II, and MPS VI were within the normal range.
+Given the low levels of GALNS enzyme activity in the blood, we strongly suspected a diagnosis of MPS IVA disease. To definitively diagnose, we measured GALNS enzyme activity in dermal fibroblasts; this assay showed a clinically significant low level (0.01 nmol/hour/mg protein) compared with normal levels (7.48–9.52 nmol/hour/mg protein). This finding established a definitive diagnosis of MPS IVA , also known as Morquio A syndrome.
+At 30 months of age, treatment with elosulfase alfa enzyme replacement therapy (ERT) at 2 mg/kg/week was initiated and continued throughout the reported follow-up period (36 months after the start of treatment). Treatment did not begin before this date because ERT in Japan had not been approved. Both acetaminophen (10 mg/kg) and loratadine (5 mg) were given 30 minutes prior to ERT administration to reduce pain, fever, and allergic reaction.
+For this report, the progress of the patient was followed for 36 months, during which time he was adherent to treatment and assessed yearly.
+Urine KS levels at the start of ERT were high (71.05 µg/mg creatinine) compared with the reference range (1.75–6.81 µg/mg creatinine) and decreased over time: 69.5%, 36.8%, and 47.1% of the pre-ERT level at 12 months, 24 months, and 36 months of treatment, respectively.
+The patient grew 14.5 cm during the 36-month treatment period. To assess spinal deformity, a thoracolumbar MRI after 24 months of treatment showed deformity and hypoplasia of the vertebral body, hypoplasia of the odontoid process, and spinal canal stenosis at C2–C4 and Th2–Th4 (which worsened at 36 months). However, no neurological abnormalities were observed.
+To assess physical endurance and exercise performance, a 6-minute walk test and a 3-minute stair climb test were conducted. The initial 6-minute walk test was conducted 12 months after the start of treatment; at 36 months the walking distance had increased by 68 m. The 3-minute stair climb test was conducted 24 months after the start of treatment; at 36 months the number of steps taken had decreased by 31.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2277_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2277_en.txt
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index 0000000000000000000000000000000000000000..b2f4406bd99ecd4e19ea8bbd16284c74efcd2c9d
--- /dev/null
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+Here, we report on a 53-year old man with stage IV adenocarcinoma of the lung with no predictive genetic abnormalities (no EGFR mutation, no ALK or ROS1 translocation). On his initial computed tomography (CT) scan, he presented with multiple bilateral pulmonary nodules, masses in mediastinal lymph nodes, liver, and ribs. The patient had no history of auto-immune disorders. MRI of the skull revealed 2 cerebral lesions, which were treated by irradiation with one fraction of 20 Gray and showed consecutive regression. A subsequent palliative chemotherapy with cisplatin and pemetrexed led to disease stabilization after four cycles. Pemetrexed was continued as maintenance therapy. Two months later, progression of several lesions prompted a second line therapy with the PD-1 inhibitor nivolumab. Serological testing for human immunodeficiency, hepatitis B and C virus infections were negative. Under PD-1 blockade peripheral lesions regressed and quality of life improved. Soon thereafter, however, walking ability deteriorated, and cranial MRI showed a new parieto-temporal lesion in proximity of the formerly irradiated masses . Suggestive of further metastatic spread, this new lesion was irradiated with 24 Gray over 7 days , and nivolumab continued. A few days later, the patient was admitted to the emergency department with progressive gait disturbance and speech difficulties. He had no clincial symptoms for auto-immune disorders such as a systemic lupus erythematodes or generalized vasculitis. Corticosteroid treatment was initiated and provided partial relief only. MRI demonstrated progression of the newly irradiated lesion , whereas extracerebral masses remained stable. The progressive brain lesion was surgically removed and subjected to neuropathological examination.
+Histopathological analysis revealed necrotizing encephalitis with no evidence of metastatic lung cancer . The dimensions correlated with the radiographic size of the lesion (diameter approximately 3.3 cm). Staining for cytokeratins (CK22), performed on all paraffin embedded specimens was negative . A high perivascular density of CD45 positive cells was found with predominance of PD-1 positive T cells over B cells (CD20, PD-1, CD4 and CD8 staining, Fig.). Staining of CD68 demonstrated accompanying resorptive changes of the brain tissue . We also found a predominance of CD8 positive T cells over CD4 positive T cells . PD-L1 expressing cells were sparse . Further analysis of infectious diseases including Toxoplasma were negative (not shown). Parallel panel sequencing (Oncomine™ Comprehensive Cancer Panel, Thermo Fisher) was performed on the initial lung biopsy as well as on DNA extracted from the necrotizing encephalitis. Most prevalent mutations identified in the primary tumor and present in ATM, TP53, and NOTCH1 could not be detected in the brain lesion. This result confirms our histological findings, making it unlikely that tumor cells had been present in the biopsied brain region. We hypothesized that the brain lesion was the consequences of an autoimmune phenomenon during PD-1 blockade.
+To evaluate for a potential autoimmune syndrome, we screened for anti-neuronal autoantibodies, as well as antinuclear antibodies (ANA). No antibodies against neuronal antigens (i.e., Hu, Yo, Ri, CV2, Ma1, Ma2/Ta, and amphiphysin, NMDA, GAD65) could be detected, but high titers of antinuclear anti-SSA/Ro and anti-SSB/La antibodies were found (>240 U/mL, reference <10 U/mL). High antibody titers against SSA/Ro (Ro52, Ro60) were already found in serum samples that were taken before the initiation of anti-PD-1 treatment. Inflammatory chemokines and cytokines in serum were measured by a flow cytometry bead assay that allows measurement of 13 inflammatory chemokines or cytokines simultaneously (both from Biolegend). Binding of chemokines/cytokines to the beads were measured by a Fortessa analyzer (BD Biosciences). Multiplex analysis of serum samples showed a measurable level of TNFα at the time point when the encephalitis was diagnosed (25.4 pg/mL). At other time points, the TNFα level was below the detection limit. Measurement of inflammatory chemokines showed an increase of blood levels upon treatment initiation with anti-PD-1 antibody including CCL11, IP-10, and MIP-3α . Only MIP-1β and IL-8 were increased at the time point of resection of the encephalitic lesion . The increase in inflammatory chemokines and also TNFα in our patient supported the presence of an inflammatory process. Moreover, when histological cerebellum sections from an unrelated healthy control individual were incubated with patient’s serum taken at the time point when the vasculitis was diagnosed, a strong staining of the endothelial layers of cerebellar vessels was found . Testing of control cerebellar sections with control serum or patient’s serum before nivolumab treatment showed no staining . However, increasing concentrations with pre-PD-1 serum from the patient led to some but overall weaker endothelial staining (not shown) indicating that the anti-vascular antibodies were present before PD-1 blockade, but the titer was lower.
+The patient’s neurological symptoms rapidly improved after excision of the lesion. Nivolumab treatment was stopped and corticosteroids were tapered over the course of two months. Follow-up imaging of head and chest showed slowly progressive pulmonary lesions and a new neocortical contrast agent-enhancing lesion, which was asymptomatic at the time of imaging. This new lesion was interpreted as encephalitis, and corticosteroids were administered again. In parallel, a second line chemotherapy with docetaxel was initiated. After three cycles of chemotherapy, restaging showed a partial response of the lung lesions and a regression of the cerebral lesion.
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index 0000000000000000000000000000000000000000..eaccc2e8494fd65fd71bf485b669cf1072a292ee
--- /dev/null
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+During a routine health check-up of a 73-year-old woman, abdominal ultrasonography incidentally revealed a retroperitoneal tumor with a maximum diameter of approximately 80 mm at the upper pole of her right kidney. She was admitted to our institution for examination of the tumor. The patient had been taking medication for hypertension, and her blood pressure had been maintained at 120–130 mmHg with 20-mg/day nifedipine and 2.5-mg/day carvedilol. She had no notable abnormal findings in her general biochemistry, complete blood count, or the coagulation test. Various tumor markers, including carcinoembryonic antigen, carbohydrate antigen 19-9, squamous cell carcinoma-related antigen, and carbohydrate antigen 125, levels were also within normal ranges. Her blood noradrenaline and dopamine levels were within normal ranges, but her adrenaline level was elevated at 0.12 ng/ml and the 24-h urinary excretion of catecholamines and their metabolites were all increased . The adrenal cortical hormone seemed to be within the normal range, but the 1-mg dexamethasone suppression test revealed mild autonomous cortisol secretion (5.9 μg/dl). Contrast-enhanced computed tomography (CT) revealed a cystic retroperitoneal tumor with a maximum diameter of 88 mm within the right adrenal gland . The tumor included a walled nodule, revealed by its contrast effect in the early phase. The interior of the cyst was filled with a low-density fluid with no observed contrast effect. On magnetic resonance imaging (MRI), the nodule exhibited a low signal in the T1-weighted image and a high signal in the T2-weighted image. The cyst wall accumulated an abnormal level of the marker in both 123I-MIBG scintigraphy and positron emission tomography with 2-deoxy-2-[fluorine-18] fluoro-D-glucose/CT . From these findings, although the 24-h urinary excretion of catecholamines and their metabolites were not sufficiently high enough to meet the diagnostic criteria of pheochromocytoma, in consideration of image findings and clinical course, we strongly suspected that the tumor was predominantly a degenerating pheochromocytoma. The patient was scheduled to undergo tumor resection.
+However, preoperative MRI incidentally revealed a cerebral aneurysm, 8 mm in diameter, at the junction of the basilar and superior cerebellar arteries . We, therefore, discussed with a neurosurgeon, anesthesiologist, and endocrinologist whether the retroperitoneal tumor or the cerebral aneurysm should be prioritized for treatment. Based on its size and location, the annual rupture rate of this cerebral aneurysm was estimated to be approximately 1% , and its deep location and large size posed a relatively high surgical risk. We, therefore, decided to proceed with the resection of the tumor, aware of the risk of an intraoperative rupture of the aneurysm subsequent to surgery-induced hypertension.
+We decided to conduct more rigorous blood pressure management for the patient’s surgery. Her preoperative blood pressure was managed under 120 mmHg using 32-mg/day doxazosin and 2.5-mg/day carvedilol. We used epidural anesthesia for thorough analgesic management and general anesthesia centered on propofol and remifentanil, and we carefully monitored the blood pressure. After inducing general anesthesia, a lumbar catheter was placed to monitor for intraoperative rupture of the cerebral aneurysm. In addition, we used transcranial motor-evoked potential and somatosensory-evoked potential monitoring to track her intraoperative neurological function. Subsequently, the surgical procedure was performed via a right subcostal incision with upper midline extension. During the surgery, we focused on fluctuations in blood pressure. Prior to full-scale tumor mobilization to prevent excessive secretion of catecholamine, we first ligated and separated the feeder arteries, consisting of three right adrenal arteries, followed by the drainage vein, consisting of a right adrenal vein. Next, we removed the tumor with minimal mobilization. The tumor had not noticeably invaded the surroundings. There was no blood outflow from the lumber catheter during the procedure. We withdrew the catheter immediately post and used head CT to confirm there had been no intracranial hemorrhage. No intraoperative blood pressure fluctuation was observed, and the cerebral aneurysm monitoring devices showed no abnormality. Complete resection (R0) was achieved by pathologically determining the negative surgical margin during surgery.
+Macroscopically, the cystic tumor was approximately 100 mm in diameter with an interior that was almost necrotic . Microscopically, two types of atypical cells with enlarged heterozygous nuclei were observed in a part of the cyst wall : neuroblastic cells positive for neuron-specific enolase and cells morphologically similar to ganglion cells and positive for S-100 . The ganglion cells were also immunohistochemically positive for tyrosine hydroxylase, DOPA decarboxylase, dopamine-beta-hydroxylase, and phenylethanolamine-N-methyltransferase. These two types of atypical cells were observed to form nodules without intermixing. Because no tumor cells judged as pheochromocytoma were observed, the tumor was histopathologically diagnosed as nodular GNB within the right adrenal gland. In addition, because the position of the tumor cells coincided with the site where 123I-MIBG scintigraphy showed abnormal accumulation, the tumor was diagnosed as a catecholamine-producing GNB.
+The postoperative course was good, and the patient’s blood pressure after surgery was maintained under 110 mmHg with no antihypertensive agents. She was discharged on the 7th day postoperatively. An examination after discharge confirmed that her blood and urinary catecholamine levels and metabolite excretion had returned to normal . Three months postoperatively, no recurrence was observed.
+GNBs frequently occur in children, but their onset in adults is extremely rare . Adult GNBs have a high potential to be malignant, and there have been many reports of distant metastasis to various organs, including the liver and bones . Most reported adult GNBs do not produce catecholamines; therefore, catecholamine-producing GNBs are considered to be particularly rare . In our case, GNB developed in the adrenal gland. Including this case, there have been only 14 case reports in the English-language literature on GNB in adult adrenal glands [–], except for composite types with pheochromocytomas. Among these 14 cases, only four (including the present case) involved catecholamine-producing GNBs [–] . Hypertension has been reported in approximately 10% children with neuroblastoma , but only one other case of an adult GNB patient with hypertension has been reported . In that case and ours, the 24-h urinary excretion of catecholamines and their metabolites showed abnormally high levels, suggesting a relationship between the tumor and hypertension. It is difficult to distinguish a catecholamine-producing GNB complicated with hypertension from a pheochromocytoma based on catecholamine dynamics, such as the 24-h urinary excretion of catecholamines and their metabolites, or 123I-MIBG scintigraphy. We, therefore, assumed that the tumor was a pheochromocytoma preoperatively. However, because both pheochromocytomas and GNBs are classified as malignant tumors, it was appropriate to resect the tumor.
+It was also noteworthy that our case had a cerebral aneurysm. A catecholamine-producing tumor with a cerebral aneurysm requires much more cautious management, but there is no definite consensus over management because of limited reports. A search of PubMed found no previous reports of GNB with a cerebral aneurysm, although there have been five reported cases of pheochromocytoma with cerebral aneurysms [–]. In four of these cases, treatment of the tumor preceded the treatment of the cerebral aneurysm [–], even though in all four cases, the risk of rupture was very high or there was a history of rupture. One of these four cases developed cerebral infarction during the cerebral aneurysm surgery. In the fifth case, treatment for the pheochromocytoma proceeded because of the low risk of rupture . In all of these cases, the focus during surgery was only on fluctuations in blood pressure. In the present case, we thoroughly monitored for a potential rupture using an intraoperative lumbar catheter, monitored somatosensory and motor-evoked potentials to track neurological function, and performed a head CT immediately after surgery. Even though the risk of spontaneous rupture of the cerebral aneurysm was low, the intraoperative blood pressure fluctuation owing to the catecholamine-producing tumor had the potential to affect the status of the aneurysm. If any of these intraoperative monitoring processes suggested an aneurysmal rupture, we would have performed an immediate craniotomy to repair it. If the tumor surgery was in its final stage, we would have performed a craniotomy after completing the resection; conversely, if the feeding arteries had not been treated and the tumor surgery was still at an early stage, we would have given priority to the craniotomy.
+For catecholamine-producing tumors with a cerebral aneurysm, whether the tumor is pheochromocytoma or GNB, careful consideration should be given to the order in which the treatments should take place, taking into consideration the risk of rupture and the possibility of malignancy. Our strategy for this catecholamine-producing tumor with cerebral aneurysm may be helpful in the treatment of similar cases in the future.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2289_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2289_en.txt
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index 0000000000000000000000000000000000000000..cf70f80da3588fcaf91289feef5fae11c0e65bd7
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+A previously healthy 35-year-old Sri Lankan man presented with high-grade intermittent fever for 3 days with constitutional symptoms. He had spontaneous gum bleeding with no other overt bleeding manifestations. He had associated intermittent frontal headache of moderate severity at presentation and subsequently developed gradually worsening drowsiness. Rest of the history including his past medical and family histories were unremarkable. In particular, he did not have diabetes mellitus, history of recurrent infections, unprotected sexual contact or recreational drug abuse.
+On examination, his body temperature was 100 °F and his Glasgow coma scale score was 10/15. He was mildly pale. There was no neck stiffness. Fundoscopic examination was normal. There were no focal neurological signs. His pulse rate was 100 bpm and blood pressure was 130/80 mmHg, Rest of the cardiovascular, respiratory and abdominal examinations were normal.
+His full blood count showed a white cell count of 9.2 × 103/dl (Normal Range (NR) 4–11 × 103) with neutrophil predominance (77%). Haemoglobin was 6.9 g/dl (NR 11–15) and platelet count on admission was 7 × 103 (NR150–400 × 103). His coagulation profile was normal with prothrombin time of 12.8 s (NR 10–13) and APTT 30 s (NR 26–40). Serum creatinine was slightly elevated at 137 mmol/l (NR 60–120 umol/L) and the electrolytes were normal. There was indirect hyperbilirubinaemia with total bilirubin of 44.7 μmol/l (NR 1.7–20.5) and direct bilirubin of 7.3 μmol/l (NR 1.7–5.1). The serum lactate dehydrogenase level was 3115 U/l (NR 160–450). Direct coombs test and dengue serology were negative. Non-contrast CT scan of the brain was normal. Blood picture showed evidence of severe thrombocytopenia with microangiopathic haemolytic anaemia (MAHA).
+A diagnosis of TTP was made and he was promptly commenced on therapeutic plasma exchange and 1 mg/kg of oral prednisolone. However, he developed two episodes of generalized tonic-clonic convulsions which progressed in to a non-convulsive status epilepticus on the fifth day of illness, which required elective ventilation in the intensive care unit. On day 18, he developed flaccid paraparesis with sphincter dysfunction. Magnetic resonance imaging showed haemorrhage at multiple spinal levels including cervical spine sub-arachnoid space, anterior epidural space and intra-thecal space from T10 to L3 vertebral levels, and in the the region of the conus medullaris.
+Surgical drainage of the spinal haematoma was considered hazardous. At this point his platelet count was 85 × 103 and remained < 100 × 103 with MAHA persisting despite 16 plasma exchanges and high dose steroids.
+Initially, the refractoriness of the TTP was attributed to ventilator associated pneumonia. However, since successful treatment of sepsis did not improve the MAHA, an alternative aetiology was investigated. Polymerase chain reaction of serum revealed 2100 IU/ml copies of CMV (Reference laboratory cutoff value more than 640 IU/ml was considered clinically significant). CMV DNA was quantitatively determined by RealStar® CMV PCR Kit 1.0 (Altona diagnostics). Screening tests for autoimmune diseases, other chronic infections and immunodeficiency, which included ANA, serum complement levels, serum immunoglobulin levels, HIV 1, HIV 2, VDRL, hepatitis screen and HbA1c were negative.
+The patient was commenced on oral valganciclovir 450 mg/daily and continued for 21 days. After about 6 days of valganciclovir treatment his platelet count increased to 198 × 103/cumm and the MAHA resolved. After resolution of the TTP, the patient was transferred to a rehabilitation facility for further care. At three months’ review, he had normal haematological and biochemical parameters and a negative PCR quantification of CMV. He had regained ability to walk with support and had normal sphincter function.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2299_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2299_en.txt
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index 0000000000000000000000000000000000000000..4085c790c5de9113d6bea51b42fdc04de94bcc65
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+A 36-year-old male presented with a painless ulcer on the right forearm lasting for 2 mo.
+The patient had been working in central Asia for several years. He returned to China after noticing a soybean-sized nodule that gradually increased in size to an ulcer over a period of 2 mo on the right forearm. He was initially diagnosed with a bacterial skin infection, but the treatment of debridement and levofloxacin (0.5 g/d orally for 7 d) was unsuccessful.
+The patient was in good health and had no history of other diseases.
+The patient had been working in central Asia for 3 years. Family history was unremarkable.
+A 5.8 cm × 4.0 cm ulcer on the right forearm with black crust in the center and raised borders was observed. After squeezing, a clear, thin liquid secretion appeared. Three hard, peanut-sized subcutaneous nodules could be palpated around the ulcer . No enlargement of lymph nodes was palpable in the right axilla or other areas.
+The results from routine tests, such as blood, urine, stool routine, liver and kidney function and bacterial culture, were normal. Histopathological examination revealed diffuse mixed inflammatory cell infiltration within the superficial and deep layers of the dermis. Amastigote of Leishmania existed in the cytoplasm of the histocytes . Giemsa staining showed the amastigote more clearly . Leishman-Donovan bodies were seen on scrapings of the skin lesion , and no Leishman-Donovan bodies were seen on bone marrow smears. Serum immunoglobulin G antibody test of Leishmania donovani was negative.
+Computed tomography examination of the chest and abdomen showed no abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_231_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_231_en.txt
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index 0000000000000000000000000000000000000000..32b3537a4812329a4d4c146d900a4c3506dc94b1
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+A 12-year-old Syrian boy was admitted to our hospital due to epistaxis, anorexia, weight loss, and night sweats. Medical and family history were unremarkable. The physical examination revealed preauricular, postauricular and submandibular lymphadenopathy with the largest node measuring approximately (3 × 5) cm . Furthermore, a hard palate mass was found deviating the uvula to the right causing dysphagia and dyspnea. Laboratory tests showed WBC count 35380/μL, Hgb 10,1 g/dl, platelets 641 × 103/μL and ESR 124 mm/hr.
+Abdominal ultrasound showed mild spleen enlargement without focal lesions. Chest radiography was normal without mediastinal widening.
+A CT scan revealed multiple enlarged lymph nodes on the right side of the neck .
+Excisional biopsy of the enlarged cervical lymph node (3 × 4)cm was performed and further pathological assessment showed complete effacement of lymph node architecture with proliferation medium to large-sized anaplastic and Reed-Sternberg-like cells in the interfollicular zones and subcapsular sinuses admixed with histiocytes, small lymphocytes and few eosinophils. In addition, the neoplastic cells showed cohesive growth pattern with abundant cytoplasm, wreath-like or multiple nuclei, multiple nucleoli, and occasional mitotic figures .
+In addition, a bone marrow sample showed reactive inflammation with hypercellular bone marrow. No evidence of involvement by neoplastic cells was found. Consequently, the patient was diagnosed with Classical Hodgkin Lymphoma (CHL) based on routine staining with the recommendation to proceed with immunohistochemistry staining to confirm the diagnosis. However, immunohistochemistry was not available in our institution at the time.
+The patient received chemotherapy based on ABVD protocol. However, the patient reentered our hospital 5 months later with no evidence of significant improvement, therefore, the diagnosis was doubted. Consequent immunohistochemistry staining showed strong CD30 positivity for large Reed-Stenberg-like cells and CD3 positivity whereas ALK, CD15 and CD20 were negative . Based on these findings, the patient was diagnosed with ALK-negative ALCL. The patient received 5 cycles of chemotherapy comprising of (vinblastine 10 mg/m2, methotrexate 500 mg/m2, ifosfamide 1g/m2, etoposide 100 mg/m2and cytarabine 1g/m2). Unfortunately, the patient passed away after 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2324_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2324_en.txt
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index 0000000000000000000000000000000000000000..d21761f9bc4e547159f4d5fce8b6946766614c93
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+A previously healthy 34-year-old Korean female was admitted to a regional hospital for fever, myalgia and severe headache that had started 2 weeks ago. Brain MRI showed a high T2 signal intensity change and diffuse swelling of the right temporal lobe, insula and hippocampus . Lumbar puncture showed lympho-dominant pleocytosis. The patient was started on intravenous (iv) dexamethasone and acyclovir under a high suspicion of viral encephalitis.
+She was transferred to our institution 4 days later due to persistent headache despite treatment. A noncontrast computed tomography (CT) brain scan taken at our institution showed a hemorrhagic transformation of the right temporal lobe, which was not observed on the initial MRI . Follow-up lumbar puncture showed 510 white cells per mm3 (82% lymphocytes), 144 mg/dL protein and 61 mg/dL glucose. CSF culture studies were negative for bacteria, fungi and tuberculosis. PCR of the CSF confirmed the presence of HSV1. The patient was free of neurological symptoms, with a Glasgow Coma Scale of E4M6V5, and was admitted for close observation and continuation of iv acyclovir. Corticosteroid treatment was discontinued upon her admission. On day 3 of hospitalization, the patient presented with a sudden onset of vomiting and severe headache. Brain CT showed an increased amount of temporal lobe hemorrhage and a leftward shift in the midline . Mannitol was administered but did not seem to have a significant effect. The patient became increasingly drowsy, and her right pupil became dilated. She underwent emergency right decompressive craniectomy, expansile duraplasty and ICP monitor insertion. Postoperative brain CT showed alleviation of midline shifting . The patient recovered fully 5 days after the surgery. Apart from mild intermittent headache and dizziness, she did not show any other significant clinical symptoms, including neuropsychological problems. There were no significant neurologic deficits upon neurological examinations performed by the attending neurosurgeon and neurologist. The patient was discharged after completion of 2 weeks of acyclovir and returned 2 months later for cranioplasty. She was followed up 3 more times after cranioplasty. She was stable, without any neuropsychological problems or neurologic deficits, and was able to successfully return to work as a public official.
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index 0000000000000000000000000000000000000000..5dac67cd3ae46c607bd2f2cc130eef1c8f6be06c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2327_en.txt
@@ -0,0 +1,3 @@
+A 33-year-old woman with no medical history was admitted to the obstetrics department because of pregnancy with uterine fibroids. She delivered naturally without anesthesia. This was the patient’s first delivery. She had no hypertension during pregnancy, but the systolic blood pressure sometimes exceeded 150 mmHg from the fourth postpartum day onward. She was discharged on the fifth postpartum day (the first day of sickness) with a morning blood pressure of 158/82 mmHg. Upon returning home, the patient experienced a mild headache. At approximately 22:00 that night, 10 min after getting into bed, she suddenly felt chills and had a severe, pulsating headache that peaked in approximately 10 s. Nausea was accompanied by headache, but there were no scintillating scotomas or ophthalmic symptoms. Her blood pressure was 159/100 mmHg. The headache resolved in the standing position but worsened and became unbearable within a few seconds when she was in the supine position. Therefore, she was unable to lie down all night. The following day, the patient visited our hospital. Her blood pressure was 156/110 mmHg at the time of examination. Acetaminophen and diazepam did not improve the headache, and she was admitted on the same day.
+On admission, her body temperature was 35.6 °C, and her blood pressure was 178/110 mmHg. No abnormalities were found upon physical examination of the chest or abdomen. Consciousness was clear, and there were no neurological symptoms, including nuchal rigidity. Laboratory findings showed a white blood cell count of 7390/µl, C-reactive protein 0.94 mg/dl, and no anemia. Liver and renal function were normal, and electrolyte levels were within the normal range. D-dimer was elevated at 8.1 µg/ml, but there was no other abnormality in the coagulation system. Contrast-enhanced computed tomography (CT) of the brain on admission (day 2) at the time of headache relief showed no abnormalities, and computed tomography angiography (CTA) showed no vascular stenosis or venous occlusion .
+After admission, the headache pulsated over the entire head and became extremely severe within 10 s in the supine position. The headache resolved within a few seconds in the standing or sitting position but did not disappear. Headache intensity was variable and exacerbated for approximately 10 min/h. Scintillating scotomas were not observed. One hour after nifedipine administration, the headache decreased, and she was able to sleep in a sitting position for a short time on day 2. On the third day after discharge, brain magnetic resonance imaging (MRI) showed no direct thrombosed vein sign and no other abnormalities , but magnetic resonance angiography (MRA) showed poor visualization of peripheral arteries . We suspected RCVS and prescribed verapamil 120 mg/day (in three divided doses). After taking verapamil at night, her headache resolved approximately 1 h later and she was able to lie in a supine position. On day 4, she experienced a thunderclap headache preceded by chills when she got to bed; however, she did not experience any subsequent thunderclap headache. On day 10, brain MRA showed diffuse and segmental stenoses in the bilateral middle and posterior cerebral arteries and basilar artery. Thereafter, she experienced a mild headache once a week for several hours; however, the headache did not exacerbate in the supine position. The headaches completely disappeared by day 42. MRA performed on day 43 showed an improvement in vascular stenosis. Verapamil was discontinued on day 62; however, the headache did not relapse.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2332_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2332_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ee38c0e5e91f301c4ac42958172e5ad728d641fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2332_en.txt
@@ -0,0 +1,5 @@
+A 54-year-old African American man initially presented to his primary care provider (PCP) with a two-week history of a non-productive cough and night sweats. The patient was a former smoker (~ 25 pack years) but otherwise had no other significant medical history and his HIV status was negative. Additionally, patient’s travel history as well as pet, home, and occupational exposures were non-contributory. The patient’s PCP prescribed a five-day course of azithromycin for acute bronchitis but he reported no improvement in symptoms. He was subsequently prescribed prednisone and albuterol for bronchospasms but the patient’s cough and night sweats worsened. In addition, the patient reported a 4.5 kg weight loss since the onset of his illness.
+Given his worsening symptoms, 3 weeks later he underwent a chest x-ray (CXR), which revealed a left hilar mass with extension into the anterior segment of the upper lobe . A computer tomography (CT) scan revealed a 4.2 × 6.4 × 7.2 cm mass in the left upper lobe (LUL) with numerous satellite nodules concerning for primary lung malignancy. A positron emission tomography (PET)/CT revealed 18-fluoro-2-deoxyglucose (FDG) uptake in the LUL mass with a maximum standardized uptake value (SUV) of 24.3 as well as FDG uptake in left hilar lymph nodes with a maximum SUV of 4.3. There was also FDG uptake within a subcutaneous nodule along the superior left gluteal cleft with a maximum SUV of 21.1. The patient reported that this area was initially cystic looking and had been developing for a few weeks to months but was first noticed to be draining purulent fluid around the time of his illness. He was placed on doxycycline by his PCP after the PET/CT result for suspected pilonidal cyst. Bacterial culture from this lesion yielded no growth.
+Given the concern for primary lung cancer, the patient was referred to cardiothoracic surgery to obtain a tissue diagnosis. His radiographic findings were thought to be consistent with primary lung cancer at a T2N2M0 clinical stage. The patient was taken to the operating room (OR), about 5 weeks after his initial presentation, and underwent a flexible fiberoptic bronchoscopy with biopsies of the LUL mass as well as cervical mediastinoscopy with biopsy of regional lymph nodes. These biopsies revealed no evidence of malignancy and thus the decision was made to pursue video-assisted thoracoscopy surgery (VATS) with lobectomy to obtain a definitive diagnosis and for therapeutic purposes. The patient underwent this procedure the following week. During the procedure, the mass was found to be adherent to the mediastinal pleura in the region of the phrenic nerve and thus not amenable to wedge resection. An intraoperative frozen section of the mass revealed necrotizing granulomatous inflammation. Given this information, the plan for resection was aborted and flexible bronchoscopy with washings for cultures was performed to rule out infection.
+The biopsy of the LUL mass again revealed no evidence of lung cancer on histopathology. However, yeast forms were seen on the biopsy concerning for Cryptococcus. Concurrently, the fungal cultures obtained from the patient’s bronchial washings had yeast on staining with growth of a mold on culture. These findings were consistent with a dimorphic fungus. This prompted mucicarmine and Fontana-Masson staining of the lung tissue which revealed 5 to 15 μm yeast forms with a double cell wall appearance consistent with Blastomyces . A DNA probe was performed on the positive cultures and this confirmed that the fungus was B. dermatitidis. A fungal culture on his gluteal lesion also grew a mold consistent with B. dermatitidis. In addition, the patient had a positive B. dermatitidis urine antigen. Rest of the patient’s laboratory workup remained negative including Cryptococcus and HIV serology were negative.
+The patient was started on posaconazole for disseminated blastomycosis for a planned 6–12-month course. He started his course of posaconazole about 7 weeks after his initial visit to his PCP. A repeat CXR 1 month into posaconazole therapy revealed interval decrease in the size of the LUL mass . At his two-month follow-up appointment, the patient reported resolution of his cough and night sweats. He lost about 10 kg over the course of his illness but reported that his weight was stabilizing while on therapy. On examination, his left gluteal cleft lesion had completely healed .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2362_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2362_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec71395acfbb1d3ef476833067e7633883e829ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2362_en.txt
@@ -0,0 +1,6 @@
+Mrs RB, a 25-year-old Kuwaiti woman primigravida, married for 18 months, presented to the Maternity Hospital, Kuwait, at 31 weeks of gestation with rupture of membranes of 3 hours duration. This pregnancy was spontaneous and resulted from a non-consanguineous marriage and was followed up in the private health care service. The antenatal period had been uneventful until this emergency presentation. There was no evidence of antenatal ultrasonography in the private health services as the patient did not present any information or reports of such an investigation. She was not known to have diabetes mellitus. Her past surgical/medical/gynecological history was not contributory.
+At admission, the patient was calm, afebrile and the vital signs were normal. There was no abnormality in the respiratory and cardiovascular systems. Obstetric examination confirmed a 31 weeks of gestation, the fetus in breech presentation and the presence of normal fetal heart sounds. She was managed conservatively, and she was placed on prophylactic antibiotics. A course of dexamethasone injections was given, and she was transferred to the antenatal ward. After 8 hours, the patient was readmitted to the labor ward complaining of labor pains, and pelvic examination revealed that the cervix was fully dilated with a frank breech presentation at station 1 cm below the ischial spine. An assisted breech delivery of a premature baby, birth weight 1570 g, was conducted. The Apgar scores of 3 and 9 were recorded, and an endotracheal tube was inserted into the baby.
+The baby was discovered to have the following abnormalities:
+fusion of both lower limbs ; ambiguous genitalia ; cloacal anomaly and tracheoesophageal fistula with atresia Active resuscitation of the new born was undertaken, the baby was then transferred to the neonatal intensive care unit. Fluorescent in situ hybridization (FISH) study was conducted on the baby, and it revealed 46 XX chromosome patterns with no numerical or structural abnormalities. Skeletal survey showed that the baby had two femoral bones, two tibias, two fibulas with sacral segmentation defect with 13 bilateral ribs and a normal vertebrae. The baby passed urine through a single partial opening over the sacral area.
+Exploratory laparotomy was performed, which showed distal jejunal atresia with dilated proximal bowel of 10–15 cm. The distal colon was atretic. The esophagus was ligated, 15 cm of dilated proximal loop was resected and jejunostomy along with gastrostomy was performed. Renal ultrasound showed left polycystic kidney, and the right kidney was not visualized (query for right ectopic kidney). No magnetic resonance imaging (MRI) was performed on the baby. The baby was discharged after 123 days to continue medical treatment in the USA.
+There was a discussion between two of the authors (FAH and AAA) and the parents about the authors’ intention to make a report of the case using all the information provided and the illustrations/pictures/X-rays of the neonate, and the parents gave their written informed consent for such a publication effort.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2374_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2374_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..72a4d292ed78f68411bdbee0a126cce870401ce8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2374_en.txt
@@ -0,0 +1 @@
+A 50-year-old housewife was diagnosed to have end-stage renal disease of uncertain etiology. After being on hemodialysis for one year, she underwent living unrelated renal transplantation at another centre with basiliximab induction followed by triple drug immunosuppression with tacrolimus (trough level 6.7-8.8 ng/mL), mycophenolate mofetil (1 gm twice daily) and prednisolone (5 mg daily). The pretransplant CMV sero-status of the donor and recipient was not known and she was not on prophylaxis for CMV. Three months post transplant, she was admitted with fever, headache, oral ulcers and dysphagia of one week duration and soon after admission she developed slurring of speech with drowsiness and weakness of left upper and lower limbs. During the preceding three months, she had maintained normal graft function and did not receive any anti-rejection therapy. There was no history of contact with pets or occupational exposure. At presentation, she was hemodynamically stable, febrile, had multiple oral ulcers with left hemiparesis and right upper motor neuron facial palsy. Her hemoglobin was 112 gm/L, total leukocyte count 7.8 × 109/L, platelet count 145 × 109/L and serum creatinine 78 μmol/L. Noncontrast computerized tomography (CT) followed by magnetic resonance imaging of brain revealed a 3 × 3 cm hypodense lesion in right temporo-parietal region with significant peri-lesional edema . An endoscopic examination for dysphagia revealed multiple esophageal ulcers, biopsy from which was positive for cytomegalovirus inclusions. Whole blood quantitative polymerase chain reaction (PCR) for CMV was positive with 17500 copies/mL. Simultaneously, a stereotactic biopsy from the brain lesion was performed. Fungal staining of the material showed septate hyphae, while fungal cultures grew melanin producing filamentous fungi with brown-black colonies. A lactophenol cotton blue mount demonstrated numerous single-celled, broadly clavate to ovoid conidia, 4–9 × 6–10 mm in size, rounded above with truncate bases, borne singly or in small groups on elongated, simple or branched conidiophores or on hyphae. These features confirmed the diagnosis of Scedosporium apiospermum . Mycophenolate mofetil and tacrolimus were stopped and she was started on intravenous (i.v.) ganciclovir and i.v. voriconazole. After one week of therapy, she became afebrile with improvement of power in the left upper limb. A repeat CT scan of the head done after one week showed reduction in size of the lesion . After 3 weeks of therapy, the patient showed significant improvement in the slurred speech and she became ambulatory with support. There was significant reduction in size in repeat CT scan. Repeat CMV PCR done after three weeks was negative and patient was started on valganciclovir prophylaxis and oral voriconazole. The levels of voriconazole were monitored and maintained between 1–5.0 μg/mL for initial 3 months. At the end of two months, she was readmitted with fever and dry cough. Chest radiograph and high resolution CT chest showed thin smooth walled cavitary lesion with surrounding consolidation. A fine-needle aspiration demonstrated acid-fast bacilli, which were confirmed to be Mycobacterium tuberculosis on culture. A CT chest was not obtained during the first hospitalization, thus we cannot exclude the possibility of either Scedosporium or tuberculosis in the lung at that time. She responded well with rifampicin based four drug antituberculous therapy. During the first month of rifampicin therapy, the median dose of voriconazole needed to be increased to 600 mg per day to maintain its levels in the therapeutic range, while subsequently voriconazole was given at a fixed dose of 200 mg once a day as secondary chemoprophylaxis. At six months of follow-up, she had recovered completely. She was maintaining normal graft function with prednisolone 10 mg once a day with a plan to introduce azathioprine. She continues to take 200 mg of voriconazole, while her antituberculous therapy and valganciclovir have been stopped. She was evaluated for an occult primary immunosuppressive disorder with defective cell mediated immunity, in view of the repeated life threatening infections. There was no hypogammaglobulinemia or CD4 cytopenia and her human immunodeficiency virus (HIV) status was negative.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2377_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2377_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6003581bf38757ace22b4ad7dd7ae51dbe2c22c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2377_en.txt
@@ -0,0 +1,6 @@
+A 66-year-old man was admitted to our hospital for repeated hemoptysis accompanied by fever for 8 months. A large amount of bloody purulent sputum was coughed out at the beginning, followed by brown pus. The largest amount was about 100 ml. He denied chest pain or dyspnea. The patient took amoxicillin and oral hemostatic drug and the symptoms were relieved. However, the symptoms recurred and gradually worsened. He was admitted to another hospital and received antibiotic therapy with levofloxacin and imipenem. His relevant past medical history included cholecystectomy for gallstone 5 years ago.
+On admission, he had a temperature of 37.0 °C, heart rate of 80 beats per minute, blood pressure of 120/70 mmHg, and an oxygen saturation of 95% on room air. Physical examination revealed no positive sign. Chest CT scan demonstrated a consolidative mass located in the right middle lobe, together with scattered inflammation in the bilateral lower lobes and mediastinal lymphadenopathy . The patient received ceftriaxone and moxifloxacin intravenously with no improvement. Bronchoscopy exhibited no evidence of tumor or tuberculosis . Percutaneous lung puncture found inflammatory and tissue cells, and puncture fluid grew Escherichia coli. Pulmonary abscess was diagnosed and the antobiotic was changed to biapenem according to the drug sensitivity result . The condition improved and the patient was discharged.
+However, the patient presented with hemoptysis again 2 months later but he refused surgery. So, he received right middle lobe arterial embolization. Digital substraction angiography showed a right bronchus common bronchial artery (canal-like expansion of right bronchial artery and right middle lobe pulmonary artery), a left and right common bronchial artery, and abnormal right inferior phrenic artery (tumor-like expansion at the traffic of right inferior phrenic artery and right middle lobe pulmonary artery).
+Three months later, the patient suffered from hemoptysis again with about 1000 ml a day. Since conservative treatment failed, the patient agreed to right middle and lower lobectomy by open surgery. During the operation, the middle lobe was found to adhere to the diaphragm. However, when the adhesion was removed, a hole was observed on the diaphragm and colonic perforation was seen. The colon and the diaphragm were closed by suturing separately. Pathology demonstrated bronchogenic cysts with epithelial squamous hyperplasia. In addition, intestinal epithelium was found on the adhesion of middle lobe with diaphragm . Three days after operation, turbid stool like fluid drained out from the chest tube , and the patient developed continuous fever and increased white blood cell. Enterogenic empyema was diagnosed and emergent surgery found the diaphragm repair ruptured. Considering the pus was derived from the colon, a jejunostomy and empyema drainage was performed. The pus in the chest cavity was removed and a drainage tube was put into the colon from the chest cavity . Blood culture grew Staphylococcus aureus, and he received imipenem and piperacillin/tazobartan alternately upon drug sensitive results . The right lung re-expanded after surgery and no drainage came out from the colon tube.
+Three weeks later, there was air leak from the chest tube again and CT scan showed bronchopleural fistula (BPF) at the bronchial stump . A rib bed drainage was performed since the visceral pleura was adhered to the lung tissue. Together with large amount of protein intake, the BPF closed in 3 months and all the chest tubes were removed.
+Nine months after the first operation, enteroscopy demonstrated disuse colitis without other digestive tract pathology. The patient underwent right hemicolectomy and closure of ileostomy . The pathology reported chronic inflammation without evidence of Crohn’s disease. He was doing well when he was seen in clinic 2 months after the last surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2381_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2381_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..284f37816775f7ddff960d29f74d571fadf828e6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2381_en.txt
@@ -0,0 +1,11 @@
+In 2003, the Department of Oral Pathology and Surgery at the School of Dentistry, University of Athens referred a young 22-year-old female with Hajdu-Cheney Syndrome (HCS) to the Postgraduate Clinic of the Department of Periodontology, in order to receive periodontal treatment . The patient was diagnosed in 2001 with HCS after clinical, radiographic and histological examination . After gene examination of both parents, none of them was found bearing a mutation in the NOTCH2 gene . Her physical examination showed that her height was 145cm and her weight was 45kg. The patient had thick coarse hair, low-set ears, small face and stature, thin lips, small mouth and short hands with clubbing of the fingertips . According to her medical history, the patient suffered from emphysema and allergic rhinitis, whereas oral intake of Vitamin D and calcium were prescribed daily for the treatment of osteoporosis [, ].
+During orthodontic treatment between the ages of 12 and 21 years, all of her first premolars were removed . At the age of 20 years, the patient received non-surgical periodontal treatment (scaling and root surface debridement), as well as limited periodontal surgery in the lower anterior region [, ]. Detailed records regarding both orthodontic and periodontal treatment were not available. The patient was a non-smoker, visited her dentist every 6 months, brushed her teeth twice every day (Bass technique) and used dental floss and interdental brushes. At the time of the referral, the patient suffered from generalized advanced chronic periodontitis, increased tooth mobility and premature tooth loss . Clinical and radiographic examination of both parents and her 4 years younger brother showed that the mother and the younger brother had normal dentition, whereas the father was diagnosed with chronic advanced periodontal disease with increased mobility of various teeth.
+The patient was treated in collaboration with the Department of Prosthodontics. Clinical and radiographic examination of the patient revealed a number of significant findings. There was generalized horizontal bone loss of ~ 50%. However, alveolar bone loss around various teeth such as #4 (in place of #5), 14 and 24 was extensive (~ 100%). Tooth roots appeared short and cervical, whereas cervical resorption lesions were also evident (teeth #3, 10, 20 (in place of #19), 26) [, ]. The patient received non-surgical periodontal treatment in all four quadrants, which included scaling and root surface debridement. During this period, teeth #4, 14 and 24 were extracted due to extensive alveolar bone loss . The maxilla was then rehabilitated with the placement of a provisional fixed partial denture of metal acrylic and the anterior region of the mandible with the placement of a Maryland bridge . Upon completion of the periodontal treatment, the patient was enrolled in a periodontal maintenance program.
+After careful consideration of the possible implications deriving from the patient’s condition (osteoporosis, generalized advanced periodontitis) and having taken her young age into account, we decided to proceed with the placement of dental implants, while implementing specific protocols such as longer healing periods. So, although in the current literature no other case of implant placement in a patient with HCS was described, in February 2005, a dental implant (Nobel Biocare, Replace Select Straight, TiUnite RP 4.3 x 13mm) was placed in the upper right first premolar region .
+During the healing period, in March 2009, further teeth were extracted (#2,3,30). During the extraction of tooth #30, a bovine xenograft (Geistlich Bio-Oss Collagen 250 mg) was placed in the post-extraction site, in order to achieve ridge preservation and the region was rehabilitated with a resin-bonded bridge (Maryland bridge).
+Five years after placement and successful osseointegration of the dental implant in position #5, an additional implant (Nobel Biocare, Replace Select Tapered TiUnite Regular Platform (RP) 4.3 x 8mm) was placed in the upper right first molar region . Bone mineral density appeared physiological (Bone Type III) .
+Six months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 3 (4) 5 was placed in the upper right region . During this period of time, teeth # 18, 19 were extracted due to excessive bone loss.
+Clinical and radiographic examination of the patient during the periodontal maintenance program in three months interval after implant placement revealed no abnormalities in the implant region. After successful oral rehabilitation of the posterior upper right region, 2 additional dental implants were placed in the posterior left region (during surgery tooth #20 - in place of #21- was extracted) and 1 in the posterior right region of the mandible (Straumann Standard Platform (SP) Tissue Level) .
+Six months after implant placement, a porcelain fused to metal, three unit implant supported fixed partial denture 19 18 was placed in the left region of the mandible, whereas a porcelain fused to metal implant supported crown was placed in the right region of the mandible .
+Five years after implant placement, clinical and radiographic examination of the patient during the periodontal maintenance program (in three months interval) revealed no abnormalities .
+For the reader’s better understanding, Table presents the patient’s detailed dental treatment chronologically.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2400_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2400_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..160662559230cae3b8fac16405b9a50d8ae4df70
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2400_en.txt
@@ -0,0 +1,2 @@
+We report here a case of 37-year old woman with schizophrenia, hospitalized for an exacerbation of psychotic symptoms. She had no personal/family history of cardiac diseases or sudden deaths. Besides benzodiazepines, she was treated at the admission with aripiprazol (20 mg/day), haloperidol (3 mg/day) and escitalopram (20 mg/day). The routine laboratory and clinical check-up (including ECG and blood electrolytes) revealed no abnormalities. The patient developed the aLQTS in response to small doses of risperidone (1–2 mg/day), confirmed at three independent drug challenges. Noteworthy, the patient responded with significant QT prolongation to risperidone (QTc increase from 458 to 508 ms), also when all other drugs, which might potentially affect QT length, were discontinued (Figure ). The reason of this extreme sensitivity to risperidone was unclear but the contribution of a cytochrome polymorphism or other elimination failures is unlikely since risperidone prolonged QT at very low blood concentrations (19.1 nM). Moreover, the concentration of paliperidone, an active metabolite of risperidone with QT-prolonging potential , was very low too, and the cumulative blood concentration of risperidone and paliperidone was subtherapeutic. Interestingly, the patient did not respond with QT prolongation following the administration of other antipsychotics (e.g. aripiprazol, clothiapine, haloperidol; data not depicted). In particular, the administration of clozapine, known to be associated with higher QT-prolongation risk than risperidone , had no effect on QT-length (Figure ).
+We hypothesized that our patient carries a mutation or polymorphism in the KCNH2, which could determine conformational alterations of the channel and thus differentially affect its capacity to bind risperidone and clozapine. Therefore, we have sequenced all the coding exons and exon-intron boundaries of the KCNH2 (isoforms 1a and 1b), but no mutation or polymorphism was found (data not depicted). We have also excluded any mutation in the SCN5A gene, as well as in the KCNE2 (data not depicted), the gene encoding the β–subunit of the Ikr channel, as well as G38S and D85N polymorphism in the KCNE1, reported to cause the LQTS [,]. Since a subtle mutation in the KCNQ1 could affect the repolarisation reserve, indirectly leading to the aLQTS [,], we have sequenced also this gene but found no mutation (data not depicted). Additionally, we have excluded any exonic deletion and duplication of the KCNH2 by Multiplex Ligation-dependent Probe Amplification (data not depicted; P114-A2-LQT probemix, MRC-Holland).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2437_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2437_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28357fc43e1524d6222ae78b66af254e16888a68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2437_en.txt
@@ -0,0 +1 @@
+A 50-year-old hypertensive woman presented to the emergency department of our hospital presenting headache while shopping. There was no history of preceding falls or head injuries. She had not been administered steroids, anticoagulants, or antiplatelet agents. At presentation, the patient was fully awake and did not exhibit any focal neurological deficits. The blood pressure was 176/113 mmHg, and blood examination revealed normal findings. Cranial computed tomography (CT) revealed a subtly compressive, apparently ASDH in the left cerebral convexity. It was 15 mm in thickness without displacement of midline structures and showed a regression in 1 day with resolution of the headache . Three-dimensional CT angiography showed no vascular lesions in the intracranial dural sinuses or major cortical veins . Cerebral magnetic resonance imaging (MRI) performed on post hospitalization day (PHD) 6 revealed a non-enhancing, nodular lesion in the subdural hematoma, and adjacent to the left parietal cortex . The patient was conservatively managed based on a probable diagnosis of non-traumatic ASDH. However, the patient presented with disorientation and aphasia on PHD 14; CT showed a considerable enlargement of the subdural hematoma with better delineation of the nodular lesion on T2-weighted sequence . Catheter angiography performed on PHD 14 did not reveal any intracranial vascular lesions. The patient underwent removal of the microsurgical hematoma including the nodular lesion through a 5 × 5-cm parietal craniotomy. The subdural hematoma showed a bi-layered structure comprising a thick outer membrane and inner semisolid clots. The cerebral cortex underneath the hematoma was intact. The nodular lesion identified previously on MRI, possessed a fibrous capsule, included clots, and adhered to the outer membrane of the hematoma and arachnoids. These attachments were bluntly dissected without injuring the cortical vessels coursing underneath . Abnormal vasculature was not found between the lesion and surrounding tissues. The outer membrane of the hematoma and the semisolid subdural clots were partially removed. Microscopically, the resected outer membrane of the CSDH and the nodular lesion revealed areas of microvascular proliferation . The patient’s postoperative recovery period was uneventful. On postoperative day 35, CT showed a remarkable resolution of the residual hematoma .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2451_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2451_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..96ab966068a0e6a4ac725dda993cad6cfd19a660
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2451_en.txt
@@ -0,0 +1,2 @@
+A 59-year-old man had a history of four years of paroxysmal AF. He was normotensive and euglycemic. Due to recurrent symptomatic AF episodes and subsequent failure of antiarrhythmic drugs, he underwent a cryoballoon ablation of the PV. Under local anesthesia, His and coronary sinus catheter were inserted via the left groin. Cryoconsole was switched on for cryotherapy, but it displayed “low refrigerant level”. After trans-septal puncture, angiogram of the left atrium revealed left-sided common PV ostia of 29.4 mm, right superior PV of 24 mm, and right inferior PV of 14 mm. Successful ablation of all other PVs except for the right inferior PV were performed using six application cycles of four minutes each with 28 mm cryoballoon (Arctic FrontTM, Medtronic; CB, Medtronic, Minneapolis, MN, USA). Then cryoballoon was positioned to the ostium of right inferior PV. Vein occlusion was monitored for cryoballoon-to-PV contact by observing during the injection of a 50%-diluted contrast medium distally into the PV. This is graded on a 1 to 4 scale, with 1 being minimum occlusion and 4 being complete occlusion. For this PV, the grade of occlusion obtained was 4/4 . Freezing was started. In spite of waiting for more than 60 seconds, the minimum temperature did not cross beyond -34°C. Special maneuvers as “pull-down technique” and “hockey stick technique” were tried, without any success (11). The application was stopped considering the nonoptimal temperature (9). The cryoballoon was repositioned for better PV contact, reverified by diluted contrast injection to be 4/4 of grade of occlusion. However, the temperature again did not cross beyond -30°C. The application was again stopped at 60 seconds. After optimal positioning cryoablation was reattempted. Surprisingly, again, the temperature did not cross beyond -28°C. We were intrigued for the reason behind this. Afterwards, a final try with cryoballoon was thought for before switching to cryocatheter for AchieveTM (Medtronic Inc.) guided touchups. Finally, after observing the 4/4 occlusion grade, freezing was restarted for the third time. To our disappointment even after 60 seconds, the temperature was still hovering around -9°C. The moment the freezing application was to be stopped, the cryoconsole screen flashed, “The pressure is low in the system. Ensure the refrigerant tank is open”. Ultimately, the refrigerant cylinder was changed. Cryoablation was reinitiated after ensuring the 4/4 occlusion and optimal positioning. Minimum ablation temperature of -47°C was reached with acute successful isolation of PVs . We faced similar situation described above three times in a span of nine months for different PVs. After communicating about this problem to Medtronic’s local representative, data was retrospectively collected from cryoconsole for further investigations. The flow of the gas through the umbilical (displayed at a cryoconsole) was measured and investigated in the data files. However, the analysis showed no known technical issues.
+If nonoptimal temperature is obtained in spite of good grade of occlusion of cryoballoon and optimal positioning, early change of a refrigerant cylinder ought to be considered in case of “low refrigerant level” cryoconsole display. Earlier change may be considered in spite of absence of the system notice, stating “The pressure is low in the system”, to decrease the procedure time and unnecessary radiation exposure. Retrospectively, it may be suggested to the device manufacturer for use of better pressure-sensitive refrigerant cylinder valve or earlier system notification for change of the refrigerant cylinder.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2472_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2472_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1ac4cfd1a0fb54ea277e2c54122fb5bcf615f12a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2472_en.txt
@@ -0,0 +1,6 @@
+A 7-year-old female patient, residing in an urban area and with no prior medical history, was brought to the emergency department by her parents. The patient had a history of consuming pork daily. Clinical symptoms had begun the day before admission, characterized by abdominal pain in the lower quadrants of a colic-like nature, accompanied by abdominal distension. Additionally, the patient exhibited fever, multiple vomiting episodes, and diarrhea. She had been self-medicated with an antidiarrheal (Loperamide) in an unspecified dose by her parents.
+Laboratory tests revealed leukocytosis (13,160 × 103/μl) without neutrophilia and thrombocytosis (554,000 × μl). Urinalysis showed no pathological findings. Imaging evaluation included an abdominal radiography, which reported the presence of multiple air-fluid levels and absence of gas in the distal segment, suggesting an intestinal obstruction. Given these findings, management with Ampicillin/Sulbactam was initiated, and she was transferred to a higher complexity center on the third day of the onset of symptoms.
+Upon admission to the institution, the patient exhibited signs of dehydration, tachypnea, a restrictive respiratory pattern, a distended and tympanic abdomen with pain upon palpation in the lower abdomen. Additionally, she presented with fever, multiple vomiting episodes of food content, and diarrheal stools without the presence of mucus or blood. Resuscitation management was initiated, and she was assessed by the pediatric surgery department, which found no signs of peritoneal irritation on physical examination. A rectal examination revealed the presence of abundant fecal matter in the rectal ampulla, leading to the placement of a nasogastric tube and administration of an enema with 175 ml of isotonic saline solution and 75 ml of soapy solution, resulting in minimal fecal return. Post-enema abdominal radiography showed coprostasis and distension of the small bowel without evidence of air-fluid levels . Admission laboratory tests showed leukocytosis (16,630 × 103/μl) with an increase in neutrophils (12,940 × 103/μl), thrombocytosis (478,000 × μl), and elevated levels of C-reactive protein (35.06 mg/dl, with a reference range of 0–5 mg/dl). Arterial gases revealed compensated respiratory alkalosis and hypokalemia (3.2 mEq/l). Given the inadequate response to medical treatment for intestinal obstruction, treatment was escalated to Piperacillin/Tazobactam, and the patient was transferred to the intensive care unit.
+Given the lack of response to medical treatment, a decision was made to perform an abdominal computed tomography (CT) scan on the first day of admission to the institution. The images revealed notable dilatation of the small bowel, with a maximum diameter of 4.3 cm, without evident transition zones, and an appendix measuring 9 mm with increased enhancement of its walls, presence of gas within, surrounding peritoneal thickening, free abdominal fluid, and pneumoperitoneum . These findings led to the diagnosis of acute appendicitis with secondary ileus. The patient was prepared for surgical intervention. The procedure, initially planned as a laparoscopic appendectomy, had to be converted to an open surgery via a midline infraumbilical laparotomy due to the development of respiratory distress caused by the insufflation of pneumoperitoneum and limited visibility due to intestinal distension. During the surgical procedure, an appendiceal phlegmon formed by loops of the small intestine was mechanically released without requiring intestinal resection. The appendix was found in a subcecal position, necrotic, and perforated at its tip. Given the extensive fecal contamination, a peritoneal irrigation was performed until clear fluid return was achieved.
+In the postoperative period, the patient was taken to the ICU, where she continued antibiotic management with Piperacillin/Tazobactam. The use of vasopressors or ventilatory support was not necessary. She remained with ileus for six days, necessitating the use of parenteral nutritional support. Control laboratory tests performed on the fourth postoperative day showed improvement in inflammatory markers, with a reduction in the levels of leukocytes (12,980 × 103/μl), neutrophils (7,300 × 103/μl), and C-reactive protein (7.94 mg/dl). The patient was then transferred to general ward care. Resolution of the ileus and tolerance to oral intake were achieved by the sixth postoperative day.
+Pathologic analysis revealed an inflammatory infiltrate and perforation of the appendix with liquefactive necrosis, along with the presence of Balantidium coli trophozoites, leading to the definitive diagnosis of acute appendicitis caused by Balantidium coli . Following this finding, Metronidazole was added to the medical management, administered at a dose of 500 mg every 8 h. The postoperative recovery proceeded without complications. She completed treatment with 10 total days of Piperacillin/Tazobactam and 7 days of Metronidazole. Ten days after the surgical intervention, she was discharged. At the two-week outpatient follow-up no signs of infection in the surgical wound were seen, adequate wound healing was observed, and no abdominal pain was present .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2479_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2479_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..92b2e3924daec88bb346ee2d7a2f35eb02597af3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2479_en.txt
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+The 70-year-old female was electively admitted to our institution for an open pancreaticoduodenectomy for the treatment pancreatic adenocarcinoma. The patient had the chief complaint of painless jaundice.
+The jaundice had arisen insidiously over a 6-mo period. It was associated with weight loss and poor appetite. Extensive investigations had been performed, including computed tomography of the chest, abdomen and pelvis, magnetic resonance cholangiopancreatography, endoscopic ultrasound, endoscopic retrograde cholangiopancreatography, and positive emission topography scan. She had also had a diagnostic laparoscopy.
+The patient’s only past medical history included an open appendectomy for appendicitis.
+As per unit and hospital protocol, immediately post-operation, the patient was admitted to the intensive care unit (ICU) with nasojejunal (NJ) feeding tube. EN commenced 6 h post-operation at 30 mL/h. She required no vasopressor support and on day 1 had the feed rate increased. She was transferred to the surgical ward and the only concern in the immediate post-operative period was high nasogastric (NG) output. This initially improved, and slowly oral intake was introduced. She was prescribed an osmotic laxative at this time.
+On day 5, the patient developed nausea and vomiting, with increasing pain in her central abdomen. Clinically, she had a mild tachycardia and central abdominal tenderness. The initial differential diagnosis of the presentation was postoperative anastomotic leak, particularly supported by the sudden deterioration in clinical picture and timing of the deterioration. Other differentials included postoperative collection and small bowel obstruction, potentially caused by internal hernia. To investigate, a computed tomography was organized; the finding was a large volume of fluid in distal thoracic esophagus and stomach. The tip of the NJ feeding tube was located appropriately within the efferent small bowel loop. There were also features of proximal to mid small bowel obstruction with faecalisation . The transition point was not clearly defined . Adhesions were postulated as a possible cause.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2488_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2488_en.txt
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index 0000000000000000000000000000000000000000..524624b00251f7c9fd2e2e98271b03aa097cb1bc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2488_en.txt
@@ -0,0 +1,7 @@
+A 66-year-old female presented to the ER for abdominal pain and vomitting.
+She had a 4-d history of food intolerance with post-prandial vomiting and diffuse colic type abdominal pain, her bowel movements were maintained. She denied having previously experienced similar symptoms or symptoms suggesting of cholecystitis during her post-operative interval.
+She is known to have bipolar disease treated with Perphrenazine 8 mg and known to be a 5 pack/year smoker. She was operated of OAGB 6 years ago for morbid obesity [body mass index (BMI): 66.7 kg/m2]. Previous comorbidities that included hypertension and diabetes mellitus were rectified after her weight loss of 90 Kg (BMI: 26.66 kg/m2). Previous surgical interventions include 2 C-section deliveries.
+She has no significant family history.
+On physical examination, her abdomen was soft with mild tenderness in the lower right quadrant. She had a supra-umbilical hernia from her previous intervention.
+Her labs showed a mild hyper-leukocytosis white blood cell 12000 and C-reactive protein level was 80.8, her liver enzymes were in the normal range.
+An abdomino-pelvic computed tomography scan with injection and ingestion of contrast was ordered . It showed a fistulous tract between the gallbladder and the duodenal bulb, extending over 15 mm. The fistula was confirmed with the leakage of the ingested contrast in the lumen of the gallbladder, which was not distended and contained an air-fluid level. It was associated with pneumobilia and small bowel dilation of 42 mm in diameter, with an intestinal segment in the right lower quadrant showing parietal thickening and submucosal edema upstream of a transition zone located at the level of the right iliac fossa, downstream of a probable oval intraluminal calculus of 45 mm. The previous findings evoking a GI with a probable gallstone located at the level of the efferent alimentary loop. It is associated with a trabeculation of the fat at the level of the two flanks, especially on the right, with perihepatic and pelvic ascites of low abundance. Sequelae of gastric surgery with gastro-jejunal anastomosis (Roux en Omega) was identified.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2491_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2491_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..80f10fbc78bd1f460a977590005073a1d5c8e970
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2491_en.txt
@@ -0,0 +1,6 @@
+A 42-year-old male complained of recurrent episodes of melena and dizziness, fatigue and reduced exercise capacity for more than 2 mo.
+The patient's symptoms started 2 mo ago with recurrent episodes of melena and he frequently felt fatigued. He was diagnosed with a gastric ulcer and anemia after undergoing gastroduodenoscopy, colonoscopy and laboratory blood tests. Then he took oral proton-pump inhibitors and iron for 1.5 mo, but these therapies did not ameliorate the symptoms.
+The patient had no previous medical history.
+On examination, anemic face and upper abdominal tenderness were noted. The vital signs were normal with a respiratory rate of 18/min, heart rate of 96/min and blood pressure of 102/62 mmHg.
+Blood analysis revealed severe iron-deficiency anemia with hemoglobin of 53 g/dL, and fecal occult blood was positive. Blood biochemistry, tumor biomarkers, other blood tests as well as urine analysis were normal. Electrocardiogram and chest X-ray were also normal.
+When the patient presented in our hospital, two units of blood were transfused. The gastroduodenoscopy was performed again. A sealed ulcer without any signs of bleeding sign were found in the antrum. We then performed a CE. Bleeding was found in the jejunum after running the capsule for 97 min. The total running time in the small bowel was about 300 min. The CE cannot determine the cause of bleeding due to the short stay around the lesion and the influence of the blood. An anterograde BAE was performed, and a protruded lesion was revealed in the jejunum at about 150 cm distal to the ligament of Treitz. It filled half of the intestinal cavity. The tumor was lobulated with white patches on the mucosal surface with blood oozing in the fundus . Multiple biopsies were taken, and pathological findings further revealed that hyperplastic thin-walled lymphatic and venous with luminal dilation presented in the submucosal area .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2493_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2493_en.txt
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index 0000000000000000000000000000000000000000..c728fb63cfe12a362dcf5da83d9bb6bef923c779
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2493_en.txt
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+A 43-year-old Malay female was referred by an ophthalmologist to the low vision clinic for low vision rehabilitation assessment. She was diagnosed with tractional retinal detachment secondary to diabetic retinopathy. She reported that she was diagnosed with diabetes mellitus 5 years ago. Currently, the patient is on follow-up and receiving treatment for diabetes mellitus from a government hospital. Her treatment includes metformin 500 mg twice daily, glicazide 60 mg daily and insulin 18 unit/day (nocte). Her glycosylated hemoglobin (HbAIc) assay at her last visit was 7 mmol/L. Apart from the diabetes mellitus, she is also on treatment for hypertension with hydrochlorothiazide 12.5 mg daily and for cholesterol with atorvastatin 20 mg daily. However, there was no evidence of any end organ damage i.e. diabetic nephropathy or diabetic neuropathy. There was no family history of diabetes mellitus or retinal detachment. Her main complaints at presentation at the low vision clinic was 1) blurred vision at both distance and near but she had never used nor was ever prescribed with any contact lens or glasses, 2) difficulty in recognizing faces and 3) difficulty with orientation and mobility. She had exhausted all her efforts to get treatment/rehabilitation for her visual problem and was frequently told that “nothing more can be done” to alleviate her condition. She agreed to be referred to the low vision clinic by the private ophthalmologist as a last attempt to improve her vision and quality of life through low vision rehabilitation.
+Upon examination, her distance vision for right eye (RE) and left eye (LE) was 6/48. Her near vision was N28 at 20 cm bilaterally. Subjective refraction, improved her distance vision to RE 6/48 using -1.75Ds, and LE 6/38 with a +3.50 Ds. For near, addition of +2.50 Ds enabled her to read N24 for RE and N16 for LE both at a reading distance of 20 cm. Visual field assessment testing at near using an Amsler’s chart revealed no abnormality. Contrast sensitivity function was not measured. Examination of her fundi using binocular indirect ophthalmoscopy and fundus photography showed diabetic retinopathy changes and tractional retinal detachment . She was informed of her eye condition with respect to the pathological process and its effect on her functional vision. The DASS score showed that she was in a state of severe stress (score = 34); she was severely anxious (score = 16), and she was depressed (score = 38). The LVQoL questionnaire assessment score was 43, which indicated that her quality of life was at the moderate stage.
+Low vision assessment was conducted for near and distance vision. Using a +6.00 Ds spectacle magnifier she was able to improve her near vision to N10 at a reading distance of 20 cm. For her LE distance vision, a 3× monocular telescope was able to improve her vision to 6/12. She was also introduced to eccentric viewing techniques to identify/recognize faces. To assist her with orientation and mobility, a pair of distance spectacles with prescription of RE-1.75 Ds, LE +3.50 Ds and a 3x monocular telescope was prescribed. She was also referred to an orientation & mobility clinic at a training center organized by a blind person’s association. She agreed to a referral to the Social Welfare Department for registration purposes and eligibility assessment for benefits. To help her cope with her mental health status, she was referred to a clinical psychology clinic. She was also referred to an occupational therapy clinic to cope with her daily living activities. She was advised to return for a review at the low vision clinic in 3 months to monitor her functional vision for distance and near work and to repeat her DASS and LVQoL evaluations. Her mental health state will be monitored using DASS and her quality of life scores will be measured using the LVQoL questionnaire at the follow up.
+After 3 months, the patient returned for a follow-up low vision. A routine low vision assessment was conducted and the DASS and LVQoL questionnaire was readministered. It was found that the patient’s visual acuity for both eyes remains the same i.e. 6/48. Subjective refraction and visual field status were similarly unchanged. The DASS and LVQoL questionnaire on the other hand showed significant improvement. The DASS score indicated that the stress level had come down from extremely severe (score = 34) to normal (score = 14) and the depression level also registered a decrease from extremely severe to moderate (score = 18) level. The anxiety score remained at 16 while the LVQoL score markedly improved from 43 to 98. A further three months review was given to the patient at the low vision clinic. At the same time, the patient was advised to continue with her sessions at the psychology clinic, occupational therapy clinic and the orientation & mobility clinic at the association for the blind.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2557_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2557_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbbd7c0c224ee67ebd32de32797929851ad6cf68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2557_en.txt
@@ -0,0 +1,7 @@
+A 57-year-old woman presented in 1995 with a six-week history of acute onset polyarthralgia. She also had Raynaud’s phenomenon, dry eyes, dyspepsia, intermittent night sweats, brittle nails, intermittent hair loss, mouth ulcers and fatigue. A provisional diagnosis of mild connective tissue disease (Sjögren’s or lupus) was made, based on her symptoms and a single positive doubled-stranded deoxyribonucleic acid (DNA) result.
+Her past medical history included Hashimoto’s thyroiditis and osteoarthritis. In 2007, she was infected with a sheep bot fly while in Morocco. She subsequently had larvae removed from her left maxillary sinus and her right eye by our ear, nose and throat team.
+In 2010, she re-presented to our rheumatology department with intermittent left-sided facial pain and swelling, accompanied by hearing loss in her left ear. She also described gradually worsening epiphora, blepharospasm and left eye swelling.
+An autoimmune screen was negative, including anti-Ro and anti-La, anti-neutrophil cytoplasmic antibodies, autoantibody and antinuclear antibodies. Her erythrocyte sedimentation rate was 6mm/h (normal range: 1 to 20mm/h) and her levels of immunoglobulin G and A were mildly elevated. A Schirmer’s test was also normal. In view of these results, it was felt that her symptoms were unlikely to be due to connective tissue disease.
+Magnetic resonance imaging (MRI) of her sinuses, skull base and parotid glands showed only mild thickening of her sinuses. She was referred to our ear, nose and throat team for further investigation. A tympanogram demonstrated low tone loss and negative pressure. An ultrasound scan of the left side of her face found no cause for the swelling, and a flexible naso-endoscopy was normal.
+In 2012, our patient was referred to our ophthalmology team because of the persisting symptoms. She had been started on carbamazepine and botulinum toxin injections to her facial muscles, with minimal symptomatic improvement. A second MRI scan was performed and reviewed by a neuroradiologist. This scan suggested vascular compression of her left facial nerve. A vascular loop protocol MRI showed a loop of her posterior inferior cerebellar artery taking a long course around the seventh and eighth cranial nerves into the meatus and back, resulting in compression of her seventh and eighth cranial nerves.
+Our patient was referred to our neurosurgical team for microvascular decompression. Her symptoms of pain, epiphora, blepharospasm and swelling completely resolved following this procedure.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_259_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_259_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a5c25359aaed14cd3b2e93052c4e1ccf82d056c1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_259_en.txt
@@ -0,0 +1,2 @@
+A 57-year-old female patient with a weight of 70 kg presented at our hospital with a neck mass 5 years ago. She complained of neck discomfort in 2014 but was not prescribed medication. She presented again in May 2015 due to painless neck lymph node tumefaction without fever, for which she also did not receive medical treatment. By September 5, 2015, the bilateral lymph nodes in the neck had grown significantly, and more lymph nodes were affected. On September 8, 2015, a computed tomography (CT) scan showed tumefaction of bilateral cervical and supraclavicular lymph nodes, and the largest lymph node was 3.4 cm × 4.3 cm. Multiple enlarged lymph nodes were also found in the upper mediastinum, and the largest one was approximately 2.3 cm × 1.7 cm and occupied the thyroid. On September 11, 2015, PET/CT imaging showed bilateral cervical and supraclavicular lymph node involvement and multiple enlarged lymph nodes in the upper mediastinum (SUVmax: 9.05). Thyroid cancer with bilateral cervical lymph node metastasis or lymphoma was suspected, and cervical lymph node biopsy was performed. The pathological findings suggested T cell/histiocyte-rich large B cell lymphoma . The detailed immunohistochemical findings were as follows: CD20 (2+), PAX-5 (2+), ALK (−), BCL-6 (scattered weak+), CD10 (−), CD2 (−), CD21 (−), CD3 (−), CD30 (1+), CD4 (−), CD5 (±), CD56 (±), Ki67 (+60%), PD-1 (−), TIA1 (−), CD15 (−), LCA (3+), S-100 (−), CD68 (±), CD1a (−), and CD35 (−). The biopsy was negative for Epstein-Barr virus (EBV)-encoded RNA (EBER). The specific treatments are shown in .
+Re-examination by PET/CT showed multiple small and swollen lymph nodes in the right lateral iliac vessels and the right groin area that were partially fused into a clump, with a size of approximately 71 mm × 72 mm × 98 mm. The boundary with the adjacent abdominal oblique muscle and skin was unclear, the adjacent abdominal oblique muscle was thickened, the surrounding fat was turbid, and fluoro-deoxy glucose (FDG) metabolism was increased, with a SUVmax of 24.48. The right abdominal oblique muscle was invaded by lymphoma . Based on the above analysis, repeated systemic chemotherapy and local radiotherapy were applied, but the tumor still recurred in the local superficial area. This recurrence may be related to changes in the local anatomy of the patient after repeated treatment, and as a result, the drug could not reach an effective concentration locally. However, related chemotherapy drugs have no indication for local subcutaneous injection; therefore, CD19 CAR-T cell therapy was considered. On June 6, 2019, the baseline levels of cytokines (including IL-2, IL-4, IL-6, IL-10, TNF-α, and IFN-γ) were normal. An FC preconditioning regimen (fludarabine 30 mg d1-3 and cyclophosphamide 400 mg d1 + 600 mg d2) was administered on the same day, June 11, 2019, CD19 CAR-T cell treatment was started. Due to the local “barrier effect” of the lesion, we considered the possibility that the applied cells may not be able to affect the local area after intravenous infusion. Therefore, an approach of intravenous infusion combined with local injection was undertaken. Our center uses second-generation CD19 CAR-T cells generated by genetic engineering technology, in which the CAR domain that specifically recognizes tumor cells is transferred to activated T cells by lentivirus. The extracellular antigen-binding region is a single-chain variable region of a CD19-specific mouse antigen. With regard to the selection of intracellular costimulatory domains, related studies indicate that 4-1BB has better efficacy than CD28 ; therefore, our center utilizes the 4-1BB costimulatory domain. After the CAR-T cell therapy is constructed, it undergoes in vitro amplification and then is infused into patients. At present, the number of cells infused intravenously for this treatment at home and abroad is 1–10 × 106/kg (; ; ). The total number of cells administered to this patient was 5.78 × 108, and the following results were recorded: cell viability: 98.51% (trypan blue staining); cell marker detection: CD3 + CD4 + + CD3 + CD8 + > 95%; CAR19-positive rate: 63.65%; cell death activity: 48 h, F: T = 1:1, Raji: CD19 ratio < 20%. The cells (5.48 × 108) were suspended in 100 ml of physiological saline for intravenous infusion, which proceeded normally, and the remaining 3.0 × 107 cells were suspended in 10 ml of physiological saline for local treatment. According to the requirements for conventional surgery, under ultrasound guidance, we first selected an injection point in each of the four directions around the right lower abdominal wall mass. We injected 2 ml along each edge of the mass and then injected 2 ml in the center of the mass . The patient experienced no obvious discomfort except local swelling and pain. After 7 days of evaluation, the patient had no discomfort. The patient’s body temperature was 36.5°, the local skin temperature was 37.2°, and a scab appeared on the original skin mass with little exudation and was disinfected and covered with sterile dressings. The levels of the cytokines IL-6 and IL-10 in the blood appeared to slightly increase, 10.49 and 8.47 pg/ml, respectively, but the other factors were normal. At the evaluation on day 14, the patient complained of nocturnal pain in the mass, had a body temperature of 36.6° and a local skin temperature of 38.0°, and the levels of cytokines IL-6 and IL-10 had increased again (24.92 and 8.66 pg/ml), but the other factors were normal. At 16 days after the injection, ultrasonography detected a blurred mass of fused flakes (53 mm × 15 mm) with a slightly enhanced heterogeneous internal echo and abundant internal and surrounding blood flow in the right lumbar region and subcutaneous area of the right inferior abdomen. A cytological examination was suggested, but the patient requested to be discharged. Her out-patient treatment regimen was ibrutinib 400 mg/d + venetoclax 200 mg/d, and she reported a stable general condition. PET/CT imaging in August 2019 showed that the muscular tissue in the right antero-inferior abdominal wall had become thicker, with a slightly low-density shadow, unclear boundary and increased radioactivity uptake. The maximal cross-sectional area of the enhanced uptake shadow was 34 mm × 11 mm (SUVmax: 9.5), indicating increased tissue metabolism and a suspected malignant lesion. A regional flocculent, flaky, radiopaque shadow was observed in the subcutaneous areas of the right anteroinferior abdominal wall and right inguinal region (CT value: 27 Hu) with unclear boundaries. The radioactivity uptake was slightly increased (maximum SUV: 2.0), suggesting a higher level of metabolism. There was a soft tissue nodule beside the right lateral iliac artery with a maximum cross-sectional area of 20 mm × 8 mm (CT value: 54 Hu), slightly enhanced radioactivity uptake (SUVmax: 6.3), and increased metabolism, suggesting malignant lymph node lesions .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2618_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2618_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4495f303a6004db409ae20c517a5f7f04beb7f5d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2618_en.txt
@@ -0,0 +1,2 @@
+A 77-year-old Japanese woman was diagnosed with malignant melanoma in the right sinonasal cavity using biopsy approximately three years ago. She complained of nasal bleeding at that time. She underwent proton beam radiation therapy with sequential chemotherapy; however, she experienced double vision, and 1.5 years later, MRI revealed a local recurrence. After several courses of additional chemotherapy, the disease remained stable for the last 1.5 years. She underwent follow-up PET–CT and FDG uptake was detected at the gallbladder . Hematological examination revealed no specific findings. Contrast abdominal CT revealed an early enhanced mass in the gallbladder, and the enhancement persisted in the equilibrium phase . On MRI, the tumor showed low signal intensity on T1-weighted images and slightly high intensity on T2-weighted images . Endoscopic ultrasonography (EUS) showed no apparent tumor infiltration to the liver.
+The patient did not present with any symptoms. Because of the remaining nasal melanoma, surgical indication for the gallbladder tumor was controversial. We, however, recommended surgical treatment and she agreed for fear of its malignant potential. The primary preoperative diagnosis of the lesion was gallbladder cancer, and the secondary assessment was metastatic melanoma. Her general condition was good. After obtaining informed consent, which included advisement of the risk of relapse of nasal melanoma, we performed laparotomy and cholecystectomy with partial liver resection. In addition, lymphadenectomy of the hepatoduodenal ligament was performed. No ascites or macroscopic peritoneal dissemination was observed, and the tumor was localized in the gallbladder. The distal margin of the cystic duct was cancer free and the common bile duct was preserved. The tumor was soft, whitish, and measured 7.5 cm × 5 cm . Microscopically, it was diagnosed as a poorly differentiated malignant melanoma. Immunohistochemical examination revealed that the tumor was not similar to nasal melanoma, i.e., HMB-45 staining was far less positive in the gallbladder tumor than in the nasal tumor . The tumor cells reached the subserosal layer with mild vascular involvement, and the lymph nodes gave negative results for metastasis. No gallstones were observed. The postoperative course was uneventful. No distal recurrence has been detected for more than 13 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2642_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2642_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..50bbb5aeace82355ff17093a0a599e5d66c8c6c0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2642_en.txt
@@ -0,0 +1,3 @@
+A 53-year-old nulliparous woman was brought to our hospital after resuscitation from cardiopulmonary arrest. She was found lying in the park and a rescue team attempted defibrillation. On admission, an electrocardiogram showed V4–6 ST elevation, transthoracic echocardiography showed apical wall hypokinesis, and a computed tomography (CT) scan showed no aortic dissection or pericardial effusion. Creatine kinase level was 149 U/L (normal range, 0–165), creatine kinase myocardial band level was 20 U/L (normal range 0.2–5.0), and cardiac troponin I level was 0.26 ng/ml (normal range, 0.01–0.05). Because myocardial infarction was suspected, we performed emergency coronary angiography. The distal left anterior descending artery (LAD) was dissected, and PCI was performed. After this procedure, the proximal LAD and left circumflex artery were found to be newly dissected, as confirmed by coronary angiography and optical coherence tomography , so PCI was also carried out in these arteries. Pericardial effusion collection was recognized by transthoracic echocardiography and increased gradually, and CT showed type A AAD with a primary entry tear from the left main coronary artery trunk (LMT), which had not seen when the patient was arrived at our hospital . The patient’s systolic blood pressure decreased to 60 mmHg, so we proceeded with surgery.
+We performed a median sternotomy under general anesthesia. Bloody pericardial fluid and a hematoma in the fatty tissue of the right ventricle were present. Cardiopulmonary bypass was established with left femoral artery cannulation and bicaval venous cannulation, then the body temperature was lowered. When the bladder temperature reached 26 °C, circulatory arrest was initiated and the ascending aorta was opened. No hematoma was observed in the false lumen or primary entry tear. We hollowed out the left coronary ostium from the ascending aorta and observed it carefully. We found the primary entry, which is the posterior wall of the LMT ostium, and the outer membrane of the LMT was blown-out . The distal end of the ascending aorta was sutured to a 24-mm artificial vascular graft, and antegrade blood delivery was started from the side branch of the vascular graft. Because the primary entry was at the LMT, it was impossible to perform ostial patch plasty, so we closed the LMT ostium by continuous suture and bypassed grafting to LAD and left circumflex artery. The hole in the ascending aorta (the LMT ostium) was closed using a trapezoid artificial vascular graft patch . The proximal ascending aorta was sutured to the artificial vascular patch and the clamp was removed from the ascending aorta. As the bladder was warming, we carried out a coronary artery bypass graft (CABG) to the LAD and left circumflex artery using great saphenous vein grafts .
+Weaning from the cardiopulmonary bypass went smoothly. Bypass time was 192 min, circulatory arrest time was 17 min, cross-clamp time was 156 min, and operation time was 321 min. Postoperative transthoracic echocardiography revealed anteroseptal hypokinesis with an ejection fraction of 54%. The postoperative course was uneventful and the patient was discharged from our hospital on postoperative day 24. However, on postoperative day 64, she was brought back to our hospital with cardiopulmonary arrest, but did not recover. The cause of death was not identified, because of her family did not expect autopsy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2644_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2644_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..631667542ba57bf9f27175226ce028b8a0a5628d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2644_en.txt
@@ -0,0 +1,4 @@
+Our case here is related to a 54-year-old Iranian woman who was referred to emergency room of Sina hospital. She was feeling pain in her right hip after a simple falling, and could not bear weight on her leg. The anteroposterior and lateral radiography of hip joint showed a fracture of neck of the femur .
+Because of a lucency at the base of femur neck, we came to the conclusion that a pathologic fracture had occurred at that region. There was no abnormality in laboratory data of the patient, and she had no other underlying disease except a chronic low back and hip pain. Roentgenogram of the spine showed space narrowing and calcification of the intervertebral discs. The patient had also ochronotic pigmentation of the sclera .
+Thus, before any definite treatment of fractured region, we decided to take biopsy from the lesion. After incision of skin and subcutaneous fat, there was a dark blue or even black lesion in the deep fascia and proximal portion of tensor fascia lata which had extended to deeper structures and joint capsule of hip joint .
+We took a sample of the black tissue for pathologic exam and also another sample of the base of greater trochanteric region, which had a lytic appearance in x-ray of hip. The result of pathologic exam of these samples had shown nothing but ochronosis. In another operation, after about 2 weeks, we replaced the fractured hip with cemented hip prosthesis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2656_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2656_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..87329a680bbdf209eafb5104157fbef5858f5c7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2656_en.txt
@@ -0,0 +1,8 @@
+On January 31, 2021, a 75-year-old male presented at the Gastroenterology Department of our hospital complaining of intermittent melena with epigastric discomfort for 1 mo.
+The patient reported that melena occurred several times a day and was accompanied by epigastric discomfort and fatigue, without dizziness or severe abdominal pain.
+The patient detected a plantar nodule on the right side in November 2016. It gradually grew and developed an ulceration. Biopsy results showed melanoma. He underwent an extended resection of the melanoma on the right plantar. Postoperative pathological diagnosis was acral malignant melanoma. He received interferon α2b (1800 WU three times per week) and continued maintenance therapy of a decreased dose of interferon α2b. He had no history of other chronic diseases.
+The patient had no history of smoking or drinking. He denied a history of allergies, and his family history was unremarkable.
+At admission, the patient’s temperature was 36.5 °C, heart rate was 70 beats per min, respiratory rate was 20 breaths per min, and blood pressure was 140/70 mmHg. Abdominal examination found soft tenderness in the left quadrant, without rebound tenderness. Lung and heart examinations were normal.
+Routine blood tests revealed a normal white blood cell count (7.5 × 109 cells/L), moderate anemia (hemoglobin of 75.0 g/L; normal range: 130.0-175.0 g/L), hypoproteinemia (31.0 g/L; normal range: 35.0-52.0 g/L), and elevated levels of creatinine (136 µmol/L; normal range: 59-104 µmol/L). Transaminase, amylopsin and lipase levels were normal, and coagulation function was normal.
+An abdominal computed tomography (CT) scan (January 30, 2021) showed an irregular shape of the jejunum in the left upper quadrant and shadows of fat, which indicated intestinal intussusception . Multiple gallstones were also found. Upper gastrointestinal endoscopy (February 2, 2021) showed multiple linear ulcers in the antrum, superficial gastritis, and small polyps. Magnetic resonance enterography (February 3, 2021) showed partial thickening of the jejunal wall in the left upper quadrant and formation of a soft tissue mass (32 mm × 24 mm), indicating a neoplastic lesion . The mass showed increased signal intensity in diffusion weighted imaging with intussusception of the distal jejunum and mesentery (jejunojejunal intussusception), and intestinal lumen expansion with air and fluid accumulation . Chest CT (February 7, 2021) showed a nodule in the superior lobe of the left lung (7 mm) and tiny nodules in the right lung (2-4 mm).
+The patient underwent partial small bowel resection. Pathological findings revealed a 4.0 cm × 3.0 cm × 2.5 cm protrusion tumor. Histopathology showed diffuse growth of tumor tissue, with the majority located in the submucosa and nearly invading the mucosa . Tumor cells presented with patchy distribution, large nuclei, prominent nucleoli , and red cytoplasm . Some tumor cells showed pigment granules in the cytoplasm . Epithelioid tumor cells contained mitotic figures . Immunohistochemical staining showed HMB45 (+), Melan-A (+), S-100 (+), SOX10 (+), Braf (-), PCK (-), LCA (-), Ki-67 (about 50%) . Lymph node metastasis was detected in one of the five lymph nodes biopsied. Combined with the patient’s history of past illness, the pathologic diagnosis was small intestine metastatic melanoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2698_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2698_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ab331f2ca4347aff8a602a9112ac8cdbcd64a599
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2698_en.txt
@@ -0,0 +1,7 @@
+A 22-year-old Caucasian female with a remote history of transverse myelitis presented with 3 years of worsening midline low back pain. The episode of transverse myelitis occurred 8 years prior to presentation . At that time, she suffered paraplegia, bowel and bladder incontinence, complete sensory loss localized to the T8 level, diffuse pains and paresthesia in the upper extremities, and low back pain below the sensory level. One and a half years after the initial episode of TM, the patient reported a pain burden score (PBS) in her low back below the sensory level of 22/28. She also reported loss of function and inability to do transfers, indicating worsening quality of life.
+Due to worsening lower back pain, loss of function, and development of neuromuscular scoliosis secondary to TM, the patient decided to undergo posterior spinal fusion T3 through pelvis. Preoperatively, in addition to low back PBS score of 22/28, her lower extremity physical exam was notable for complete paraplegia with wheelchair bound status and inability to ambulate, atrophy and edema in all muscles in the lower extremities, a sensory level of T10 on the right and T8 on the left, with only some patchy sensation to pressure evident over her left thigh but otherwise no neuropathic pain or other sensation in the lower extremities bilaterally, and absence of lower extremity reflexes. She underwent surgery of posterior spinal fusion T3 through pelvis which was complicated by wound infection and subsequent incision and debridement. She was discharged following a 60-day hospital stay, and 6 months postoperative the patient reported improved low back pain with PBS 13/28 and unchanged motor and sensory exams in the lower extremities. At this time, she also reported improved mood and ability to conduct activities of daily living, indicating improved quality of life compared with prior to surgery. Unfortunately, at 1.5 years post spinal fusion T3-pelvis, the patient presented to clinic with worsening lumbar back pain and PBS increased to 22/28, worsened with prolonged sitting. Bilateral loosening of the pelvic fixation screws were demonstrated on imaging and deemed to be the cause of the patient’s pain as a result of increased load at the L4–S1 levels. She underwent revision of the pelvic fixation, which improved her PBS to 18/28. The postoperative course was complicated by a new MRSA infection at the incision site and recurrent wound dehiscence, leading to seven incision and drainage treatments over a 6-month duration. The patient then underwent removal of segmental instrumentation T3-pelvis, which initially improved back pain to PBS score 12/28. The patient’s quality of life had clearly increased, as she reported doing remarkably well with increased mobility. Additionally, her mother reported the patient was more functionally active than she had been in a year. Unfortunately, her low back pain continued to progressively worsen over the next 3 years, with lower back pain increasing to PBS score 15/28, at which point she approached our team to consider redo L4–S1 decompression and fusion.
+Magnetic resonance imagaing (MRI) of the lumbar spine demonstrated severe central spinal stenosis at L4–5 and L5–S1 due to facet and ligamentum flavum hypertrophy . Flexion–extension X-ray of the lumbar spine demonstrated axial distraction of the posterior edges of the vertebral bodies at L4–5 and L5–S1 on flexion with alignment improving on extension .
+Given her worsening pain with evidence of lumbar spinal stenosis and instability, she underwent redo L4–S1 decompression and fusion. She underwent L4 and L5 laminectomies with bilateral L4–L5 medial facetectomies and foraminotomies and posterior lateral lumbosacral fusion with bilateral pedicle screws at L4, L5, and S1. She tolerated the procedure well and endorsed improved pain compared with prior to surgery. She was discharged to home on postoperative day 3.
+On postoperative day 16, she presented with fever, chills, tachycardia, and return of her midline low back pain. MRI demonstrated a surgical site infection with severe compression of the lower lumbar thecal sac . Of note, the patient reported severe midline low back pain similar to what she experienced prior to surgery, identifying this as a separate pain from her postoperative soreness.
+The patient underwent lumbar wound washout with significant improvement in low back pain. During her convalescence, she experienced incisional pain but reported significant improvement in her deeper, chronic pain, with an increased ability to perform transfers.
+At 1 year postoperative, the patient’s chronic low back pain remained improved compared with preoperative baseline. The pain was described as “moderate” and “not as severe as preoperative back pain”. The patient reported doing well, with improved ability to bend and overall mobility. Follow-up MRI demonstrated decompression at L4–L5. Imaging also demonstrated increased spondylosis at L5–S1 . Repeat decompression at L5–S1 with revised fusion at this level was offered, but the patient ultimately decided not to proceed with surgery as her back pain was no longer severe.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2709_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2709_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..733cc40b1288bb0b82b9d3b9c60d2390ca22224f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2709_en.txt
@@ -0,0 +1,3 @@
+Since 2019, a 47-year-old man has been affected by episodic CH [according to the International Classification of Headache Disorders, ICHD-3 criteria ]. He had only two bouts in his history. The first bout lasted for 15 days and resolved without treatment, while the latter was more severe and disabling. The attacks lasted for 120–180 min, and they were characterized by excruciating pain in the left orbital and temporal regions, associated with ipsilateral lacrimation, conjunctival injection, ptosis, eyelid edema, and rhinorrhea. Headaches occurred during the night, with one or two nocturnal attacks appearing at 11.30–12 p.m. and 4–4.30 a.m. A preventive treatment with verapamil was started, gradually increasing by 40 mg every 2 days until 120 mg daily. The patient had to monitor blood pressure and heart rate during therapy, which showed no significant changes. The follow-up visit was performed 2 weeks later: the patient reported only two other nocturnal attacks after the start of therapy. Interestingly, he started to experience consecutive nocturnal awakenings for a couple of weeks after attack resolution, without any pain or autonomic symptoms. These were described as sudden awakenings every night, always around the same time, around 4–4.30 a.m.; he was not agitated and did not need to get out of bed, but after the awakening, he had sleep disturbances characterized by vivid dreams .
+The patient was otherwise healthy. General and neurological examinations, routine blood tests, electroencephalogram, and brain magnetic resonance imaging, including arterial and venous magnetic resonance angiography, were normal.
+Regarding the sleep–wake habits, he did not complain of any sleep disorder and denied any need to take sleep medications in the past. This unusual phenomenon, characterized by a very regular pattern of presentation in the absence of a previous sleep disorder, has not been categorized as a specific sleep disorder.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2740_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2740_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d3a906cd9089daeeb0d9e586e02936f1fd6db5d6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2740_en.txt
@@ -0,0 +1,8 @@
+This is the case of a 13-year-old black African boy of the Bantu ethnic group, a student, who presented at the pediatric emergency room of Yaounde University Hospital Center with intense chest and vertebral pains, evolving for 48 hours before admission. A week before, in the course of a brawl his left forearm was twisted, resulting in a sharp and permanent pain in his left forearm associated with a functional impotence without any cutaneous lesions. At home, his tutor gave him paracetamol and diclofenac that were administered orally followed by a consultation the next day at a traditional healer. The traditional healer carried out scarifications on our patient’s forearm, consisting of multiple superficial incisions of the skin made by a blade, supplemented by the application on the cutaneous lesions of an ointment composed of herbs, leaves, and earth, which would be likely to contain Clostridium tetani spores. Less than 48 hours later, there was an onset of a generalized pain, predominant in our patient’s back and in his sternal region.
+The adolescent lives with his aunt in town. There were no elements in favor of a non-accidental injury or child abuse. He had no history of chronic disease; he has never had an operation. The immunization status of the child was unknown to the next of kin.
+On general examination on his presentation to our emergency department, he was conscious and ill-looking. His temperature ranged between 36.8 and 38.3 °C, his pulse was 88 beats per minute, his pupils were equal and reactive to light stimulus, and his blood pressure was 105/70 mmHg. He presented a trismus, spinal stiffness, a generalized contracture with abdominal rigidity, and opisthotonus. In addition, there were also spasms triggered by noise, light, and touch during care.
+The loco-regional examination of his left upper limb revealed a balm based on herbs and black earth placed under a traditional splint. After removal of the latter, scarifications were visible with areas of cutaneous necrosis . The rest of the examination was otherwise normal.
+An X-ray of his left forearm showed a slightly displaced shaft fracture of the two bones of his forearm classified Orthopaedic Trauma Association (OTA)/AO 22-A3 . His hematological and blood electrolytes profiles were within normal limits. No biologic test was performed for the detection of tetanus antitoxin antibodies in whole blood due to the non-availability of this test in our setting at the time.
+The diagnosis of generalized tetanus complicating a closed fracture of the forearm with subsequent opening was made. Generalized tetanus was thus diagnosed a few hours after our patient’s admission on the basis of the clinical examination in particular, and an obvious point of entry in an individual with unknown vaccination status who clinically presented a trismus, a generalized contracture, as well as paroxysms.
+He was subsequently admitted 6 hours later to our intensive care unit. He was placed in solitary confinement in a dimly lit room; a nasogastric tube was placed, and sedation and diazepam myorelaxation were performed. The etiological treatment consisted of an antibiotherapy based on metronidazole that was intravenously, directly, and slowly administered and an immunotherapy with equine anti-tetanus serum. Subsequent disinfection of the point of entry with resection of necrotic tissue was performed to reduce microbial growth and release of toxins.
+The evolution was marked by a gradual deterioration in his state of consciousness, dysautonomic manifestations, particularly blood pressure surges, and tachycardia alternating with bradycardia. Moreover, the occurrence of several episodes of tonic–clonic paroxysms required additional doses of muscle relaxant and intubation. He died a few hours later in our intensive care unit, 12 hours after admission to our hospital.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2774_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2774_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0dfc4c32ebf22d99b87ec4a67478c28a306ce535
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2774_en.txt
@@ -0,0 +1,5 @@
+A 27-year-old Caucasian man presented to the emergency department (ED) following the acute onset of severe, sharp chest and abdominal pain radiating to his shoulder blades and testicles. These symptoms began acutely five hours earlier, waking him from sleep and were associated with nausea and generalized weakness. He was initially able to return to sleep although he clearly stated that the pain was exacerbated in the supine position. On presentation to the ED, his initial vital signs included a blood pressure of 80/60 mm Hg and a heart rate of 60 beats/minute described as 'thready.' His respiratory rate was 26 per minute and he was afebrile. His blood pressure while supine prior to fluid resuscitation was 98/60 mm Hg. The patient had a single episode of emesis in the ED. The initial abdominal examination demonstrated both guarding and rebound tenderness with normal bowel sounds but the remainder of the physical examination, including the testicles, was unremarkable. Fluid resuscitation was initiated and blood pressure stabilised at 110/60.
+His past medical history and review of systems were unremarkable including no peptic ulcer disease and no travel history. Family history did not include any bleeding diathesis, connective tissue or rheumatologic condition. His only medication was ranitidine recently taken for heartburn as needed.
+Initial blood work demonstrated a hemoglobin level of 115 g/L without any obvious history of bleeding and a white blood cell count of 13.8 g/L. Liver enzymes, electrolytes, blood glucose, blood urea nitrogen, creatinine, and amylase were essentially normal, and an electrocardiogram was unremarkable. Both the ED physician and consultant radiologist reported erect and supine views of the abdomen and postero-anterior and lateral views of the chest were normal. In particular, no rib fractures were evident on the chest X-ray, and the left hemi-diaphragm appeared normal. The point of care ultrasound machine was out-of-service at the time this patient presented.
+Intense pain persisted after a total of 20 mg of morphine, 50 mg of dimenhydrinate and 20 mg of hyoscine. He was sent for a contrast enhanced computed tomography (CT) scan of the chest, abdomen and pelvis which demonstrated a macerated spleen with rupture resulting in a significant hemoperitoneum . Only after this revelation and with repeated specific questioning did the patient recall an apparently trivial injury to his left side about one week prior to presentation while playfully wrestling with his partner. He did not present for assessment of the injury at that time.
+Splenectomy and post-operative recovery were uneventful and he was discharged home one week after presentation. The pathology report of our patient's spleen later documented an organ weighing 235 grams and measuring 14.0 × 9.5 × 5.5 cm. This weight is within the reported range of normal . Approximately 30% of the splenic parenchyma contained dilated hemorrhage filled vascular areas but the uninvolved parenchyma appeared grossly and histologically normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2782_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2782_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..962228cd9b8bff955f3bfe209e77b79c8289f5f4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2782_en.txt
@@ -0,0 +1,7 @@
+Our patient is a 70-year-old male, right-hand dominant farmer who presented at the outpatient clinic after falling on the concrete and landing on his left hand. The patient complained of pain on the ulnar side of his hand and swelling was noted on examination. No apparent deformity of the little finger was noted, finger cascade was normal, and full range of motion was elicited but with pain on motion. Ulnar nerve function was intact. Radiographs of the left hand were performed and showed no fractures or dislocations .
+The patient denied any interval injuries but had persistent pain on the ulnar side of his left hand, prompting him to come back to the clinic 9 weeks later.
+Repeat radiographs showed complete ulno-palmar dislocation of the 5th CMCJ. A CT scan with 3-D reconstruction was also done, confirming said injury, and no associated fractures were noted .
+Manual closed reduction was done under fluoroscopic guidance, but the joint was noted to be unstable when traction was removed. The patient was then indicated for open reduction of the 5th CMCJ.
+The dislocated joint was approached from the dorsoulnar side and scar tissue was carefully removed from the 5th CMCJ . All ligaments of the 5th CMCJ were torn including the pisometacarpal ligament. Using manual longitudinal traction and dorsally directed force to the 5th metacarpal base, the 5th CMCJ was repositioned to its anatomic location. A K-wire was inserted perpendicular to the long axis of the 5th through 4th metacarpals as a temporary fixation. Thereafter, intermetacarpal fixation was performed between the 4th and 5th metacarpals using Mini TightRope® (Arthrex, FL, USA) .
+Under C-arm guidance, 1.2-mm holes were drilled with a trajectory about 1 cm distal from and parallel to the articular surfaces of the 5th metacarpal base to the 4th metacarpal base, approximating the original location of the intermetacarpal ligament. Together with one of the stainless-steel metal buttons, a loop of the Mini TightRope® construct is passed from the ulnar to the radial hole of the 4th metacarpal. Mini TightRope® construct was then pulled to tension until the button was flush on the radial cortex of the 4th metacarpal base. The two strands of Mini TightRope® FiberWire were then passed through the radial to ulnar holes of the 5th metacarpal, and second button was then loaded into the sutures and pushed until it was flush against the ulnar cortex of the 5th metacarpal. While maintaining tension, a provisional knot is created, and range of motion and finger cascade are then checked. Once deemed acceptable, sutures were then tied for up to 5 knots over the ulnar button. Remaining strands are then cut using a blade 11 scalpel. Capsule, fascia, and skin were then closed. Immediately after surgery, the patient was allowed to use his fingers freely with unrestricted range of motion.
+K-wires were removed at 2 weeks postoperatively. Follow-up radiograph at 1 year postoperatively showed maintained proper alignment of the 5th CMCJ and the little finger had no limitation of motion. There are no plans to remove the Mini TightRope®, unless the patient begins to complain of pain related to the aforementioned hardware.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2811_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2811_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..947a39923d886766f8b918604538a97f4fa0127b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2811_en.txt
@@ -0,0 +1,4 @@
+An 81-year-old female patient presented to our emergency department with acute onset of hematemesis and melena. On admission, the patient appeared to have a poor general health condition and was hemodynamically compromised. Her initial laboratory exams revealed a hemoglobin concentration of 7.7 mg/dl without leukocytosis or C-reactive protein (CRP) elevation. The patient had a history of a 6.5 cm gastrointestinal stromal tumor (GIST) of the cardia, for which she initially received downsizing treatment with imatinib 400 mg/d, followed by surgical resection of the gastroesophageal junction and reconstruction with a jejunal interposition (Merendino procedure) 4 years earlier . Histopathological studies of the tumor revealed a T3-tumor with a positive c-Kit mutation in exon-11 and a Ki-67 proliferation rate of 15%. The risk for disease progression based on Miettinen's criteria was determined as high (size > 5 cm; mitosis rate > 5/HPF), and the patient was subsequently placed on 1st line adjuvant therapy with imatinib 400 mg/d . After two years on 1st line treatment, the patient developed hepatic and peritoneal metastasis and was placed on sunitinib as 2nd line therapy for metastatic GIST. Treatment with a proton pump inhibitor (PPI) was suspended for an unknown reason two years prior to presentation.
+The patient was immediately transferred to our intensive care unit, where she was intubated and received two units of packed red blood cells (pRBCs). An emergency gastroscopy was carried out, which revealed active bleeding from a vessel stump in the jejunal interposition, corresponding to a Forrest stage I b upper gastrointestinal bleed. The bleeding was successfully stopped endoscopically by local injection of adrenaline and the application of polymer powder. A CT scan of the thorax and abdomen showed no signs of active bleeding or free abdominal fluid . The known hepatic and peritoneal metastasis were described as constant in size, but increasingly necrotic compared to a previous CT scan. Due to a renewed drop in the hemoglobin concentration during the course of the day, a repeat gastroscopy was performed. This time, it showed diffuse bleeding without a circumscribed source. As a result, we acted to stabilize the coagulopathy by transfusing the patient with 9 units of pRBCs, 6 units of fresh frozen plasma (FFPs), and 6 units of platelet concentrates. In addition, the patient received 3 g of fibrinogen and 4000 IU of PPSB®, a prothrombin complex concentrate containing the coagulation factors II, VII, X, and IX.
+On the second day after admission, a temporary improvement in the clinical condition of the patient was observed. It was possible to extubate the patient, who was hemodynamically stable with no signs of active bleeding. A phase of atrial fibrillation was cardioverted following treatment with a beta blocker, digoxin, and amiodarone. On the third day following her admission, the patient's condition deteriorated rapidly with the occurrence of fever, gross hematuria, and decreased oxygen saturation. A delayed hemolytic transfusion reaction was suspected, and positive Rh antibodies (anti-c antibody) were detected. Clinically as well as biochemically, the patient was suffering from a hemolysis with a decline of the hemoglobin concentration to 4.8 mg/dl and an increase of lactate dehydrogenase (LDH) to 3842.0 U/l. Given the lack of a septic focus, only a marginal increase in the inflammatory parameters, and pending blood culture results, no antibiotic treatment or surgical therapy was initiated. Due to imminent respiratory failure, the patient was reintubated. Vasopressors, atropine, and crystalloid solutions were administered to treat bradycardia and shock. However, the patient died on the same evening, following an unsuccessful cardiopulmonary resuscitation.
+The results of blood cultures taken on the day of the patient's death revealed gram-labile rods without bacterial growth after two days. The subsequent external analysis confirmed bacteremia with C. perfringens and the detection of the alpha toxin gene by polymerase chain reaction, but without any traces of the beta toxin, enterotoxin, epsilon toxin, or iota toxin. The autopsy of the patient revealed a 6 cm sized local recurrence of the GIST and multiple necrotic liver metastases. In addition, a diffuse spread of C. perfringens in multiple organs with advanced tissue lysis was histologically confirmed . The mucosal ulcer of the jejunal interposition was located 1.5 cm distal to the esophagojejunal anastomosis, which itself was intact. Death due to a septic-toxic shock caused by C. perfringens sepsis was determined as the cause of death. A contamination of the administered blood products with C. perfringens as the source of the infection was excluded by a subsequent analysis, which was confirmed by an external laboratory.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2813_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2813_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5c4f06d69ad90b4bf974118b87cb1eef6ebe3051
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2813_en.txt
@@ -0,0 +1,24 @@
+A 63-year-old woman came to our hospital complaining of recurrent upper abdominal
+fullness discomfort for almost 10 years. She experienced exacerbation of intermittent
+nausea, vomiting with chyme (5 mL), heartburn, acid regurgitation, and eructation
+for 6 months. No history of hypertension, diabetes mellitus, or coronary heart disease
+was noted. Upon physical examination, a 5 × 4 cm mass with a hard texture
+and poor mobility was observed in the upper abdomen. Routine blood and tumor marker test
+results were within normal range. Abdomen computed tomography (CT, ) showed a 32 mm ×
+22 mm soft tissue mass shadow with homogeneous density in the descending
+duodenum, which was protruding into the duodenal lumen. Moreover, thickening of the
+adjacent intestinal wall was noted. Upper abdomen magnetic resonance imaging (MRI, ) revealed a
+significant thickening of the wall of the duodenal bulb and descending duodenum. The
+wall thickness was 1.1 cm. The signals were slightly low in T
+1-weighted images and slightly high in T
+2-weighted images. Endoscopic ultrasonography demonstrated that there was a
+protrusion in the duodenal bulb of about 26 × 18 mm in size with a clear
+boundary, smooth surface, and irregular shape and the base being about 17 mm,
+color signals abound.
+Neoplasm resection of duodenum was performed, and we found a mass measuring about 25
+× 30 × 10 mm located in the descending duodenum. It was soft,
+brittle, and mobile with a clear boundary. The pathological result of the mass revealed multiple
+Brunner’s glands with tubes, fibers, and smooth muscle diffuse distribution. No
+dysplasia was noted on the epithelium. It was diagnosed as Brunner’s gland
+adenoma of the duodenum. The patient was discharged from the hospital a week after
+recovery. To date, no relapse has occurred.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2843_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2843_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..022bd6f5ec862e5d9f9b4932d376b94139276cfd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2843_en.txt
@@ -0,0 +1,4 @@
+An 84-year-old woman was admitted to our institution because of rapidly progressive dyspnoea and orthopnoea over the past month despite aggressive dehydration during outpatient dialysis.
+She had a history of ESRD due to diabetic nephropathy and had been on haemodialysis for two and a half years. Additionally, she had a history of dyslipidaemia and hypertension. One and a half years prior, she began experiencing chest discomfort and shortness of breath on exertion. A Levine three-sixths degree systolic ejection murmur and a coarse crackle were heard from her. Electrocardiogram showed sinus rhythm, high voltage, and strain T pattern in chest leads suggesting left ventricular hypertrophy. Chest X-ray revealed cardiomegaly and pulmonary congestion, and serum brain natriuretic peptide level was 1290 pg/mL (normal range ≦ 18.4 pg/mL). Echocardiography revealed severe AS with a mean aortic valve pressure gradient (mAVPG) of 41 mmHg and an aortic valve area of 0.72 mm2. She underwent TAVI with a 23 mm SAPIEN3 (Edwards Lifesciences) a year and a half prior to this admission. Following the procedure, the patient’s recovery was uneventful, and echocardiography showed no paravalvular leak, a mAVPG of 17 mmHg, and an effective orifice area (EOA) of 1.92 cm2 at discharge (see ). She had been receiving antiplatelet therapy with clopidogrel 75 mg after TAVI. Echocardiography at the one-year follow-up revealed no evidence of prosthetic valve dysfunction, with a mAVPG of 18 mmHg and an EOA of 1.82 cm2 (see ).
+The patient underwent transthoracic echocardiography at admission, which revealed stiffening and complete loss of mobility of the aortic prosthetic valves (see ). This resulted in severe AS with a mAVPG of 68 mmHg and an EOA of 0.65 cm2. Contrast-enhanced computed tomography (CT) showed severe calcification and thickening of all three prosthetic valve leaflets .
+The CT findings suggested a high risk of coronary artery occlusion if TAV in TAV was selected. Even in the case of a repeated SAVR with a bioprosthetic valve, there remained a concern about high surgical risk, with an STS score of 13.8% and a significant likelihood of early SVD. Following a rapid multidisciplinary team discussion, we performed an emergency SAVR with a 19 mm On-X valve (CryoLife). Pathological observation of the explanted SAPIEN 3 valves demonstrated severely degenerated bioprosthetic pericardial leaflets with severe intrinsic and extrinsic calcifications that could cause limitation of the leaflet motion . The patient did well post-operatively, and there were no other major complications. Post-operative echocardiography showed improvement in AV peak flow [2.6 m/s, mAVPG (14 mmHg], and EOA (1.84 cm2). No heart failure exacerbations, warfarin-induced bleeding events or prosthetic valve dysfunction were observed in the first year after SAVR.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2902_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2902_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..144e0bc619d0da9d893768ae1785af4ed69d12f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2902_en.txt
@@ -0,0 +1 @@
+An 83-year-old woman slipped and fell, complaining of the left hip pain and was unable to bear weight. She referred she was submitted to a hip arthrodesis 53 years ago, after an undiagnosed congenital hip dislocation. She also suffered from poliomyelitis and walked around with a cane. The radiographic and tomographic evaluation showed an intertrochanteric fracture in a long-lasting ankylosed hip ( and ). After carefully assessing scientific evidence and discussing the appropriate treatment strategy, the patient was prepared for surgery. She was positioned in lateral decubitus and a lateral approach was used, centered on the great trochanter. The fracture was exposed and fixated with two plates. One proximal locking femoral plate, with 6mm×4.5 mm cortical and 4mm×6.5 mm cannulated screws, was applied to the head and proximal femur. Expecting a great stress in the fracture site, this construction was reinforced with a 3.5 mm pelvic reconstruction plate, with 8mm×3.5 mm cortical screws, spanning from the iliac wing to the proximal femur ( and ). Due to the poor bone quality and the unusual long lever arm, the patient was not permitted to walk until 3weeks after the intervention and only partial weight-bearing afterward. Bone healing occurred after 3months, allowing the patient to walk with a single cane and full weight-bearing .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2914_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2914_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..88250e006230fe2d2b63e08d8d4aa34391e626dc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2914_en.txt
@@ -0,0 +1,48 @@
+A 71-year-old male with past medical history significant for diabetes mellitus,
+coronary artery disease, chronic hypotension, hyperglycemia, chronic obstructive
+pulmonary disease, nicotine use, obstructive sleep apnea, and peripheral artery
+disease presented to the ED with right buttock and scrotal swelling for three days,
+associated with generalized weakness, shortness of breath, and urinary retention
+with dysuria. One day prior to presentation, the patient noticed non-traumatic
+bruising to his scrotum. He additionally reported increasing buttock pain that was
+not controlled by home oxycodone/acetaminophen 5/325 milligram (mg) tablets.
+Upon arrival, his vital signs were notable for an oral temperature of 38.2°
+Celsius, blood pressure of 119/54 millimeters of mercury (mm Hg), and heart rate of
+93 beats per minute. He was also tachypneic with a respiratory rate of 25 breaths
+per minute; oxygen saturation was 97% on room air. The physical examination
+was notable for an ill-appearing gentleman. He was awake and alert. Heart sounds
+were unremarkable aside from tachycardia, and lungs were clear to auscultation.
+Abdominal examination was soft, protuberant, and nontender. A focused genitourinary
+examination revealed an edematous, erythematous and exquisitely tender scrotum. Of
+note, there was a coin-sized, ecchymotic-appearing lesion on the scrotum with
+erythema and induration extending from the scrotum and perineum to the right
+buttock. No crepitus or fluctuance was palpated on examination.
+Laboratory results were remarkable for leukocytosis to 15,000 thousand per
+millimeters cubed (K/mm3) (reference range: 4–10 K/mm3), lactic
+acidosis of 3.4 millimoles per liter (mmol/L) (0.4–2.0 mmol/L), marked acute
+kidney injury with creatinine of 5 mg per deciliter (mg/dL) (0.55–1.3mg/dL),
+and venous blood gas pH of 7.22 (7.310–7.410) secondary to the lactic
+acidosis and severe sepsis. The patient was mildly hyponatremic at 133 mmol/L
+(136–145 mmol/L) and hyperkalemic at 5.3 mmol/L (3.5–5.1 mmol/L),
+with the remainder of electrolytes within reference range. Intravenous antibiotics
+were initiated and emergent consultations with surgery and urology promptly
+obtained. Despite initial fluid resuscitation with administration of 30 milliliters
+per kilogram (ml/kg) of normal saline, the patient decompensated into septic shock.
+His blood pressure decreased to 88/41 mm Hg during the ED course; thus, he was not
+stable for transport or advanced imaging. By this time, the ecchymotic-appearing
+lesion and edema had expanded across his scrotum and perineum.
+We used POCUS for the rapid assessment of the patient’s presumed clinical
+diagnosis of Fournier’s gangrene, a specific type of necrotizing fasciitis
+involving the perineum. Transverse and sagittal views of the perineum and scrotum
+were obtained using a high-frequency linear probe and revealed diffuse hyperechoic
+foci with posterior “dirty” shadowing, representative of
+subcutaneous air, and small fluid collections tracking along the fascial planes
+.
+After confirming the diagnosis using POCUS imaging, the patient was taken directly
+from the ED to the operating room for immediate surgical debridement within three
+hours of his arrival at the hospital. An area of tissue measuring 25 centimeters
+(cm) × 30 cm that included both fascia and muscle was debrided from the
+scrotum, perineum, and right buttock. Dark, necrotic tissue and foul-smelling fluid
+were noted during surgery, consistent with Fournier’s gangrene. The patient
+was admitted to the intensive care unit until being transferred to a tertiary care
+center where he ultimately died of complications related to his illness.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_291_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_291_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b3b6b917ce03cfb1a197d8daaac5b066d9102235
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_291_en.txt
@@ -0,0 +1,3 @@
+A 5.5-year old girl had undergone surgical patch closure of a large secundum atrial septal defect with valvotomy of a moderate pulmonary stenosis at the age of 2 months; a mild aortic stenosis with a thickened tricuspid aortic valve was not corrected. She was born as the first child to non-consanguineous parents. The family history was negative for sudden cardiac death, but the maternal grandfather had epileptic seizures without fever in his youth. At the age of 12 months the girl suffered from a first afebrile seizure and at the age of 23 months from a first febrile seizure. Four months later she suffered from a series of afebrile seizures. Therefore valproic acid was started and maintained for 2 years. During this treatment she was seizure-free with normal electroencephalogram (EEG). After tapering valproic acid over a period of 2 months, short generalized paroxysmal discharges appeared on the EEG for the first time without clinical correlate. One year later she suffered from two further uncomplicated febrile seizures. Since then she is seizure-free without anticonvulsive treatment but the 24 h-EEG persistently shows subclinical absences. Since the intellectual and physical development of the patient is normal it was decided together with the parents not to restart the antiepileptic medication but to follow her up closely. Cerebral magnetic resonance imaging was normal. Clinical cardiologic, echocardiographic and neurologic examinations of the first degree relatives were normal except for the mother who showed epicanthic folds and hypertelorism. Unfortunately, the maternal grandfather did not consent with any investigations.
+At inspection, she had bilateral epicanthic folds; broad eyebrows, a broad nasal tip and hypertelorism, however no ptosis or low-set ears (Figures and ). Her body weight was 18 kg (25th percentile), head circumference 51 cm (50th percentile) and height 115 cm (75th percentile). She did not complain about any cardiac symptoms and did not suffer from heart failure. Twelve-lead electrocardiogram showed normal sinus rhythm alternating with an atrio-ventricular-nodal rhythm and an incomplete right-bundle-branch-block. Twenty-four-hour electrocardiogram showed sporadic ventricular and supraventricular ectopic beats. Echocardiography revealed a mild residual valvular pulmonary stenosis with moderate pulmonary valve regurgitation and mild aortic valve stenosis with mild aortic regurgitation. Left ventricular function was normal, however, extensive hypertrabeculation resulting in a two-layered structure of the myocardium was visible in the mid-ventricular and apical segments of the left ventricle, consistent with the diagnosis of LVHT (Figures and ). Review of previous echocardiographic examinations disclosed that LVHT had been present already at age 2 years. As a primary prophylaxis for cardiac embolism aspirin 50 mg/d was started. Since she was symptom-free, no further cardiac medication was prescribed. At the latest follow-up investigation in September 2011, she was in a good cardiac and neurologic condition, no seizures had recurred and her intellectual development was normal. Echocardiography was unchanged.
+Molecular genetic analyses of the PTPN11, KRAS, RAF1 and SOS1 genes were negative. Array CGH using a 1 M oligonucleotide microarray platform (Agilent Technologies, Santa Clara, CA) was performed to screen genome-wide for submicroscopic deletions and duplications . Genomic positions are given according to genome-build hg18. Array CGH detected five previously not described CNVs as listed in Table . FISH analyses were not carried out because of the size of the CNVs. Regarding the duplications it could not be assessed whether they were tandem-duplications on the same locus or whether the duplicated fragment was inserted or translocated in another chromosome. By application of quantitative Real-Time PCR (qPCR) we could show, however, that none of the changes had developed de novo. All five CNVs are currently not listed in the Toronto Database of Genomic Variants (DGV), therefore, have to be considered as non-frequent variants in normal controls. Follow-up and testing of the index patient and her parents by qPCR revealed that all CNVs were inherited from one of the unaffected parents (maternal: deletion 1q42.3, duplication 3q26.32q26.33; paternal: duplication 14q32.11, deletion and duplication 20q13.33). We thus conclude that these changes are most likely not clinically significant CNVs but rare benign variants, although a reduced penetrance of inherited CNVs cannot be excluded.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2933_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2933_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4c110b169a95546962b6336ee1f80dd77c6149e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2933_en.txt
@@ -0,0 +1,3 @@
+A 51-year-old male was transferred to our hospital after an out-of-hospital cardiac arrest. He had family history of sudden cardiac death in one brother with autopsy study that reported normal cardiac findings, and genetic test was not performed. Moreover, he had a body mass index of 28.5, and medical history of uncomplicated renal colic, otherwise there was no more relevant medical history in their electronic health record system. In this regard, his family denied medical history of hypertension, diabetes, dyslipidemia, allergies, smoking and illicit drugs. In addition, his family states that he used to drink 1–2 alcoholic drinks each week. He had no prescription medication, over-the-counter medications or supplements. Regarding his social history, he was of Caucasian and Hispanic ethnicity, and his occupation was computer engineering. Based on his income, he was on middle social class. He lived independently with his wife and two children. Furthermore, he had received the first dose of the vaccine Ad26.COV2.S (Janssen®) against COVID-19 48 h ago. His family admitted that the patient stated asthenia, myalgias, atypical chest discomfort, and low-grade fever (37,4 °C) in the last 24 h.
+The patient had a witnessed collapse by his son, and basic cardiopulmonary resuscitation was started by the local police. An automated external defibrillator advised shock, and he was defibrillated twice. Then, 15 min later, paramedics arrived and found the patient in ventricular fibrillation, advanced cardiopulmonary resuscitation was performed by mechanical chest compressions (Lucas®), pulse activity was restored, an ECG showed atrial fibrillation with ST elevation in V1-V2, AVR, and diffuse ST depression in all the leads. During ambulance transportation, the patient had several ventricular fibrillation episodes that were defibrillated and finally came out in asystole. After approximately 1.5 h since the patient experienced a sudden cardiac arrest and 75 min of advanced cardiopulmonary resuscitation, of which 45 min were in asystole, the patient arrived at our center. On admission, the patient was unconscious and in asystole rhythm. Bedside echocardiography ruled out pericardial effusion and pneumothorax.
+The coronary angiography was performed by the senior interventional cardiologists. A 6-Fr sheath was introduced into the right femoral artery and another 6-Fr sheath in the right femoral vein. A JL 4 guide catheter 6-Fr was placed over the wire into the ascending aorta, and the left coronary artery was cannulated; it was patent, and there were non-obstructive coronary arteries . Then, the catheter was exchanged for a JR 4 guide catheter 6-Fr, while the right coronary artery was cannulated, an image of probable aortic dissection was observed . The right coronary artery was patent and without angiographic stenosis . Given the persistent asystole despite a prolonged advance cardiopulmonary resuscitation and the possibility of aortic dissection, a prompt in-room heart team discussion was performed with the senior cardiac surgeons. It was decided to stop and withdraw potentially life-sustaining treatment due to futility. Of the note, the SARS-CoV-2 RT-PCR test was negative. In addition, genetic testing and necropsy were performed with the consent of his family. The genetic testing reported a negative result for explaining the sudden cardiac death. On the other hand, the aorta in the necropsy study revealed some mild atherosclerotic plaques but without either aneurysm or thrombosis (, , ). The coronary arteries were reported as with patency. In the proximal left anterior descending artery (LAD), the intima layer presented a thickness that decreased 50 % of the luminal area, with mild calcification and macrophages but without complicated acute plaques such as rupture, erosion, or thrombus. For the rest, the necropsy study was reported as without relevant pathologies. This case report has been reported in line with SCARE 2020 criteria .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2937_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2937_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d0545d8459d5f43395ed3cdd706100e7447b21b8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2937_en.txt
@@ -0,0 +1,8 @@
+An 84-year-old man was admitted to our hospital complaining of muscular weakness while rising up from a chair that led to a fall. He was admitted for further studying, but his head CT and MRI did not report any abnormal structural findings. He reported a significant 10% weight loss in the past 6 months associated with decreased appetite and diminished mobility associated with progressive muscular weakness and difficulty rising from chair, with preservation of activities as combing his hair, or lifting small objects.
+The physical examination was remarkable for muscular weakness with 3/5 muscle strength in the lower extremities and 4/5 of the upper extremities, confined to the proximal muscles. Tendon reflexes were diminished and the tone examination revealed mild bilateral quadriceps hypotonia and atrophy. There were no other clinical findings on the physical examination.
+The patient reported a medical history of stage G4 chronic kidney disease, erythroid and megakaryocyte-predominant myelodysplastic syndrome, and high blood pressure, receiving medication with azacytidine, diltiazem, and darbepoetin. The patient did not smoke, consume alcohol, or use illicit drugs, and his family history was negative for neuromuscular diseases.
+During the present admission, laboratory investigation showed an elevated creatine kinase level of up to 78,924 U/L (more than 50 times the normal reference range) and an aldolase value of 181 U/L (more than 20 times the normal reference range). Elevated serum creatinine was found (4.4 mg/dl; steady-state level 3 mg/dl), with mild hypocalcemia (7.2 mg/dl) and mild hyponatremia (130 mg/dl) with normal albumin (4 mg/dl). Thyroid hormones were normal, and cardiac enzymes were also in normal range. Coprologic examination revealed positive testing for rotavirus. Antibody testing reported negative results for antinuclear antibodies (ANAs), anti-Jo1, anti-3-hydroxy-3-methylglutaryl-coenzyme A reductase (HMGCR), anti-Mi-2, and also for antiganglioside antibodies.
+The electromyography (EMG) of the upper and lower limbs showed myopathic changes in proximal muscle, with lower limb predominance, with short duration, low-amplitude polyphasic potential with no positive sharp waves, and spontaneous electrical activity.
+An FDG-PET/CT scan was performed searching for neoplasia due to the patient's past history and revealed increased FDG uptake in bilateral quadriceps, without posterior compartment muscle uptake or increased metabolism in any other region of the body . No other location of FDG uptake was found.
+We performed an open biopsy of the left vastus lateralis muscle, which on light microscopy showed 50% myonecrosis, mild fiber atrophy, and lymphocytic infiltrate with CD8+ predominance and perivascular involvement. There were no immune deposits in the skin microscopic examination .
+The diagnosis of PM was made and then the patient started on intravenous hydration with medium saline solution/bicarbonate for rhabdomyolysis and prednisone 0.5 mg/kg/day and intravenous immunoglobulin with a total dose of 2 g/kg distributed in 5 days, along with calcium supplementation and azacytidine. For the myelodysplastic syndrome diagnosis, steroid-sparing drugs such as azathioprine or methotrexate were not considered. The renal function of the patient improved within 5 days, with partial recovery of lower limb strength, and the patient was discharged for external consultation follow-up. After 2 months from discharge, the patient had increased muscle strength and diminished CPK levels, with low-dose prednisone as maintenance therapy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2997_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2997_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a46b7a1e0ee4195673f24152089b9c02091fa066
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2997_en.txt
@@ -0,0 +1,3 @@
+We present the case of a 65 year-old lady referred to us from a rural hospital where she was treated with thrombolytic therapy for a presumed acute anterior myocardial infarct. She had presented with central chest pain radiating down her left arm with ECG findings of 2 mm ST elevation in V2 and V3. There was no recent history of psychological stress although she had been on antidepressant drugs for two years. Four hours after thrombolysis she developed acute pulmonary oedema and a new systolic murmur. At this stage it was presumed she had acute mitral regurgitation secondary to a ruptured papillary muscle, ischaemic dysfunction or an acute ventricular septal defect.
+She was transferred on heparin and glyceryl trinitrate infusion, in acute pulmonary oedema (confirmed by chest X-ray), with a systolic blood pressure of 110 mmHg, and heart rate of 130/minute. Urgent echocardiogram showed severe mitral regurgitation (see Figure ). Her mitral valve annulus was slightly widened at 3.2 cm and subvalvular structures were intact. She also had left ventricular apical ballooning (LVAB) and systolic anterior motion (SAM) of the mitral valve leaflet with septal contact – left ventricular outflow tract gradient (LVOT) 60–70 mmHg (see Figures and ). Coronary angiography fourteen hours after her presentation showed no obstructive coronary lesions. Ventriculogram revealed akinesis of the anterolateral wall and apex of her left ventricle, more extensive than any single coronary territory, and grade 4/4 mitral regurgitation (see Figures and ).
+She had an intra-aortic balloon pump (IABP) inserted and was transferred to theatre shortly thereafter. She was in cardiogenic shock, with severe MR and SAM still prominent, despite the IABP. We elected to replace her mitral valve, and at operation, the mitral valve was mildly myxomatous but there were no structural abnormalities, chordae and papillary muscles being intact. She had a mechanical mitral valve replacement (MVR) with a 29 mm St Jude valve. The anterior leaflet was excised and PTFE (gore-tex CV4) was used to reconstruct the subvalvular apparatus. The posterior leaflet was plicated to the annulus. Post-operatively there was no LV outflow obstruction and ventricular function improved to within normal limits by the 10th post-operative day. She recovered well.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_29_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_29_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..76f77733165363c4eaa0c9aa1e0c02cfbc6f392b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_29_en.txt
@@ -0,0 +1,4 @@
+A three-week-old Caucasian male born at term was found to have an abnormally shaped head and subsequently was referred for craniofacial surgical evaluation. The 21-year-old mother’s pregnancy course was uncomplicated; she had routine prenatal care and an uncomplicated vaginal delivery. The physical examination demonstrated bifrontal bossing, a raised and thickened sagittal suture, and an elongated anteroposterior diameter skull, consistent with scaphocephaly secondary to sagittal synostosis . Computed tomography (CT) imaging of the head confirmed synostosis of the sagittal suture, with the remaining sutures open . The parents were counseled regarding treatment options. Both open and endoscopic-assisted surgical techniques were explained. In the case of the endoscopic procedure, the need for up to 12 months of postoperative helmet therapy was emphasized. The family opted to proceed with the endoscopic approach.
+At two months of age, our patient underwent an uncomplicated endoscopic-assisted strip craniectomy with excision of an 11 × 5-cm strip of bone containing the fused suture, in accordance with our described technique . He was fitted for an orthotic helmet two weeks postoperatively. The family failed to follow up with the orthotist, but presented to the craniofacial clinic eight weeks postoperatively. Our patient was noted to have occipital flattening and increased height of the posterior vault. At the time, the flattening was interpreted to be secondary to excess occipital helmet pressure, which could have been avoided by adherence to the routine monthly orthotic adjustments. Our patient was sent to the orthotist for refitting.
+Our patient was lost to follow-up for the next six months. During this time the same helmet was inconsistently used, without follow-up with the craniofacial surgery team or the orthotist. According to our patient’s parent, a complicated social situation led to long periods in which the helmet use was discontinued altogether. Our patient next presented 18 months postoperatively. His head circumference was noted to be less than the first percentile for age, and his head shape was oxycephalic. The fontanelle was small, but patent and flat. Additionally, our patient was walking unsteadily and was slightly delayed regarding his language skills. A CT scan of his head showed pansynostosis . The brain parenchyma, ventricles, and cisterns were normal in appearance. Our patient underwent open cranial vault reconstruction .
+Postoperatively, our patient progressed well, having a good secondary result at the one-month follow-up visit . At the six-month postoperative follow-up for the open cranial vault reconstruction, his head circumference had increased to the fifth percentile for age, and his head shape remained significantly improved . In addition, no clinical signs or symptoms of increased intracranial pressure were noted.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_302_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_302_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf162c9bc6f73040c85a0463565754cdb013972d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_302_en.txt
@@ -0,0 +1,8 @@
+A 1-year-old female baby visited our department for the evaluation and treatment of an accessory opening above the left nostril which had been existed since her birth. The patient and her parents’ medical history was non-specific except that the patient had an accessory nostril. Also, the age of her mother was 32 years old and there was nothing wrong at parturition.
+Physical examination showed a left accessory nostril that connected to the normal left nostril. The internal diameter of the accessory opening was measured about 0.2 cm . Normal ipsilateral nostril was a little smaller than the other side, but the size of the alar base was similar to the right nostril. There was no columellar deviation. The nasal cavity structure was normal. Also, there was no any other deformity on her body. The patient was diagnosed to have a supernumerary nostril.
+Surgery was operated under general anesthesia. First, we drew the abnormal structure around the left nostril by gentian violet solution . The incision was performed around the accessory nostril, and then, dissection of the tract was done by using Metzenbaum scissors . After opening the nostril, the soft tissue across the normal and false nostril was removed. De-epithelialized part of false and normal nostril was attached to each other . A wedge-shaped tissue of the alar side wall was removed. Layered suture of the alar rim was applied . Minimal surgical procedure was applied. To consider her growth, rhinoplasty will be left as an option for treatment.
+After 1-year follow up, the accessory nostril on the left side was totally obstructed but the irregular-shaped soft tissue was remained . The operated left nostril was larger than the contralateral side. To correct the nostril asymmetry, rhinoplasty was performed . The patient got cured without special problem. At 1-year postoperative examination, the result and cosmetic appearance was satisfied .
+The nose develops from a frontonasal process in the early fourth week of gestation. The frontonasal process is formed from the forebrain by enlarging and pushing the ectoderm anteriorly and laterally. Nasal placode appears on both sides of the frontonasal process. The nasal placode is the surface ectoderm becoming thicker in two to three cell layers on frontonasal process. In the beginning of the fifth week, the center of the nasal placode sinks to form a nasal groove. As a result, a horseshoe-shaped lateral and medial nasal process appear. As the lateral nasal process and the medial nasal process develop, the nasal groove gets deeper and forms a nasal pit. In the end of the fifth week, the nasal pit gets deeper and becomes nasal sacs. The nasal sacs move into the middle, as maxillary process develops medially. And then, the nasal sacs forms nasal cavity and nostrils .
+Although the exact pathogenesis of supernumerary nostril has not been revealed, it might cause problem of division of lateral nasal process.
+In 1906, Lindsay was first to report the bilateral supernumerary nostril . An accessory nostril was above the normal nostril and connected to the ipsilateral nasal cavity. In 1920, Tawse reported the case of unilateral supernumerary nostril above the right normal nostril . An accessory nostril was connected to the right nasal cavity. In 1962, Erich reported a patient who has two noses . He described that if the position of the accessory olfactory pit is too lateral, the fusion of the laminae is not interfered, which causes the supernumerary nostril. In 1987, Nakamura and Onizuka reported a patient who has divided right alar to medially and laterally . An accessory nostril was located medially. Nakamura and Onizuka hypothesized that supernumerary nostrils resulted from fissuring of the lateral nasal process accidentally. They proposed that the lateral nasal process is divided into two segments and each segment develops into each nostril on the one side of the nose. Also in 1987, Reddy and Rao reported a patient with triple nostrils . An accessory nostril is located below the left normal nostril and connecting into the nasal cavity posteriorly. They assumed that if an accessory olfactory pit appears either above or below the normal location of the placode, consequently, a supernumerary nostril will be formed. In 2009, Kashyap and Khan reported a case of supernumerary nostril on the left side with an accessory alar cartilage . An accessory cavity was smaller than the normal cavity and was not connected with the ipsilateral nasal cavity. Kashyap and Khan proposed that the presence of alar cartilage from the accessory nostril describes the embryological fissuring of the lateral nasal process. In most of the cases, the supernumerary nostril was located on the left side and above the normal nostril. It was either isolated or associated with other congenital anomalies such as cleft lip and palate, naso-ocular cleft, esophageal atresia, and patent ductus arteriosus . Franco et al. reported that 45 % of the patients were related to other congenital anomaly .
+In the treatment of supernumerary nostril, it is important to remove the accessory nasal tract entirely and preserve the normal nostril. In most cases of supernumerary nostril, fistulectomy and reconstruction with local flaps was performed as a surgical technique. Surgery should be performed as early as possible, because in early age, it is easier to access the deep portion of the nasal cavity, avoid serious affect to nasal cartilage, and avoid deformity around the ala nasi due to fistula. In this case, the accessory opening was obstructed by using simple incision and primary closure without forming local flap. Although the patient had two surgeries to remove the accessory nostril, small and recognizable residual defect on nostril rim of affected side is observed. For the patient’s psychosocial growth, rhinoplasty will be performed after re-evaluating face.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3032_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3032_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd7046415215a9e1ec0216675a479d827754f9a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3032_en.txt
@@ -0,0 +1,3 @@
+The patient, a 17-year-old female, reported ocular floaters in her left eye persisting for 1 day. The patient had an unremarkable medical and family history, devoid of any reported trauma. BCVA was 1.0 (decimal) in both eyes. Both eyes exhibited myopia, while no additional ocular abnormalities were detected in the right eye apart from myopia. The intraocular pressure was measured as 17 mmHg in the right eye and 18 mmHg in the left eye. The slit lamp examination revealed unremarkable anterior segments of both eyes accompanied by normal bilateral pupillary responses. C/D in the right eye was 0.4, whereas it measured 0.5 in the left eye.
+
+In the left eye, CFP revealed indistinct optic disc margins and small patchy hemorrhage, whereas no evident abnormalities were observed in the right eye (Clarus 500, Carl Zeiss Meditec, Inc). FAF showed hypofluorescence in the hemorrhagic area of the left optic disc (Panoramic ophthalmoscope, Daytona P200T). The PHOMS on B-scan SD-OCT image of the left eye exhibited an ovoid shape and appeared as peripapillary hyperreflective bright regions on en-face Min-IP image which corresponded to B-scan SD-OCT findings. The active blood flow signal of PHOMS was detected on SD-OCT/OCTA images of the left eye (Cirrus HD-OCT 5000, Germany). The results should be consistent with the diagnosis of spontaneous hemorrhage of the left optic disc, PHOMS and ocular floaters in the left eye, binocular ametropia.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3033_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3033_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d7a7978ed1ad8aabd788cd6e5021b19e005087ab
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3033_en.txt
@@ -0,0 +1,18 @@
+Patient and observation
+A 36-year-old female patient with obesity (Body Mass Index: 34) presented to our service after a fall down the stairs, causing an indirect injury to her right elbow.
+
+The initial clinical examination showed signs of trauma to the upper limb, without any distal neurovascular deficit.
+
+Radiographs revealed a 2R2A2 radial diaphyseal fracture and a 2R1A2 radial neck fracture with approximately 15° of angulation, along with a posterolateral humeroulnar dislocation.
+
+The first step was an emergency reduction of the humeroulnar dislocation. Ligament testing was difficult due to the diaphyseal fracture. The patient was immobilized in a BABP splint, and a computed tomography (CT) scan was performed to assess the potential involvement of the stabilizing structures of the elbow. No coronoid involvement was noted.
+
+The second step involved osteosynthesis of the radial diaphysis under regional anesthesia using a compression plate (Synthes), with a working length two screw holes and a lever arm spanning six contiguous cortices on both sides.
+
+The third step involved elbow testing, which showed no recurrence of dislocation up to −40° extension, but a persistent displacement of the radial neck fracture.
+
+The fourth step included a reduction and osteosynthesis via a Cadenat approach (between the ulnar extensor and the anconeus muscle), exposing the fracture, particularly the metaphyseal shift, while protecting the motor branch of the radial nerve by keeping the elbow in pronation. The fracture was then stabilized using an anatomical radial head plate (Trilock Radial Head Plates, Medartis), and the posterolateral structure was reattached. Given the good stability of the elbow, no additional medial procedure was performed.
+
+The patient was immobilized for 6 weeks in a brachio-antebrachial-palmar splint, with immediate rehabilitation for flexion and extension. Pronation and supination were allowed starting from the third week.
+
+At 6 weeks, the patient's range of motion was as follows (in degrees): Flexion-extension: 10°/0°/20°; Pronation-supination: 0°/0°/10°, with a deficit in thumb flexion. At 3 months, the range of motion was: Flexion-extension: 0°/40°/120°; Pronation-supination: 0°/60°/110°, with radial hypoesthesia but no motor deficit. At 5 months, the range of motion improved to: Flexion-extension: 0°/10°/140°; Pronation-supination: 0°/20°/180°, with complete recovery of thumb flexion and partial hypoesthesia in the radial nerve territory. The patient was able to resume her professional activities at 5 months postoperatively, working as a funeral director.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3096_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3096_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ebf772f08d0272a7525becf7146895149ac08c49
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3096_en.txt
@@ -0,0 +1,4 @@
+A 31-year-old man was admitted to our hospital with atrial tachycardia and cardiogenic shock. He had been diagnosed with HS during childhood and undergone splenectomy because of splenomegaly at the age of 26. He never received any red cell transfusions. He had suffered from dyspnea on exertion one to two years before admission, and his symptom had gradually worsened. At the same time, he had suffered from erectile dysfunction. He had a history of a small amount of alcohol intake.
+On admission, he had mild anemia and jaundice. He did not have any skin pigmentation. His blood pressure was 93/63 mmHg with a regular pulse of 150/minute (atrial rate was 250/minute). Hemoglobin was 9.4 g/dL, and direct and indirect bilirubin were 0.7 and 5.0 mg/dL, respectively. Hepatobiliary enzymes were elevated as follows; aspartate aminotransferase 81 U/L, alanine aminotransferase 51 U/L, alkaline phosphatase 330 U/L, gamma-glutamyl transpeptidase 78 U/L. Hemoglobin A1C was 4.7%, indicating that the glucose metabolism was normal. Plasma brain natriuretic peptide level was increased to 925 pg/mL. Serum ferritin, serum iron, and transferrin saturation levels were markedly elevated to 4068 ng/mL, 216 μg/mL, and 90.7%, respectively. After cardioversion for atrial tachycardia, the electrocardiogram showed lower atrial rhythm, and inverted T waves in V4-V6 leads. Chest X-ray showed bilateral pulmonary congestion and pleural effusion. The echocardiography revealed the left ventricle was dilated with end-diastolic diameter of 63 mm, and wall motion was diffusely and severely reduced with left ventricular ejection fraction of 13%. The wall thickness of intraven- tricular septum and posterior wall were 9 mm and 8 mm, respectively.
+His cardiac function did not improve even after the cardioversion for atrial tachycardia, and he suffered from recurrent heart failure. Finally, right ventricular endomyocardial biopsy revealed multiple myocardial hemosiderin deposits. In addition to the iron deposition in the heart, the loss of myocyte and severe interstitial fibrosis were present.
+Based on these findings, he was diagnosed with cardiac hemochromatosis associated with HS. Despite intensive medical treatment for heart failure and arrhythmias in combination with iron chelation therapy, he eventually died of progressive and refractory heart failure. Autopsy findings revealed systemic deposition of hemosiderin, especially in the heart and liver. Based on these findings, he was diagnosed with liver cirrhosis due to hemochromatosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3111_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3111_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0438608a995ac17eb010ca85397472e0e3024417
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3111_en.txt
@@ -0,0 +1,15 @@
+A 60-year-old woman presented to another hospital with shortness of breath on exertion. Her family history was unremarkable. She had undergone chemo-radiation for non-Hodgkin’s lymphoma 40 years earlier and achieved complete remission. CHOP (cyclophosphamide, doxorubicin, vincristine, and prednisone) chemotherapy did not induce cardiac toxicity. Twenty years earlier, she had an anterior myocardial infarction and underwent percutaneous coronary intervention. Moderate combined valvular diseases (aortic regurgitation, mitral regurgitation, and tricuspid insufficiency) were also followed. She had received standard treatment for chronic heart failure. However, she had suffered from acute exacerbation of congestive heart failure several times beginning 2 years before and was referred to our hospital because of refractory repeated congestive heart failure.
+
+Her vital signs were blood pressure 106/43 mmHg, heart rate 72/min, and SPO2 97% on room air, with a body mass index of 15.8 kg/m2. The conjunctiva showed no signs of anemia or jaundice. The first and second heart sounds were normal, but the third one was increased. There was a pan-systolic murmur at the cardiac apex (Levine III/VI). There were no rales in the lungs. The abdomen was flat and soft and the liver was palpated two finger widths below the ribs. There was no edema, ascites or coldness of the limbs. She had hepatomegaly and jugular vein distention remarkable at inspiration, also known as “Kussmaul’s sign”.
+
+Laboratory tests revealed mild renal and liver dysfunction, and the brain natriuretic peptide (BNP) level was 492 pg/mL. There were no signs of an inflammatory response, anemia, or thyroid dysfunction. Chest X-ray showed a cardiothoracic ratio of 47% and no evidence of pleural effusion, pulmonary congestion, or pericardial calcification. The electrocardiogram showed a pulmonary P wave, high left-side voltages, poor R progression, and ST changes in V5 and V6.
+
+Echocardiography showed decreased motion of the left anterior septum and the left ventricular ejection fraction (LVEF) was 42%. There was bilateral atrial enlargement, but no left ventricular dilatation. No pericardial effusion was seen. Although moderate mitral regurgitation, and tricuspid insufficiency were seen at the end of a previous hospitalization, severe mitral and tricuspid regurgitation were detected at our hospital admission. The septal leaflet of the tricuspid valve showed decreased mobility. The tricuspid regurgitation pressure gradient was 45 mmHg. Systolic flow reversal in the hepatic veins was observed, suggesting severe tricuspid regurgitation. Pulse doppler flow showed that the ratio of mitral peak velocity of early filling (E: 1.45 m/s) to late filling (A: 0.98 m/s) was 1.5, and the deceleration time was 211 ms. The ratio of mitral peak velocity of early filling (E) to early diastolic mitral annular velocity (E’: 6.9 cm/s) was 21. The early diastolic left ventricular filling velocity was reduced by 27% during inspiration. These findings indicate the possibility of CP and/or restrictive cardiomyopathy. The inferior vena cava was enlarged to 22 mm and the respiratory fluctuation was decreased. We diagnosed acutely developed congestive heart failure due to severe mitral and tricuspid regurgitation, which was not observed at the end of hospitalization at the previous hospital. The patient was prescribed additional diuretics to reduce volume overload.
+
+Computed tomography revealed a mild pericardial thickening of 4 mm in front of the right ventricle. Considering the history of radiation therapy, it was likely that the patient was suffering from concealed pericardial disease.
+
+Prior to the cardiac catheter examination, normal saline was infused at a rate of 50 mL/h for 12 h to manifest the pericardial disease and to protect renal function from the contrast medium. Coronary angiography showed that the coronary arteries were intact and there was a stent in the left anterior descending artery. The right atrial, end diastolic right ventricular, diastolic pulmonary artery, and pulmonary capillary wedge pressures were 15 mmHg. This finding was not seen in a right heart pressure study performed previously in hospital about 6 months ago. In the right atrial pressure waveform there were prominent x and y descents. The right ventricular systolic pressure exceeded 40 mmHg and showed a dip-plateau pattern. In the simultaneous pressure measurement of the left and right ventricle, the difference in end-diastolic pressure was within 5 mmHg. At maximum inspiration, the systolic pressure of both ventricles was dissociated, and showed mirror-image discordance. Based on these changes in hemodynamics after loading of the patient with fluids, we revealed the diagnosis of OCPD.
+
+Pericardiectomy, aortic valve replacement, and mitral and tricuspid valvuloplasty were performed. At surgery, there was a hard, thickened pericardium, and very mild pericardial adhesion. Histological examination of the resected pericardium revealed hyaline-like fibrous hypertrophy.
+
+Twelve months postoperatively, there was no acute exacerbation of the congestive heart failure. The New York Heart Association functional class had also improved from III to II. On echocardiography, although mild tricuspid and mitral regurgitation remained, the size of both the left and right atria decreased. The percent difference in E-velocity between expiration and inspiration was improved to 12% after pericardiectomy, compared to 27% before.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3133_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3133_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c7bbdd38d1da97742d9a34345b61259695e98046
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3133_en.txt
@@ -0,0 +1,9 @@
+54-year-old male who presented with acute coronary syndrome, requiring advanced airway management on arrival in the emergency department with tenecteplase 0.5 mg/kg given with an ischaemic time of 1 hour 40 minutes, without reperfusion.
+
+The patient had two episodes of pulseless tachyarrhythmias that required three defibrillation events of 200 J, advanced cardiopulmonary resuscitation, and intravenous amiodarone 300 mg for return of spontaneous circulation. The total time of cardiac arrest was approximately 11 minutes. In the rescue coronary angiography, a medicated stent was placed in the anterior descending artery and an unmedicated stent in the first diagonal artery, final flow TIMI 3, Blush 3. The patient was admitted to the coronary care unit (CCU) with deep sedation, mechanical ventilation, cardiogenic shock, and a SOFA score of 7 points.
+
+The patient was extubated 6 days after admission, but developed post-extubation delirium, stridor and iatrogenic pneumothorax, which required endotracheal tube placement and reintubation 48 hours later. During this period, he received drugs associated with myositis, such as haloperidol 5 mg intravenous in intermittent doses (accumulated 30 mg), olanzapine (accumulated 20 mg) and hydrocortisone (200 mg). After reintubation, the patient developed septic shock, so he was given supportive treatment and started with vancomycin and meropenem at full doses (with subsequent adjustment to renal function) for six days as treatment for nosocomial pneumonia. Atorvastatin was continued enterally at a dose of 80 mg every 24 hours and an elevation of the serum level of creatine phosphokinase (CPK) was detected that exceeded 10 times its upper normal limit two days after reintubation (10 days after admission to the CCU), reaching its maximum peak five days later (at which time atorvastatin was discontinued) and having a plateau for three more days. The total time of use of atorvastatin (80 mg every 24 hours) was 15 days.
+
+The oliguric LRA KDIGO 3 reached its maximum level of azoates eight days after re-intubation.
+
+A catheter for haemodialysis was placed, two intermittent sessions were given and extubation was successful six days after the start of renal replacement therapy. A biopsy of the right deltoid muscle was performed at the peak of the elevation of muscle enzymes and, finally, the patient was discharged three days later to the general hospital room.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3167_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3167_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..465fd7babe16bbaf35b782a525ddfa35dc222e29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3167_en.txt
@@ -0,0 +1,3 @@
+The patient was a 79-year-old female with NYHA class III heart failure with non-ischemic cardiomyopathy (LVEF 40%) and chronic atrial fibrillation who was referred for CardioMEMS implantation. She had been hospitalized 3 times for heart failure in the prior year despite receiving outpatient intravenous diuretic therapy at the heart failure infusion clinic. Warfarin was held for 3 days prior to the implant procedure and her international normalized ratio (INR) was 1.8 on the day of the procedure. She was taking 81 mg aspirin daily. The remainder of her laboratory studies were unremarkable.
+
+Given her obesity and body habitus, we chose the right internal jugular venous approach for the implant procedure. Right heart catheterization was performed and showed right atrial pressure of 5 mm Hg, pulmonary artery systolic/diastolic/mean pressures of 40/14/22 mm Hg respectively and a pulmonary capillary wedge pressure of 12 mm Hg. A 12 F sheath was placed in the right internal jugular vein and 4000 units of intravenous heparin was administered. Diluted contrast injection through the Swan-Ganz catheter identified a suitable sized left lower lobe branch pulmonary artery. A 0.018-inch wire was advanced into the index artery and the pressure sensor was deployed at the chosen location. The procedure was completed uneventfully. The patient started coughing 20 minutes after the procedure with evolved to mild hemoptysis and so the patient was transferred to the cardiac intensive care unit for observation. Intravenous protamine was administered to reverse heparin. She was kept off warfarin and aspirin and the hemoptysis resolved 3 days later. While the exact etiology of hemoptysis in this patient is unclear, we felt that it may have been precipitated by a minor wire-induced distal branch pulmonary artery injury.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3169_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3169_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..efb43cfdafeba016cebc773cd67759241242d087
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3169_en.txt
@@ -0,0 +1 @@
+An 86-year-old woman with a history of chronic HF due to obstructive HCM and AS was transferred to our hospital complaining of persistent dyspnea (New York Heart Association class IV). She was on multiple medications for management of chronic HF, including torasemide (8 mg/day), spironolactone (25 mg/day), metoprolol (120 mg/day), losartan (50 mg/day), and disopyramide (300 mg/day). On admission, her blood pressure was 98/74 mmHg and her heart rate was 54 beats/min. Echocardiography revealed a left ventricular (LV) ejection fraction of 68% with LV hypertrophy (maximum LV wall thickness of 20 mm), a peak left ventricular outflow tract (LVOT) gradient of 144 mmHg at rest due to systolic anterior motion of the mitral valve, and moderate to severe mitral regurgitation. In addition, echocardiography demonstrated severe AS (peak aortic valve velocity of 5.7 m/s and mean aortic valve gradient of 48 mmHg). We could distinguish between obstructive HCM and severe AS (i.e., dynamic vs. fixed obstruction) by the shape of the continuous-wave Doppler velocity curve. A chest radiograph revealed moderate pulmonary congestion and bilateral pleural effusions. Based on these findings, she was diagnosed as having ADHF with a preserved EF due to obstructive HCM and severe AS. Laboratory tests showed that blood urea nitrogen was 33.2 mg/dl, serum creatinine was 0.60 mg/dl, serum sodium was 142 mEq/l, serum potassium was 4.2 mEq/l, and B-type natriuretic peptide (BNP) was 5857 pg/ml. Oxygen saturation was below 90% on room air. She was not considered to be a candidate for implantation of a permanent pacemaker, septal ablation with ethanol, or surgical therapy because of her advanced age and insufficient motivation. Therefore, intravenous administration of furosemide (40 mg/day) was added from day 1 after hospital admission, and low-dose tolvaptan (7.5 mg/day) was added from day 4 to keep the serum sodium concentration within the normal range. Over a 4-day period after admission, a total urine output of 1000 to 1200 ml/day was transiently maintained with coadministration of furosemide (bolus infusion of 40 to 60 mg/day), spironolactone (50 mg/day), and low-dose tolvaptan (7.5 mg/day), but the patient’s orthopnea and oxygen saturation showed little improvement. Accordingly, dose escalation was performed for both tolvaptan (increased from 7.5 to 15.0 mg/day) and furosemide (bolus infusion was increased from 60 to 80 mg/day), but there was no significant improvement of ADHF by hospital day 19. In addition, her urine output gradually decreased despite up-titration of tolvaptan to 15.0 mg/day. However, soon after up-titration of spironolactone (from 50 to 100 mg/day) was added to tolvaptan at 15.0 mg/day, total urine output exceeded 1500 ml/day and was maintained at this level during hospitalization, despite tapering and discontinuation of furosemide. Her dyspnea was also markedly alleviated and she improved from New York Heart Association class IV to class III. Chest radiographs obtained on hospital day 25 showed very little pulmonary congestion or residual pleural effusion. Since discharge from hospital, she has remained on the same medications and has been followed up at our outpatient department for 18 months without adverse changes of serum electrolytes or readmission for exacerbation of HF.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3223_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3223_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..84695307de29a528bc99d407291aa2bcbdc96a9d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3223_en.txt
@@ -0,0 +1,13 @@
+A 45-year-old Tibetan female (actual age corrected from 35 years, as stated incorrectly in the medical records) presented with significant swelling and pain in the bilateral metacarpophalangeal and elbow joints. She reported muscle weakness in all four limbs, with slight swelling and discomfort in both knee joints and restricted range of motion in all four limbs, particularly in the right upper limb. She experienced morning stiffness lasting more than one hour and exhibited a right hand deformity with a right angle bend at the proximal interphalangeal joint of the ring finger. Eyelid swelling was also observed. Physical examination revealed 5–6 ulcerated wounds, approximately 1*2 cm in size, with yellow viscous secretions on the metacarpophalangeal and interphalangeal joints of both hands. These wounds showed a trend of increasing number as well as rapid expansion and deepening. There was a longitudinal ulcerated wound, approximately 8*2 cm in size, on the right elbow joint. The periorbital area showed erythema, and scattered skin rash was observed on the back. The patient did not report any ulcers or itching. Additional observations noted severe deformity, multiple ulcerations with purulent discharge, and necrotic ulcers on the metacarpophalangeal and interphalangeal joints of both hands, indicative of mechanic’s hands. The patient exhibited cyanosis of the lips, hair loss, symmetrical chest without deformities, and occasional dry and moist rales in both lungs. The spine appeared normal, and multiple joints throughout the body were tender with restricted movement. Local skin temperature was elevated.
+
+The patient was admitted with approximately normal liver and renal function, high blood lipids, creatine kinase: 40 U/L, blood count: lymphocyte count: 0.63*10^9/L, percentage of lymphocytes: 7%, monocytes: 0.28*10^9/L, neutrophil count: 7.98*10^9/L, CRP: 83.2 mg/L. The patient’s diagnosis was not clear, and a sample of his serum was sent to an external clinical Laboratory, myositis-specific antibody profile report suggested positive anti-MDA5 antibody, titre: 1:300 (fibronectin/CBA method), positive anti-SSA/RO52 antibody. Skin biopsy: the tissue was covered with slightly hyperplastic squamous epithelium, subepithelial fibrous hyperplasia, vitellosis, and culture of multidrug-resistant organisms (Escherichia coli, Staphylococcus aureus) in the mesenchyme, perivascular area, and wound secretion from the joints around the skin appendages. Chest CT scan half a month later showed interstitial lung lesions, and the patient was found to be suffering from new oral ulcers around 20 days. Twenty-four days later, the patient’s medical condition was controlled and stabilised, and the erythema and ulcers had subsided locally with no new eruptions, and the medical problems were basically resolved, but the patient’s right elbow lesion was large and deep, and in order to deal with all the lesions that were unable to heal on their own, the patient was transferred to the Department of Burns and Plastic Surgery of the Sichuan Provincial People’s Hospital, where he was proposed to have a debridement and skin grafting. In conclusion, the patient’s symptoms, signs, examinations and tests were highly consistent with the symptoms of this disease.9 Based on these results, we diagnosed a double-positive dermatomyositis with anti-MDA5 and anti-SSA/RO52 antibodies.
+
+
+Typical Skin Ulcers
+On the day of admission (2023-07-01), the patient had ulceration and crusting at the distal interphalangeal joint of the left second finger, proximal interphalangeal joint of the left fourth finger, metacarpophalangeal joints of the right second and fifth fingers. The affected areas showed exfoliation and erythema of the superficial skin, with the presence of yellow viscous secretions upon compression. There was a dark red rash at the bottom of the joint of the left foot at the first toe and on the outer side of the metatarsophalangeal joint of the left foot. A longitudinal ulcerated wound on the right elbow joint had crust formation and measured approximately 8*2cm (prior to admission, the patient had received “cauterization treatment” at a local Tibetan medicine clinic for the right elbow, but there was no significant improvement). Irregularly shaped scattered skin rashes were observed on the back, approximately 4*3cm in size, and there was noticeable erythema around both eye sockets.
+
+On the 6th day of admission (2023-07-06), the muscles surrounding the distal interphalangeal joint of the left second finger, proximal interphalangeal joint of the left fourth finger, metacarpophalangeal joints of the right second and fourth fingers, and the proximal and distal interphalangeal joints of the right fifth finger were affected. The white joint capsule was exposed, accompanied by exfoliation and erythema of the superficial skin. Yellow viscous secretions were observed upon compression. The crusts on the longitudinal ulcerated wound of the right elbow joint broke, and yellow viscous secretions spontaneously flowed out. A new ulcerated wound, measuring 1*2 cm, had developed on the left elbow joint without purulent discharge. A fresh red rash, approximately 2*1 cm in size, appeared on the right knee joint. The condition of the skin rashes in other areas remained the same as before.
+
+On the 11th day of admission (2023-07-11), the patient had severe purulent discharge at the site of the longitudinal ulcerated wound on the right elbow joint. The patient was advised to seek treatment at the dermatology department of our hospital for dressing changes. Some of the wounds were debrided and dressed by the dermatology department. There were scattered bruises near the ulcerated wound on the left elbow joint, and the condition of the skin rashes in other areas remained the same as before, with no new developments at the moment.
+
+On the day of discharge (2023-07-25), the patient had ulceration at the distal interphalangeal joint of the left second finger, metacarpophalangeal joint of the right second finger, and proximal interphalangeal joint of the left fourth finger. The white joint capsule was exposed at the metacarpophalangeal joints of the right second and fourth fingers, as well as the proximal and distal interphalangeal joints of the right fifth finger. No secretions or erythema were observed at these sites.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3238_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3238_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..942cfb83e40c1ea045494f1a1359e12f4a277a82
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3238_en.txt
@@ -0,0 +1,9 @@
+A 69-year-old female patient presented to the emergency department with a 1-year history of progressive and disabling paraparesis (ASIA C, Nurik 5) associated with right sciatica and subacute sphincter incontinence. Physical examination revealed a paraparesis with M3/5 motor strength in both lower limbs from L2 to S1, with bilateral patellar and Achilles reflexes, positive Hoffman signs in both upper limbs, positive clonus and Babinski in lower limbs associated with right sciatic pain of intensity 9/10 on the visual analogue scale (VAS) in the territory of the L5 root and positive Lassegue and Bragard maneuvers. The cervical myelopathy scores were: modified Japanese scale 5 (mJOA) 9/17, Nurik scale 6 5.
+
+Imaging studies
+An emergency MRI revealed three points of stenosis of the spinal canal: 1) a degenerative cervical narrowing C5-C6 with focal myelomalacia; 2) an intra-spinal extramedullary intradural tumour D6-D7 with a spinal imprint of 15 mm x 8 mm x 7 mm; and 3) a right posterolateral disc extrusion L4-L5.
+
+
+Surgical treatment and postoperative evolution
+
+The diagnosis of EETRS was confirmed, and a posterior decompression D6-D7 was performed by laminectomy and exeresis of the dorsal extramedullary intra-surgical blockage, associated with a right L4-L5 intra-surgical blockage. At the cervical level, the stenosis was already known and there was no evidence of a worsening of the clinical picture, mainly at the level of the upper limbs. For this reason, the rapid progression of the symptoms was attributed to the recently diagnosed oncological condition. The surgery was performed under intraoperative monitoring of somatosensory and motor evoked potentials. The total operating time was 2 hours and 20 minutes, under general anaesthesia. The anatomopathological analysis was consistent with WHO grade I transitional meningioma. During the immediate postoperative period, the patient evolved favourably, presenting a remission of sciatica with an EVA 3/10. The hospital discharge was on the third postoperative day, walking with a walker, and with effective spontaneous diuresis. In the seven and fourteen day postoperative controls, a notable improvement of motor strength was evidenced with sciatic pain of 2/10, walking with a cane at the month, and without it at the three months postoperative. The last control at the year postoperative evidenced a residual pain of 1/10, with a M4 deficit for L5 right, without instability in the gait and signs of upper motor neurone decreased, mJOA 17/17, Nurick 1. The patient continued with the presence of the bilateral Hoffman sign, however, the Lhermitte sign persisted negative and never evidenced the loss of the fine motor dexterity in the upper limbs.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3300_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3300_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ef1ce23081637ac045a061ff602244c3da9d50ed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3300_en.txt
@@ -0,0 +1,6 @@
+A 36-year-old woman with no medical history was admitted to An-Najah National University Hospital in the West Bank, Palestine for fever and pancytopenia without a known source of infection. The lab findings indicated a neutrophil count of 300 cells per microliter and she received a diagnosis of non-M3 AML. On the eighth day of chemotherapy, she experienced neutropenic fever and received IV antibiotics following culture collection. One week later, her fever persisted and the antibiotics were switched to meropenem and vancomycin.
+
+On the eighth day of neutropenic fever, a pan-computed tomography (CT) scan revealed bibasal pulmonary glass opacity, an enlarged spleen measuring 15 cm with several hypodense lesions. Because of inadequate vascular access, a catheter was placed in the right internal jugular vein. It was believed that this overall picture, combined with the positive galactomann test, indicated a widespread fungal infection, leading to the initiation of oral voriconazole. Severe thrombocytopenia prevented a biopsy from being performed, leading to an unclear diagnosis. Furthermore, there were no abnormalities detected during the ophthalmological examination and transthoracic echocardiogram.
+
+On the ninth day of treatment, primary fungal growth was observed in the peripheral blood culture, leading to the initiation of a broader antifungal agent (IV caspofungin). Nonetheless, the final growth revealed growth of Saprochaete capitata; a fungi that exhibited varying appearances when grown on blood and chocolate agar, with dry white colonies on blood agar and cotton colonies with a frosted glass appearance on chocolate agar. Based on the susceptibility report, treatment started with amphotericin B (minimum inhibitory concentrations were: voriconazole < 2 mg/l, amphotericin B < 0.25 mg/l and caspofungin > 32 mg/l), leading to a decrease in inflammatory markers, fever frequency, and cell recovery count. Subsequent blood cultures revealed no signs of bacterial growth. A second bone marrow biopsy revealed no malignant cells, and she was prescribed voriconazole tablets for a six-week course upon leaving the hospital. She was admitted again for consolidation chemotherapy but experienced neutropenic fever. Even with antibiotics and voriconazole, her fever persisted, and the CT scan indicated the disappearance of the lung opacity, but revealed that the splenic hypodense lesions had grown in both size and number (4.5 × 5 cm, previously only subcentimeters). Furthermore, there were newly emerged small hypodense lesions in both kidneys, as well as numerous hypodense lesions in the liver. Amphotericin B IV was administered in combination with oral voriconazole, and a spleen biopsy guided by CT was conducted, however, the culture revealed no organism growth. Following a two-week course of dual antifungal treatment, her condition improved; however, she had to be readmitted due to the recurrence of fever. Despite receiving antifungals and steroids, no improvement was seen in her condition, with the spleen having the largest lesions. She had surgery involving resection of spleen removal, part of the stomach, and part of the pancreas due to extensive adhesions and to control source of infection. The histopathological analysis revealed fungal spores and septate hyphae branching at sharp angles, while the tissue culture did not indicate any growth. Voriconazole and amphotericin B were prescribed for another three weeks, and a CT scan showed marked improvement in the hypodense liver and kidney lesions.
+
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3304_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3304_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2651aca8840ae5cdeecb7dce42377d2c78c1385e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3304_en.txt
@@ -0,0 +1 @@
+An 18-year-old woman sustained a neck contusion following blunt trauma to the submandibular region from her bicycle handlebar grip end after a light contact with a motor vehicle. Upon initial examination, the patient's level of consciousness and vital signs were within normal ranges, and she did not report any previous medical history of concern. The patient did not express any concerns regarding the condition of the neck or throat. A secondary survey revealed a 25-mm contusion in the submandibular region with a 3 × 5 mm laceration at its center. The wound was free of contamination, exhibited no active bleeding, and did not present with surrounding hematoma formation. Furthermore, it was determined that there was no tracheal injury due to the absence of abnormal breath sounds at the neck and the absence of any airway deformity or deviation. Computed tomography (CT) revealed the presence of interstitial air extending through the soft tissue gap between the sternocleidomastoid muscle and the larynx, extending to the retropharyngeal space. While the wound was cleansed with saline solution, the patient reported the presence of water in her oral cavity. Therefore, we established a connection between the pharynx and the exterior laceration site. Subsequently, a water drinking test was conducted to ascertain the presence of a fistula from the pharyngeal side to the neck wound. However, no fluid was observed to leak from the wound, and the fistula was thus determined to be unidirectional. A film-shaped drain was placed within the wound, and the wound was sutured in a roughly approximated manner. The patient was admitted to the hospital for a follow-up examination. Fluids and oral antimicrobials were administered 3 h after admission, and the patient was permitted to commence oral feeding after 12 h. The patient was discharged on the third day without any issues with her general condition or neck. Subsequent to her discharge from our institution, the patient did not contact us to express any concerns regarding unusual occurrences. The outpatient examination conducted on the sixth day following the injury revealed no abnormal physical findings, and the drain was subsequently removed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3305_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3305_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bb11b0c119207918c14820592b0f272e420e4556
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3305_en.txt
@@ -0,0 +1,9 @@
+A 50-year-old man was admitted to our hospital for evolution of progressive dyspnea, paroxysmal nocturnal dyspnea, orthopnea and fatigue, and abdominal distension. These symptoms began 2 months earlier, when he was diagnosed at a different hospital with bacterial pneumonia complicated by bilateral parapneumonic effusion, which required drainage. His past medical history included bilateral lipoma, which was surgically treated 1 year prior to admission, and thyroiditis 3 years earlier. He reported regular moderate alcohol intake (100 g/wk) and that he had smoked 20 cigarettes a day for 30 years. The study protocol was approved by the ethics review board of the First Hospital of Jilin University (No. 2016-263). Informed written consent was obtained from the patient for publication of this case report and accompanying images.
+
+Upon admission, his respiratory rate was 20 breaths/min, pulse was 102 beats/min, and blood pressure was 98/65 mm Hg. Bleeding points were scattered in the abdominal skin and hemorrhagic purpura were around the eye orbit. Physical examination revealed jugular venous distention and abolition of bilateral basilar breath sounds based on pulmonary auscultation. There was no cardiac murmur; however, a third heart sound was heard.
+
+An echocardiography test of the chest demonstrated small bilateral pleural effusions, 42 mm under the left 7th rib and 54 mm under the right 7th rib. Electrocardiography (ECG) demonstrated a sinus rhythm with a heart rate of 93 beats/min, poor R-wave progression in leads V1–V3 with right axis deviation, and low voltage criteria. Echocardiography revealed diffuse left ventricular hypertrophy (septal and free wall thickness of 17 and 14 mm, respectively) with normal ventricular cavity size (diastolic and systolic chamber diameters of 45 and 23 mm, respectively). Enlarged atria (35 × 50 × 45 mm), and mild mitral and tricuspid regurgitation were observed. The left ventricle was interpreted to have severe diastolic dysfunction (mitral E wave velocity = 0.8 m/s, A wave = 0.27 m/s, medial E/e′ = 20), as well as mildly impaired systolic function with an impaired ejection fraction of 54% based on 2-dimensional echocardiography. The early diastolic transmitral filling velocity to atrial filling velocity (E/A) ratio increased to 4.25. The ventricle wall was characteristic sparkling and of granular texture. The echocardiographic appearance of thickened ventricle accompanied with low QRS voltage in ECG was characteristic. These abnormalities were considered suggestive of amyloidosis. To further evaluate both myocardial and pericardial pathologies, cardiac magnetic resonance imaging (MRI) was performed on a 3.0-T MR scan system. The cardiac MRI showed diffuse, subendocardial delayed gadolinium enhancement.
+
+Additional testing revealed troponin I was mildly elevated at 0.14 ng/mL (normal 0–0.034 ng/mL). Plasma N-terminal brain natriuretic peptide (NT-proBNP) was elevated at 15,000 pg/mL (normal 0–400 pg/mL). Serum electrophoresis failed to detect monoclonal gammopathy in the serum, but immunoelectrophoresis revealed free lambda light chains. Serum free light–chain (FLC) analysis showed an altered kappa/lambda ratio of 0.01, with lambda light chains increased at 1240 mg/L (normal 8.3–27.0 mg/L). Bence-Jones protein was not detected in the urine. Bone marrow examination confirmed benign monoclonal gammopathy with 8.5% plasma cells, and biopsy stained for Congo red was negative. There was no evidence of multiple myeloma on skeletal survey. Autoantibody screening was normal. The glomerular filtration ratios were normal with daily proteinuria. A periumbilical fat aspirate sample confirmed amyloidosis. The patient was finally diagnosed with AL amyloidosis with cardiac and skin involvement, and in stage III using the Mayo 2012 staging system.
+
+The patient's therapeutic plan was to perform 3 cycles of therapy with bortezomib (1.3 mg/sqm/d) and dexamethasone (20 mg/d) administered on the 1st, 8th, 15th, and 22nd days of each 3-week course. Cyclophosphamide was subsequently administered on the 2nd, 9th, 16th, and 23rd days (300 mg/d). Unfortunately, 5 days after the second cycle of therapy with bortezomib, the NT-proBNP level increased from 15,000 to 31,100 pg/mL, and troponin I increased from 0.14 to 0.463 ng/mL. The patient died because of a fulminant syndrome characterized by infiltrative pulmonary disease with hemorrhage, severe pulmonary infection, and heart failure.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3308_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3308_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c6e3db33a08d515cc1b1eaa841f90f00d009628
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3308_en.txt
@@ -0,0 +1 @@
+The case of a 79-year-old man with a diagnosis of obesity with no history of asthma, smoking or illicit drug use, who consulted for sudden dyspnoea at rest, was described. On admission to hospital, tachypnoea, generalised hypoventilation and bilateral diffuse wheezing were noted on pulmonary auscultation, sinus tachycardia and pulse oximetry oxygen desaturation of 70% at room air was observed. In the admission laboratory, he presented respiratory failure type 1 (pO2 39 mm Hg), leukocytosis (11 300/mm3), elevated C reactive protein and LDH (17.7 mg/d and 659 U/L respectively) and hyperlactatemia (10 mmol/L). Nasopharyngeal swab with polymerase chain reaction technique for SARS-CoV-2 positive. A thoracic angiotomography was performed that evidenced bilateral areas of ground glass opacities, without evidence of pulmonary thromboembolism. Lower limb venous Doppler without deep vein thrombosis. He underwent an intensive care admission with a diagnosis of bilateral pneumonia by SARS-CoV-2 (CURB-65 of 3 points) with oxygen supply through a mask with reservoir (15 l/min), treatment with dexamethasone and ampicillin-sulbactam. He did not require central venous access or use of positive pressure devices (VNI or high flow nasal cannula). After 72 hours, due to clinical improvement and decrease of oxygen requirements to nasal cannula, he was transferred to the general ward. He improved four days later with access of cough, progression of dyspnoea, tachypnoea (30 rpm), generalised wheezing and increased oxygen requirements. He did not present thoracic pain, palpitations, odynophagia, dysphagia or neck pain. A thoracic tomography was performed where ground glass opacities and cervical subcutaneous emphysema were evidenced. Hamman syndrome was interpreted as secondary to increased intrathoracic pressure due to access of cough and bronchial obstruction. He was treated with inhaled bronchodilators and improved with symptomatic improvement, without oxygen therapy requirements.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3322_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3322_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1cc7d819ea9484ecfbd874abef1cedf60d6ab59d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3322_en.txt
@@ -0,0 +1,7 @@
+A 44-year-old female patient presented to the emergency department with a 3-week history of melena and abdominal pain. She was hemodynamically unstable with a mean arterial pressure of 60 mmHg and a heart rate of 95 bpm. In the laboratory, a baseline Hb of 4.8 g/dL was noted. Supportive measures were initiated and an upper gastrointestinal endoscopy was performed, which revealed a submucosal gastric tumor without active bleeding, but intractable by this means. The patient was hospitalized and the study was complemented with an abdominal CT scan, which reported a solid exophytic mass dependent on the gastric fundus of 11.3 cm in major diameter, of heterogeneous density and a 24 mm ulcer on the anterior face, suggestive of a gastric gastrointestinal stromal tumor (GIST).
+
+After the patient was stabilized, a surgical resection was planned. On examination, the tumor was a large exophytic lesion of the proximal third and posterior aspect of the stomach, 12 cm in diameter, with extensive adhesive and infiltrative process to the splenic hilum, including the pancreatic tail and part of the left Gerota's fascia; however, the adjacent pancreatic tissue was normal in appearance. There was no evidence of lymphatic, visceral, or peritoneal metastases.
+
+A vertical wedge gastrectomy was performed with a corporodistal pancreatectomy and a splenectomy en bloc. The histological study showed a tumour with a neoplastic, anaplastic, poorly differentiated, malignant proliferation with cells arranged in a solid pattern with increased nuclear-cytoplasmic ratio, hyperchromatic, pleomorphic, anisocaryotic nuclei with numerous mitoses and some multinucleated giant cells of osteoclastic type, circumferential surgical margins and a pancreatic margin of 0.5 cm. There was no evidence of perineural or lymphovascular invasion. Immunohistochemistry for vimentin, keratin and CD68 were positive. Immunohistochemistry for DOG, S100, CD34 and DOG1 was negative. These findings were consistent with an anaplastic cancer of the pancreas.
+
+The patient evolved in the immediate postoperative period in a good way. The only notable complication was a pancreatic biochemical leakage (fistula type A) without clinical repercussions, so it was kept drained for 6 weeks and then removed without incident. She subsequently evolved in a favorable way, receiving chemotherapy effectively with Oxaliplatino, 5-Fluorouracil and Leucovorin, with a serial follow-up with PET/CT without metastases at 5 years, in good general condition and with a good quality of life.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3341_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3341_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..666e88efbcd648c6ae7ab824a93c30dc59b2b6f0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3341_en.txt
@@ -0,0 +1,11 @@
+A woman in her 60s presented to the emergency department on April 27, 2021 with a sudden onset left hemiplegia and a severe, sudden onset, holocranial, oppressive headache in the last two hours. She had no history of vascular risk factors or heart or renal disease. She confirmed no heparin treatment in the previous 100 days. The first dose of the ChAdOx1-S vaccine was administered 16 days earlier.
+
+The physical examination revealed a blood pressure of 120/80 mmHg. Initially, the patient was alert, but with moderate dysarthria, left hemiplegia and forced rightward deviation of the eye, with a score of 16 on the National Institute of Health Stroke Scale (NIHSS).
+
+Urgent cranial computed tomographic (CT) scan showed a hemorrhage in the right frontal lobe with no evidence of intracranial hypertension and computed tomographic angiography revealed no underlying vascular abnormality to the hematoma. There was no evidence of cerebral venous thrombosis visible on computed tomographic venography. Blood work showed moderate thrombocytopenia of 51,000/uL (reference: 140,000-400,000/uL), with normal hemoglobin and leukocytes. Coagulation laboratory results showed elevated levels of D-dimer of 2,317 ng/mL (reference: 0-250 ng/mL). Biochemical analysis showed a slight elevation of alanine transaminase (114 U/L; reference: 5-31 U/L) and aspartate transaminase (56 U/L; reference: 10-31 U/L). The ion, renal profile and cardiac markers were within normal ranges. Urine drug screen was negative. The patient had normal previous hematologic and coagulation parameters in tests performed in our center during the last five years. She had not received heparin or other drugs prior to admission.
+
+The patient's level of consciousness deteriorated over the next two hours, with no ocular or verbal responses and flexion of the right limbs to painful stimuli, with a Glasgow Coma Scale score of 6. She was subsequently evaluated by neurosurgeons and intensive care doctors. The neurosurgeons decided to drain the haematoma. No vascular abnormalities were observed during surgery. A platelet transfusion was required for the procedure. She was subsequently admitted to the intensive care unit, where the post-operative CT scan showed signs of rebleeding as well as uncal and subfalcular herniation. Blood pressure values remained below 120/80 mmHg at all times. CT angiography and venography were repeated post-operatively with no evidence of vascular abnormalities or cerebral venous thrombosis.
+
+A progression of thrombocytopenia and a D-dimer increase was observed in the control blood tests showing a severe thrombocytopenia (19,000/uL; references: 140,000-400,000/uL) and higher levels of D-dimer (3,840 ng/mL; references: 0-250 ng/mL). In contrast, no data of disseminated intravascular coagulation was found. Antibodies against platelet factor 4 (PF4) were detected with the ELISA technique, suggesting a possible TTP, which was confirmed with a platelet activation induced by heparin. Therefore, it was treated with intravenous immunoglobulins from day 2 to 5 (Flebogamma© 5%, 1 g of weight adjusted to day) and methylprednisolone from day 6 to 11 (1 g of weight adjusted to day), without clinical response with either treatment. No prophylactic anticoagulation was administered.
+
+While in the ICU, the patient developed an irreversible intracranial hypertension syndrome with uncal and subfalcular herniation with a poor prognosis. A decision was made to limit the therapeutic effort and immunoglobulin and corticosteroid treatment was discontinued. Palliative sedation was initiated and the patient finally died on day 21 after the event.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3370_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3370_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd6243ab8b5e745b8edd2a44ea763200da1686b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3370_en.txt
@@ -0,0 +1 @@
+The 8-year-old girl had complained of intermittent fever for the past year and rashes all over her body that started to appear at about 6 months of age. She experienced an oil massage at the age of 6 months, which resulted in the rapid emergence of well-defined elevated skin rashes across her entire body that vanished in minutes. The rashes began to appear every day. There was no connection between these rashes and the use of oil, no discernible pattern to the rash's onset, no disruption of sleep at night, and no prior history of fever, eczema, food, medication, or insect allergies. The rashes continued to appear without any specific pattern daily. They always resolved within one to 2 h without any medication, and they were not itchy. Their parents expected she would outgrow it with time; thus, no further doctor visits or follow-ups were done. At the age of 7 years, she developed high-grade intermittent fever, for which she required admission. But fever continued to appear often, without any specific pattern. After experiencing on-and-off fever for 4 months, a positive Mantoux test, and a chest X-ray revealing a hilar shadow, she was later started on antitubercular medications. GeneXpert sputum yielded negative results. Fever did not, however, go away entirely. She reported to us at this time that she had a daily history of intermittent fever, with most episodes occurring after dark. She exhibited good activity during the inter-febrile phase and had a healthy appetite. Mother had a history of non-pruritic hives all over her body that were worse during a fever and when her skin was exposed. Hives were more common on exposed bodily parts. Antipyretics were used to treat fever and minor joint pain. There was no prior history of edema, redness, involvement of other joints, involvement of the eyes, or repeated hospitalizations. No significance was found in birth, developmental, or family history. Upon general examination, the patient had pallor and well-defined raised lesions over the body. She measured 125 cm (at the 50th centile) in height and 23 kg (25th to 50th centile). A systemic evaluation revealed no abnormalities. The results of the investigation showed neutrophilic leukocytosis (WBC: 22,740/μL, ANC: 16,470/μL) and iron deficiency anemia (Hb: 8.4 g/dL, serum iron: 30 μg/dL, TIBC: 500 μg/dL, transferrin saturation: 8%, ferritin: 15 ng/mL), high CRP of 70 mg/dL, and raised ESR (25 mm at 1 h). Pure tone audiometry revealed right-sided severe mixed hearing loss. Antineutrophilic antibody (ANA), immunoglobulins, and interleukin levels were all within normal limits. Serum amyloid level was high (295 mg/L). The complaints above of hearing loss, elevated amyloid levels, and inflammatory markers led to the suspicion of Muckle-Wells syndrome. Germline mutations in the NLRP3 gene were detected by Sanger sequencing test. A pediatric rheumatologist advised following up a month after starting Colchicine empirically to prevent amyloidosis. There were fewer events still occurring, so the next plan was to begin Anakinra.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3372_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3372_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..21be7738bff045224bba45b383830ccf8db1810d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3372_en.txt
@@ -0,0 +1 @@
+A 71-year-old man underwent a robot-assisted partial nephrectomy in 2022 at Azienda sanitaria territoriale Pesaro-Urbino, Italy, to treat a 5 cm mass located at the upper pole of his left kidney (7a according to the RENAL Nephrometry Score).8 Following appropriate preoperative preparation, the mass was enucleated with a clamp of renal artery of 21 minutes. Care was taken to close the renal wound meticulously using absorbable sutures and covered with sealing matrix (made by human fibrinogen and thrombin), and perirenal fat. Post-surgery, pathological analysis of the surgical specimens revealed stage pT1a, grade 2 renal cell carcinoma (RCC). The patient recovered well, with the temporary drainage tube removed on the fourth postoperative day, and he was discharged on the fifth day. However, six months later, was re-admitted with fever and elevated inflammatory markers, she had no history of urinary stones and did not report any recent trauma. CT urography showed a 8 cm perirenal collection at the upper pole of the left kidney, with contrast leakage from the upper calyx into the perirenal space. Subsequent retrograde pyelography confirmed the presence of a urinary fistula between the urinoma and the upper urinary calyx. To address this complication, a retrograde double pig-tail stent was inserted in the collecting system and percutaneous US drainage was positioned by interventional radiologist in the perirenal collection. Cultural examination of urine and drainage fluid yielded negative results. However, at the one-month follow-up, the urinary fistula persisted. Along with the interventional radiologist, despite the non-dilatated collection system a US guided percutaneous access into the lower calyx was obtained with a vascular introducer sheat. After confirming the presence of the fistula from the upper calyx with contrast injection, a catheterization of the fistula was obtained with a Bern catheter and a microcatheter (Progreate 2.7 F Terumo). Adhesive fibrin, a solution comprising frozen aprotinin and thrombin-calcium chloride, was then introduced via the microcatheter in the fistula, following a sudden closure of the fistula, as indicated by the urogram. The percutaneous nephrostomy was left with the distal tip within the upper calyx group after the procedure along with the double pig-tail stent, in order to optimize the drainage of the entire collecting system of the kidney. After three days, a pyelography control showed no contrast leakage in the upper calyx, which remained absent on subsequent controls at nine days and after a further 15-day period. With the urinary fistula resolved, the percutaneous drainage and nephrostomy were removed, while the double pig-tail stent remained. A final pyelography conducted one month after nephrostomy removal confirmed the sustained absence of the urinary fistula, prompting the decision to remove the double pig-tail ureteral stent.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3392_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3392_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c222af7af50d2ea6a247e72e7761ade5d59c4240
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3392_en.txt
@@ -0,0 +1,9 @@
+A previously healthy, 17-year-old white American female individual with a noncontributable past medical history brought to an outpatient pediatric clinic by her mother in January with an erythematous rash on the anterior aspect of her neck with overlying vesicles. The rash had been present for 2 days, and she described it as cramping, tingling, and itchy but denied headaches, nausea, vomiting, fevers, myalgias or arthralgias. She has no known sick contacts and no other lesions or rashes. She denied addition of new foods, supplements, skin care products, or detergents. She did not take any prescriptions or supplements and had no known allergies. She completed all her vaccination series as recommended by the CDC schedule. She did not have a reaction after either of her varicella vaccinations. Family history is notable for a brother with keratosis pilaris, a mother with plaque psoriasis, and a cousin that had a case of varicella shortly after his initial varicella vaccination. Physical examination showed vesicular lesions overlying an erythematous base on the anterior neck with various vesicular macules of various diameters in the C2 and V3 dermatomal distributions. Bilateral tympanic membranes and external ear canals were without lesions. No ocular involvement was detected; extraocular eye motion was intact, and pupils were equal and reactive to light. At that time, she was prescribed 1 g oral valacyclovir to be taken every 8 hours for seven days and topical 5% acyclovir with bacitracin 500 U/g to be applied every 12 hours for seven days for the diagnosis of probable VZV on the basis of the appearance of the lesions.
+
+Laboratory tests were drawn and ordered at the time of her initial visit to confirm this diagnosis, including a C-reactive protein (CRP), complete blood count (CBC), erythrocyte sedimentation rate (ESR), cytomegalovirus (CMV) immunoglobulin (Ig)G antibodies, VZV IgM and IgG antibodies and viral load, herpes simplex virus (HSV) 1 and 2 viral load, monkeypox viral load, and Epstein–Barr virus (EBV) profile. The only abnormalities were a VZV IgG level of 1304 (reference range: positive > 165) and a VZV viral load of 3.8 billion copies/mL, representative of a high viral load. VZV IgM antibodies were negative, as were the other viral load levels. Her CBC, CRP, and ESR were within normal limits.
+
+A total of 1 day after being seen in clinic, she presented to the emergency department owing to development of a fever, nausea and vomiting overnight. There, she had a temperature of 103.1 °F, blood pressure of 128/74, pulse of 87, respiratory rate of 17, and oxygen saturation of 97% on room air. They noted a vesicular rash and erythema extending from under the left ear to the left face and neck, with a notable spread from the C2 and V3 dermatome to the V2 dermatome. There was no rash on the tip of the nose or in the ear canal but there was a small vesicle near the left eye. She was discharged home with acetaminophen 1000 mg and hydrocodone/acetaminophen 5 mg/325 mg as needed for the pain. No labs or imaging were performed.
+
+A total of 2 days after the initial clinic visit, the patient reported new-onset lethargy. The rash was still within the V2, V3, and C2 dermatomes. Pediatric infectious disease was consulted at this time. They suggested the addition of swabbing for group A strep owing to the possibility of underlying bacterial skin infection, as well as HIV blood test, both of which were negative.
+
+A total of 1 week after the onset of the rash, she was seen in the clinic. At this time, she had been taking the oral valacyclovir and using the topical acyclovir for 5 days. Her vitals were within normal limits; she no longer had a fever, nausea, vomiting, headache, or lethargy. On physical exam, the vesicles were present in the V2, V3, and C2 dermatome and had begun to scab over; they were no longer burning or cramping but remained itchy. There were no new lesions or rashes and she did not demonstrate any vision changes, hearing loss, or focal neurological deficits. Labs were redrawn at this time; CBC and HIV remained within normal limits. Varicella viral load was undetectable at this time. On follow up, the patient reported complete recovery of the vesicular rash within 2 weeks of beginning antiviral treatment. She has no residual scarring or symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_379_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_379_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b8814fdb92de6acb11e3250d87201ce0323b57ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_379_en.txt
@@ -0,0 +1,4 @@
+A 60-year-old Japanese man with a history of low anterior resection for rectal cancer 4 years ago was referred to our department because of a lung nodule detected on chest radiography during a routine medical checkup. He had no symptoms and presented with a body temperature of 35.9°C, blood pressure of 106/65 mmHg, heart rate of 59 beats per minute, and oxygen saturation of 99% on room air. His laboratory examination results were within normal limits. As his chest computed tomography (CT) revealed a 12-mm tumor in the left posterior basal bronchus during postoperative follow-up, he underwent six cycles of chemotherapy with mFOLFOX6 and bevacizumab at standard doses. After chemotherapy, he underwent chest and abdomen CT scans, which confirmed that the tumor deeply seated in the segment had been growing continuously up to 15 mm . Fluorodeoxyglucose positron emission tomography (FDG-PET) revealed an abnormal uptake of FDG, with a maximum standardized uptake value of 2.28 in the tumor. Hence, the patient was treated with a portal robotic S9–10 segmentectomy through a PL approach.
+On the basis of the patient’s actual three-dimensional (3-D) pulmonary model, created using an in-house software as presented in the preoperative CT images, the involvement of the pulmonary vessels and bronchi were identified and the location and extent of tumor invasion were assessed to determine the surgical procedure [–].
+Under general anesthesia with single-lung ventilation and lateral decubitus positioning, RATS S9–10 segmentectomy was performed with five-port incisions, including an assistant port as a carbon dioxide (CO2) insufflation port. With the pleural space as the entry point, a 12-mm trocar (AirSeal access ports, ConMed, Utica, NY, USA) was inserted as an assistant port in the fifth intercostal space (ICS) anteriorly in the anterior axillary line. Moreover, two 8-mm robotic trocars were inserted, one as a port for the robotic camera in the ninth ICS at the middle axillary line and the other as port 4 on the posterior side of the tip of the scapula. Two 12-mm robotic trocars were inserted in port 1 and 3 in the eighth ICS anteriorly along the anterior axillary line and in the ninth ICS along the posterior axillary line, respectively, after which the da Vinci Xi surgical system (Intuitive Surgery, Sunnyvale, CA, USA) was docked . All four robotic arms were used. A CO2 insufflation system (AirSeal system, ConMed) was used at a set pressure of 5 mmHg. The robotic instruments were manipulated through a 12-mm port mounting a 12–8-mm reducer. Fenestrated bipolar forceps, a permanent cautery spatula, and Cadiere forceps were inserted through ports 1, 3, and 4 (Intuitive Surgical), respectively. After lifting the left lower lobe using the Cadiere forceps, the PL was incised up to the inferior pulmonary vein. The basal pulmonary vein was exposed, and both the lateral (V9) and posterior basal veins (V10) were transected using robot staplers . Next, the intersegmental septum was dissected to expose the bronchi and pulmonary arteries. First, the targeted bronchi were exposed and transected, followed by the targeted pulmonary arteries . An intravenous injection of indocyanine green was administered, and observation under fluorescence navigation revealed intersegmental planes, which were marked using the fenestrated bipolar forceps and permanent cautery spatula, after which the target S9–10 segments were resected using the robot staplers . An additional movie file shows this procedure in detail (Additional file ).
+The final histopathological investigations confirmed the resected tumor to be a lung metastasis of rectal cancer. The postoperative course was uneventful. Postoperatively, he received no adjuvant chemotherapy. No recurrence was observed for 6 months after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_381_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_381_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6e15e7a055d7e51907faaf812a887da65d36488c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_381_en.txt
@@ -0,0 +1,4 @@
+A 32-year-old Japanese woman with recurrent hyperthyroidism was introduced to the out-patient department of Kohnan Hospital. She had a family history of Graves’ disease. She began to feel thirst, frequent palpitations, and body weight loss from around June 2006, and hyperthyroidism was detected. Her serum free triiodothyronine (T3) was more than 20pg/mL, free thyroxine (T4) was 7.7ng/dL, TSH was less than the detectable level and anti-TSH receptor antibody (TRAb) was 77.5% (normal range, less than 10%). The 24-hour uptake of iodine-123 to the thyroid gland was 38.47% in the right lobe and 44.16% in the left lobe (total 82.63%). A head magnetic resonance imaging (MRI) with contrast medium revealed thickening of the bilateral ocular muscles, but no evident tumor in the sella turcica . The diagnosis was established as Graves’ disease, and propylthiouracil (PTU) was administered. TRAb had fallen to the normal range, and a euthyroid state was achieved in June 2008. However, occasional elevation of free T3 was detected, so PTU administration was continued. Re-elevation of TSH was seen in December 2010 . A head MRI revealed abnormal findings in the sella turcica, and she was introduced to the neurosurgical department of Kohnan Hospital in May 2011.
+On admission her blood pressure was 152/112mmHg. Electrocardiography recorded her heart rate as 70 beats/minute but she complained of frequent palpitations. Her consciousness was clear, and no abnormal neurological signs were detected. Endocrinological examinations in the morning with oral intake of 100mg of PTU revealed free T3 of 2.77pg/mL, free T4 of 1.09ng/dL and TSH of 2.433μIU/mL. Because of her frequent palpitations the thyroid-releasing hormone (TRH) loading test without discontinuing PTU was performed, which revealed no abnormal response. All other pituitary hormones were within the normal ranges, and head MR imaging with contrast medium showed an area of less enhancement in the left lateral wing of the sella turcica with a diameter of 5mm , and transsphenoidal surgery was planned under a diagnosis of TSH-secreting pituitary adenoma.
+The milky-white soft tumor was enclosed within a thin cellulose-like membrane. Total removal was achieved in addition to medical fixation of the cleavage with pure ethanol. Postoperative histological examination showed diffuse cell arrangement with mild variation in size but without atypism or mitosis of the nucleus . Immunohistochemical examination disclosed plurihormonal expression of pituitary hormones including TSH-β, and the diagnosis was established as TSH-secreting plurihormonal adenoma .
+Administration of PTU was discontinued from the day of surgery. Diastolic blood pressure did not exceed 100mmHg for six days after the operation. Pituitary and thyroid hormones were re-evaluated at 11 days after the operation, showing free T3 was 3.31pg/mL, free T4 was 1.00ng/dL and TSH was 1.567μIU/mL. Additional TRH loading test found no abnormal responses, and she was discharged at 12 days after the operation. Her blood pressure was 133/86mmHg, and palpitations had disappeared without medication.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_383_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_383_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7104a7667c7675f655b1d6e8970855b4a0b2c5e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_383_en.txt
@@ -0,0 +1,8 @@
+A 46-year-old female patient presented at our department to undergo cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) with chief complaints of intra-abdominal recurrence and metastasis of a sigmoid colon tumor.
+In the preoperative assessment, the patient’s vital signs were stable and complete blood test results were within the normal range. Further, chest X-ray findings were unremarkable, except for the presence of a chemoport through the right central vein. Meanwhile, electrocardiogram revealed a normal sinus rhythm of 60 beats per minute.
+The patient reported that she had undergone laparoscopic anterior resection of the colon 3 years ago. She also reported having the same medical conditions and undergoing CRS and HIPEC 2 years ago.
+The patient had no family or genetic history of the disease.
+Given that the patient had a chemoport through the right central vein, during anesthesia in the operating room, we decided to insert a central venous catheter through the left internal jugular vein. The location of the left internal jugular vein was confirmed using ultrasound, and the needle was inserted after confirming the course of the vein.
+Although the internal jugular vein was distinctly visible on the ultrasound scan, blood reflux was noted when the needle tip was not within the ultrasound field of view. The guide wire was pushed through the needle, and we confirmed that it entered without resistance. Further, a 7-Fr 2-lumen central venous catheter was inserted along the guide wire without resistance. After inserting the catheter up to 15 cm, the guide wire was removed. Then, to remove the air, we regurgitated blood from the catheter and assessed blood reflux. However, after approximately 1 cc of blood was refluxed, we found that when blood reflux was induced, only clear fluid regurgitated from the 16-G distal port of the central venous catheter, but no blood regurgitated from the 18-G proximal port of central venous catheter. Because intravenous fluid administration was not started and no abnormal fluid collection was noted on preoperative chest X-ray, thoracic duct cannulation was suspected. Thus, we determined that central venous catheter could not be used as a central line. Accordingly, we reinserted the central venous catheter through the left subclavian vein under ultrasound guidance. Further, while carefully monitoring the needle tip and guide wire, we easily inserted the central venous catheter . The patient’s vital signs were stable. Meanwhile, the position of the tip of the internal jugular central venous catheter that was initially inserted was unclear. However, we determined that the catheter was unlikely to affect vital signs and that removing it without checking its position could cause problems. Therefore, we decided to leave it in the same position and checked its position after surgery.
+Postoperative complete blood test results were within the normal range.
+In the recovery room, a chest X-ray was obtained , which revealed an appearance similar to that of the path of the thoracic duct.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_386_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_386_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5f7ce8b620a8db81066a2b68363557748dcd3be2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_386_en.txt
@@ -0,0 +1,7 @@
+In October 2019, a 54-year-old Arab male patient presented with 2 months history of fatigue, orthostatic hypotension followed by bruising on the lower right extremity, melena (present for one month only) and dyspnea II. Physical examination and computer tomographic scan showed hepatomegaly (4 cm). He had no familial history of malignancies and no social and environmental history of exposure to toxins or animals. Initial laboratory evaluation of peripheral blood (PB) revealed white blood cells count (WBC) of 26.3 × 109/l (10% were blasts). Pathologic examination of bone marrow (BM) aspirate characterized hybercellularity with 60% of blasts. Flow cytometric (FCM) analysis classified this case as AML-M2 according to world health organization (WHO) classification. The abnormal cell population (60%) was positive for CD45dim, CD34, HLADr, CD13, CD33 and expressed CD117 heterogeneously. Blasts cell population was negative for CD3, CD117, CD14, cCD3, cCD79a, CD14, CD11c, CD38, CD64, CD32, CD7, CD19, CD10, and CD5.
+The patient was given standard treatment for AML including 3 + 7 induction chemotherapy (daunorubicin 60 mg/m2 for 3 days and cytarabine 200 mg/m2 for 7 days). One month later, under treatment with 3 + 7 protocol, the patient relapsed, i.e. his PB showed a WBC of 107 × 109/l, anemia (hemoglobin level (Hgb) = 8.8 g/dl) and thrombocytopenia (Plt 93 × 109/l). The patient was given re-induction with 3 + 7 chemotherapy protocol (for more details see Table ). Less than one month after relapse, the patient acquired additional severe symptoms such as neutropenia, neutropenic enterocolitis, and diabetes insipidus, and the patient unfortunately passed away due to respiratory and cardiac arrest. No autopsy was performed. The patient’s brother agreed with the scientific evaluation of this case and the study was approved by the ethical committee of Pharmacy faculty at Damascus University, Ministry of High Education, Syria review Board, No. 2/2019.
+Chromosome analysis using GTG-banding was performed on BM sample taken prior to chemotherapy according to standard protocols . A normal male karyotype was diagnosed. Fluorescence in situ hybridization (FISH) using specific probes to detect translocations t(8;21), t(15;17), t(16;16), t(12;21), and deletion del(13q), were applied to excluded chromosomal abnormalities, too, as previously reported .
+For molecular analyses, whole genomic DNA was extracted from PB cells (EDTA-blood) prior to chemotherapy treatment. Polymerase chain reaction (PCR) amplification of genomic DNA and Sanger sequencing were used to screen for the presence of mutations of the following genes: FLT3/ITD (exons 11 and 12), FLT3-KTD and NPM1; using specific primers for each mutation previously reported . ITDs were confirmed by Sanger sequence analysis; the wild-type band of 330 bp length, and other differently sized PCR products were identified in our patient using the ABI Prism 310 genetic analyzer (Applied Biosystems, Foster City, CA, USA). Two novel frameshift mutations of the JMD in FLT3-ITD were identified in our patient (see also Fig. ):
+mutation 1: c.1779-1780insTTTCAGAGAATATGAATATGATCTCAAATGGGAGTTTCCAAGAGAAAATTTAGAGTTAGG (p.D593-F594insREYEYDLKWEFPRENLEF).
+mutation 2: homozygous substitution c.1836T>A (p.F612L).
+A D835 mutation was not detected by FLT3-KTD test in our patient. However, he had also NPM1 type A mutation (data not shown).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_401_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_401_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fbd9d2b5b5c7c86449326daef507f18846744fec
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_401_en.txt
@@ -0,0 +1,2 @@
+An 81-year-old man visited our hospital complaining of dysphagia. The patient received an upper lobectomy of the right lung for lymphoma and additional chemotherapy 20 years ago. Esophagogastroduodenoscopy detected an elevated tumor in the EGJ . The tumor was mainly located in the stomach, but it continued into the squamocolumnar junction . We found a submucosal invasion of the tumor in the lower esophagus . Biopsy specimens taken from the tumor showed SCC histopathologically. Laboratory examination showed that the serum level of SCC was elevated (25.2 ng/ml, normal range < 2.5 ng/ml), whereas the serum levels of CEA and CA19-9 were in normal range (3.4 ng/ml, < 5 ng/ml and 7 U/ml, < 37 U/ml, respectively). Barium meal study showed an elevated lesion in the gastric cardia , which had invaded the lower esophagus approximately 15 mm from the EGJ . Computed tomography showed a tumor, 50 mm in size, located in the EGJ and several lymph nodes surrounding the EGJ were swollen . No mediastinal node metastasis was found, and hepatic and lung metastasis were not detected. In 18F-fluorodeoxyglucose (FDG)-positron emission tomography, the standardized uptake value (SUV) max of FDG accumulation was 19.9 in the tumor . Respiratory function test showed an obstructive disorder because of previous smoking. Although the serum level of HbA1c was 6.3%, fasting blood glucose was 123 mg/dl. He was administered drugs for hypertension.
+We diagnosed the tumor as SCC, overhanging in the stomach, of the EGJ before surgery. Considering the frailty due to the influence of neoadjuvant chemotherapy, we selected surgery because of the elderly. The patient underwent a proximal gastrectomy combined with lower esophagectomy and node dissection surrounding the EGJ, the celiac trunk with its branches, and the lower esophagus. The lower esophagectomy and dissection surrounding the lower esophagus were made by a median incision of the diaphragm from the hiatus. Proximal margin of the esophagus 3 cm apart from the EGJ was taken. During the operation, washing cytology using saline showed no cancer cells. After removal of the tumor, frozen sections were made and no cancer invasion was confirmed in both the proximal margin of the esophagus and the distal margin of the stomach. We performed esophagogastrostomy using a circular stapling system in the mediastinum. Macroscopic findings showed a tumor was located in the EGJ , and the tumor showed a submucosal progression . The postoperative course was uneventful. Histopathologic examination showed the tumor consisted of SCC and adenocarcinoma . We observed SCC continuously in the squamous epithelia of the lower esophagus . Helicobacter pylori was not microscopically detected. In the distal part of the tumor, SCC was covered with the normal columnar mucosa . Several nests of adenocarcinoma were scattered in the tumor and occupied 35% of the tumor; however, the SCC component was located in the surface to the deep layer of the tumor . We observed a transition between SCC and adenocarcinoma . Node metastasis was observed in eight of dissected 32 nodes. Seven of the eight nodes showed both metastases of SCC and adenocarcinoma , and a node in the right area of the gastric cardia showed metastasis of SCC . No reaction for human epidermal growth factor receptor-2 protein (HER2) was immunohistochemically observed in SCC cells. A weak positive reaction for HER2 was observed in adenocarcinoma cells, and the staining intensity was judged to be 2+ . Thus, the tumor was diagnosed as ASC of the EGJ, and the TNM classification (UICC 8th edition) was pT3 pN3 M0, pStage IVa. The patient received adjuvant chemotherapy using S-1 orally because of the elderly with the frailty, and was well without recurrence 6 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_433_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_433_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e3249865c9a93ac95715cd1e0ef94543d1e209a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_433_en.txt
@@ -0,0 +1,6 @@
+A 43-year-old, previously healthy Caucasian female presented to her general practitioner with a few-months history of left knee pain. She had also noticed a left-sided supraclavicular fossa (SCF) mass. She had no significant medical history, never smoked, with moderate alcohol intake. A maternal grandmother had endometrial cancer aged 65 years.
+An ultrasound-guided core biopsy of the suspicious SCF mass was urgently arranged. Review by an expert soft tissue pathologist revealed grade 2 leiomyosarcoma, with immunohistochemistry positive for desmin, smooth muscle actin and h-caldesmon. CT and PET-CT imaging showed extensive metastatic disease, with no clear primary site. There were widespread cutaneous, subcutaneous, soft tissue, lung, liver, right adrenal and peritoneal metastases. A lytic lesion involving the left femoral head was identified as at risk for pathological fracture and a likely cause of the patient’s longstanding left knee pain. She initially underwent urgent prophylactic stabilisation of the left femur, followed by radiotherapy.
+She commenced first-line palliative doxorubicin chemotherapy. The patient was noted to have a mild erythematous maculopapular rash on her face and upper chest in sun-exposed areas at her pre-treatment consultation. This developed several days following femoral surgery and persisted for a few weeks. No drug, environmental or infective triggers were identified. The rash was treated with topical hydrocortisone 1% and emollient cream (diprobase), and resolved during cycle one of doxorubicin with a sustained remission throughout chemotherapy. She did not report any muscle weakness or pain during this time. Six cycles of doxorubicin were well tolerated, with one episode of febrile neutropenia requiring a 25% dose reduction. Imaging assessment at the end of chemotherapy showed overall stable metastatic disease by RECIST 1.1 criteria , with a minor reduction in some metastatic deposits noted mid-treatment.
+Two months later, the patient presented acutely unwell to her local hospital with a new-onset rash in a shawl-like distribution (upper chest, neck and arms), with flagellate erythema and associated periorbital oedema and proximal limb weakness. The patient denied breathing or swallowing difficulty. On examination periungual erythema and Gottron’s papules were noted, without visible dilated capillary nailfold loops. There was reduced proximal power in both upper and lower limb (3–4/5), but no neck or truncal weakness. Vital signs found she was tachycardic and febrile. Routine blood tests on admission showed c-reactive protein < 4 and mildly raised white cell count 11.4 (normal range 4–11 × 109L). Alanine aminotransferase (ALT) was mildly raised at 61 (normal 10–49 U/L) with unremarkable renal function. Blood cultures grew Staphylococcus hominis and she was treated with intravenous antibiotics and appropriate medical management.
+Rheumatology and dermatology review led to the diagnosis of dermatomyositis, likely paraneoplastic, in the context of known metastatic leiomyosarcoma. Investigation supporting this included; raised creatinine kinase (CK) and erythrocyte sediment rate at 695 (normal range 25–200 U/L) and 32 (normal range 0–27 mm/h) respectively. Autoantibody screen negative for ENA, dsDNA, anti-CCP, with normal complement levels and weakly positive ANA (1:160). Myositis antibody panel was positive for transcription intermediary factor-1 gamma (TIF1γ) antibodies alone, whilst anti-Jo1 and anti-Mi2 antibody negative. In addition to intramuscular metastatic disease, MRI femur showed mild increased signal within the muscles compatible with myositis. An echocardiogram confirmed normal cardiac function. Electromyography (EMG) found myopathic changes of moderate degree in lower and upper limbs, worse in the lower limbs with proximal predominance. The findings were in keeping with a diagnosis of proximal myopathy. Right chest punch biopsy histology was consistent with dermatomyositis. Muscle biopsy was not performed, given the potential risk of metastatic disease seeding.
+Treatment was commenced with a weaning course of prednisolone (initial dose 40 mg daily) and topical clobetasol 0.05% with clinical improvement in both weakness and rash over several months. Diagnosis of paraneoplastic dermatomyositis triggered re-evaluation of the patient’s leiomyosarcoma with CT imaging, which showed multifocal progression. Second-line chemotherapy with trabectedin was commenced following recovery from the acute admission and once the dermatomyositis was controlled with steroid therapy. Systemic anti-cancer therapy was again associated with mild improvement in dermatomyositis symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_451_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_451_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0fa7f1cc73443b8a2aa9ff646474a79933d1fe37
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_451_en.txt
@@ -0,0 +1,3 @@
+A 69-year-old Caucasian woman with a past medical history of low back pain, hypertension, and hyperlipidemia presented with a chief complaint of a dorsal ulnar-sided left hand-wrist mass that had been growing slowly over the previous 10 years. The patient stated that the mass had become progressively more painful over time, being particularly tender when she wore a watch. There had been no history of preceding trauma nor constitutional symptoms. On physical exam, the skin on the hands and wrist was intact with normal musculature. In the left dorsal ulnar wrist, near the extensor carpi ulnaris tendon, there was a small palpable mass that was semi-firm and not mobile; quite tender to palpation. A hand-wrist X-ray showed marked osteoarthritic changes. An initial clinical diagnosis of a probable ganglion cyst was made, and the patient underwent surgical excision of the mass.
+The pathology of the soft tissue fragments revealed a biphasic neoplasm composed of spindle cells admixed with neoplastic glands . No necrosis or active mitotic activity was seen. The tumor cells were positive for TLE1, focally positive for CK19, CK7, and S100, and negative for CDX2, SMA, CK20, and TTF-1 . Due to tissue fragmentation, surgical margins could not be assessed; although they appeared to be involved by the neoplasm. FISH (fluorescence in situ hybridization) for SS18 (SYT) gene break-apart rearrangement on chromosome 18q11.2 was performed , and the SYT gene rearrangement was detected in 71% of cells; thus confirming the diagnosis of synovial sarcoma.
+CT (computed tomography) of the thorax/abdomen and pelvis were without evidence of metastatic sarcoma. The tumor was classified as AJCC (American Joint Commission on Cancer) Stage IIA. A wide re-excision of the tumor was performed with en-bloc resection of the distal ulna. The resected tissue showed an ill-defined 1.0 × 0.5 × 0.5 cm firm mass involving the soft tissue without involving the bone. The histopathologic exam confirmed the prior diagnosis. The patient received adjuvant radiotherapy and had regular follow-ups for 5.5 years with no evidence of any local recurrence of the tumor or distant metastases. The timeline of the episode of care is summarized in Fig. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_466_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_466_en.txt
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index 0000000000000000000000000000000000000000..058782447a45c496db2142a48cfdefea21563521
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_466_en.txt
@@ -0,0 +1,2 @@
+A 34-year-old woman, gravida 2, para 1, was transferred to Shengjing hospital of China Medical University at 33 weeks of gestation. At 24 weeks of pregnancy, the patient was informed that she was pregnant with a boy during an ultrasound examination at the district hospital. However, during the 32-week ultrasound examination, the doctor found abnormalities in the perineum of the fetus. A detailed ultrasound examination was performed at 33 weeks in Shengjing hospital, and a perineal scan revealed that the fetus was female, not male. Two-dimensional ultrasound showed a hyperechoic mass (1.7 × 1.2 cm) resembling a scrotum in the perineum of the fetus . The pedicle connected the mass to fetal skin around anus. Dynamic observation revealed another small hyperechoic mass (0.8 × 0.7 cm) protruding from the fetal anus, connecting to the other end of the pedicle. The masses floated in the amniotic fluid with no obvious blood flow on color Doppler flow imaging (CDFI). Three-dimensional ultrasound showed scrotum-like masses and their relationship with other organs . The mother underwent amniocentesis, and no abnormalities were found on a comparative genomic hybridization (CGH) array.
+A female neonate was delivered, weighing 3,240 g at GA 40 + 2 weeks. Her Apgar scores were 10 and 10 at 1 and 5 min, respectively. Perineal examination revealed two soft spherical masses protruding from the patient's anus and connected by a pedicle. The masses were 2.5 × 1.5 cm and 1.4 × 0.7 cm in size . The neonate underwent an abdominal ultrasound examination, and no other abnormalities were found. We also performed a postnatal ultrasound on the perineal masses. Sonography showed two well-defined hyperechoic masses connected by a pedicle, and CDFI detected blood flow signals in the masses. The results of the sacrococcygeal magnetic resonance imaging (MRI) were normal. Surgery was performed under general anesthesia 1 day after birth. The masses were originated from the peri-anal skin at 4:00 in lithotomy position, and the anal sphincter was not involved. Histopathological examination of the masses suggested hamartomas composed of hyperplastic lymph vessels and adipose tissues . After the masses were removed, a cavity was discovered along the posterior rectal wall . The contrast agent showed an irregular cystic mass connected to the posterior wall of the rectum, and rectal duplication was suspected . An en bloc excision of the cystic mass and the posterior wall of the rectum was performed. Rectal duplication was confirmed by histopathological examination. At the time of writing this report, the patient was 2.5 years old, and recovered well after surgery without other abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_484_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_484_en.txt
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index 0000000000000000000000000000000000000000..88ba692165fd75b38f680b7b0c5b49bce9192b68
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_484_en.txt
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+A 78-year-old multiparous married housewife, who is married, were admitted to the hospital because of cervical tumor. Size of tumor was 7 millimeters in diameter. Medical history was no significant. Internal genital organs did not present abnormalities. Tumor were located at posterior side of vaginal portion. The patient underwent operative removal of the tumor and discharged home at some day. The histological examination: polypoid tissue sample is covered by squamous epithelium. Immediately below epithelium hypocellular connective tissue with thin-walled blood vessels is present. In the deeper parts of tissue, uncapsulated, moderate cellular area consists of short, oval, spindle-shaped cells with bland, oval normochromatic nuclei, inconspicuous nucleoli. The cells form discrete, short fascicle clustered about the blood vessels. Thin-walled blood vessels are dilated and filled red blood cells. Few inflammatory cells, mainly lymphocytes are present in some microscopic field. Immunohistochemical analysis showed that tumor cells are positive for vimentin, desmin and negative for small muscle actin, myogenin and p53 antigen. The proliferation index, expressed as a percentage of Ki-67 antigen-positive nuclei, is less than 1%.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_52_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_52_en.txt
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index 0000000000000000000000000000000000000000..e0c86a249772ecd6d2527a1e224091e8787544bb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_52_en.txt
@@ -0,0 +1,8 @@
+A 37-year-old pregnant woman at 33 wk and 3 d of gestation had been diagnosed with RHD 4 mo ago. She was admitted to the intensive care unit (ICU) of our hospital complaining of orthopnea, anhelation and lower extremity edema.
+The patient was first diagnosed with RHD at 12 wk of gestation. She developed cardiac enlargement with moderate pulmonary hypertension (PH) at 28 wk of gestation followed by atrial fibrillation (AF) at 29 wk of gestation. At 33 wk of gestation, she experienced severe heart failure which had worsened in the last 24 h.
+The patient was gravida 5, 1-0-0-0-1, with 3 spontaneous abortions because of embryo hepatocytes. The outcome of her first pregnancy more than 10 years earlier was a natural birth without any discomfort.
+The patient denied a history of thrombosis, smoking, tuberculosis, and alcohol or drug use. No family members had similar diseases.
+The patient’s heart rate was 145 beats/min, blood pressure was 113/82 mmHg, respiratory rate was 25 breaths/min, and oxygen saturation by pulse oximetry (SaO2) was 100% on room air. The patient’s current weight was 82 kg, BMI (before pregnancy) was 25.3 kg/m2, a total weight gain was 15 kg during pregnancy. There were no obvious abnormalities in the fetus.
+The patient’s N-terminal pro brain-type natriuretic peptide was 1880 pg/mL, activated partial thromboplastin time (APTT) was 27.0 s, fibrinogen was 4.45 g/L, and D-dimer was 660 ng/mL. The cardiogram showed AF. The urine analysis and arterial blood gas was normal.
+The TTE showed RHD with severe mitral regurgitation (MR), mild mitral stenosis, moderate aortic regurgitation (AR), severe tricuspid regurgitation (TR), heart dilatation, left ventricular ejection fraction (LVEF) of 52% and a pulmonary artery systolic pressure (PASP) of 75 mmHg. The patient’s right heart (RH) chamber was enlarged and the left ventricle was hypokinetic. The routine TTE monitoring in pregnancy are shown in Table .
+During the CS, the TTE revealed a nascent thrombus that fluttered in a serpentine manner in the IVC after placental removal. The thrombus grew rapidly. From 81 mm at discovery to 155 mm in 18 min. The average growth rate was 4.1 mm/min. At 32 min after discovery, the thrombus detached to the tricuspid valve. At 43 min after discovery, the thrombus detached off to the pulmonary artery, where it fragmented and resulted in acute incomplete bilateral pulmonary embolism, and contemporaneously with the PASP increasing sharply to 93 mmHg, SaO2 decreased to 96%. Moreover, small thrombosis attachment to the mitral valve and left atrial appendage (LAA) were detected. The detailed thrombotic changes are shown in Figure . Postoperative computed tomography angiography showed that the right main pulmonary artery, the middle and lower branch of the right pulmonary artery and its branches, and the left lower branch of the pulmonary artery were embolized . Ultrasonic examination revealed no deep vein thrombus of the lower extremities during the perioperative period.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_548_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_548_en.txt
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index 0000000000000000000000000000000000000000..a3289405aa82566429fb5e9f36aecf7ad3641cb4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_548_en.txt
@@ -0,0 +1,2 @@
+The patient was a 78-year-old woman who first presented with a mild decrease in cognitive function at the age of 75 years. She did not exhibit signs of neurological deficits such as anisocoria or diplopia. However, magnetic resonance imaging revealed a left-sided ICA-PcomA aneurysm. Three-dimensional computed tomography (CT) angiography revealed an irregularly shaped aneurysm measuring 7 mm . We limited treatment to follow-up observations of the aneurysm in the outpatient department without surgery, considering her age and deteriorated cognitive function. She had not experienced any episodes of oculomotor nerve palsy or sudden thunderclap headaches. The aneurysm gradually grew to 10 mm in size by the time she was 78 years old . We planned to clip the neck of the aneurysm to firmly preserve the fetal-type PcomA, which seemed to arise from the aneurysmal body, due to an increased risk of rupture . We performed a pterional craniotomy and approached the aneurysm through the transsylvian route. The aneurysm had adhered strongly to the oculomotor nerve and surrounding tissue. We clipped the neck of the aneurysm [ and ] followed by careful separation of the aneurysmal wall and inspection of the oculomotor nerve. We observed that the dome of the aneurysm was splitting the oculomotor nerve [ and ] . Temporary anisocoria and diplopia were observed postoperatively. These oculomotor nerve palsy symptoms improved in approximately 10 days. The patient was discharged with a Modified Rankin Scale score of 1.
+The patient provided written informed consent for the publication of this report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_562_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_562_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..976e46279f94049a00233138aba1655384f8f6ff
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_562_en.txt
@@ -0,0 +1,4 @@
+This is the case of a 15-year-old Kenyan girl of Kikuyu descent who presented with a diffuse, painful, slight cheek swelling on the right side of her face. The pain and swelling consistently increased in size just before and during meals. The painful area was well defined and the pain confined with no radiation. Her medical and dental histories were unremarkable except for treatment for otitis media 3 months before her presentation.
+On examination her chronologic age was commensurate with her physique. The right parotid area was tender with no obvious change in the skin color. Intraorally, she had unerupted 8 s, missing 12, and a peg lateral in place of 22. The intraoral soft tissue was normal in color, texture, and consistency except around the right Stensen’s duct opening, which was inflamed. A small amount of pus was expressed from the right duct when slight pressure was applied on the papilla.
+A diagnosis of acute suppurative sialadenitis was made and treatment executed in the form of copious fluid intake, amoxicillin and clavulanic acid (500 mg/12 5 mg) twice a day for 5 days, paracetamol 1000 mg three times a day for 5 days and povidone-iodine (Betadine) gargle for 7 days. The infection resolved completely until about a year later when she presented with signs and symptoms as those initially observed. A similar treatment regimen was prescribed and, after elimination of the infection, the patency of the right Stensen’s duct was checked by cannulation with no indication of obstruction.
+About 2 years following her initial submission she presented with a recurrence of the initial signs and symptoms. It was immediately decided to perform a magnetic resonance imaging (MRI) scan . This showed a homogenous well-defined right cheek lesion medial to the buccinator muscle and engulfing the ipsilateral Stensen’s duct. The clinical and radiographic features of the lesion were suggestive of a lipoma with the differential diagnosis of oral dermoid cyst, epidermoid cyst, and lymphoepithelial cysts considered. A decision was made to excise the lesion via an intraoral approach . The Stensen’s duct was cannulated for localization and protection during the surgery. Following excision of the lesion, histopathology diagnosis confirmed a lipoma of the right cheek area. Immediately following recovery from the surgery, our patient reported complete resolution of previously noted symptoms of pain, discomfort, and swelling that were related to mealtimes. Six months following surgery, our patient is symptom-free and continues to be monitored.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_56_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_56_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da01a521075a72ebe073052c7718e8cd858a1ddf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_56_en.txt
@@ -0,0 +1,5 @@
+A 60-year-old man presented to the hospital with back pain and was subsequently diagnosed with uncomplicated Stanford type B acute aortic dissection. He was hospitalized and given conservative treatment; however, a contrast-enhanced computed tomography (CT) scan at that time showed a 55-mm aortic root dilatation . Furthermore, transthoracic echocardiogram revealed severe aortic regurgitation (AR), and the patient was diagnosed with annuloaortic ectasia . Its vena contracta was 6 mm, and the pressure halt time was 430 ms. Holodiastolic flow reversal was also detected in the abdominal aorta. Cusp degeneration and mitral valve insufficiency were not observed. After discharge, false lumen stability was confirmed on follow-up CT; thus, elective surgery for the aortic root was scheduled. The patient’s other significant past medical history included hypertension, dyslipidemia, hyperuricemia, sleep apnea, and vasospastic angina, which developed 11 months before. He was 183-cm tall and weighed 83.0 kg and had no specific family history.
+During surgery, cardiopulmonary bypass (CPB) was established via cannulation to the ascending aorta and the right atrium using a 24 Fr curved-tip dispersion aortic cannula and a 34/46 Fr two-stage venous cannula, respectively. In addition, an antegrade cardioplegia (CP) cannula was cannulated to the proximal ascending aorta, and then cardiac arrest was induced with antegrade CP after cross-clamping of the ascending aorta. Aside from a small calcification at the nadir of the annulus of the right coronary cusp, aortic valve degeneration such as cusp size discrepancy, cusp thickening, or cusp fenestration was not observed; thus, the David procedure was initially performed. However, intraoperative transesophageal echocardiogram revealed eccentric AR jet due to right coronary cusp falling toward the left ventricle. Therefore, valve sparing was abandoned, and the Bentall procedure using a mechanical valve was selected. The antegrade CP cannulation site was resected and replaced with vascular prosthesis. Smooth CPB weaning was achieved, and the procedure was completed without any problems. The operation and CPB times were 416 and 308 min, respectively.
+The postoperative course was not complicated, and the patient had never complained of chest pain after the operation. However, a routine contrast-enhanced CT scan at postoperative day (POD) 14 showed new Stanford type A aortic dissection . It was thought to be caused by intraoperative aortic cannulation for CPB as the entry was just below the felt pledget used for aortic cannulation site closure. The postoperative dissection was conservatively treated as the aortic root had already been replaced, and no symptoms, or malperfusion was observed. The patient was carefully observed with continuing hospitalization, and the resting level was gradually eased. Follow-up CT at POD 29 showed no enlargement of the ascending aorta, and the patient was discharged without other complications at POD 34.
+Although he had no family history of cardiovascular diseases, including aortic dissection, or aortic aneurysm, connective tissue disease was suspected due to his own history of aortic root dilatation and recurrent aortic dissection; thus, a genetic test was conducted (tested genes: FBN1, FBN2, TGFBR1, TGFBR2, TGFB2, TGFB3, SMAD2, SMAD3, ACTA2, COL3A1, EFEMP2, FLNA, MYH11, MYLK, SLC2A10). Among the tested genes, unreported heterozygous 8-base duplication mutation in the SMAD3 MH2 domain (c.742_749dup, p. Gln252ThrfsTer7) and likely benign heterozygous missense mutation in FBN2 (c.3518C > G, p. Thr1173Ser) were detected . The SMAD3 mutation seemed to be pathogenic because it causes frameshift, and premature termination codon can be formed. When the oropharynx was examined, a bifid uvula was found . Although the patient had no history of musculoskeletal disease, such as osteoarthritis, he was diagnosed with LDS type III based on the diagnostic criterion .
+The aortic diameter was unchanged on follow-up CT at 6 months after surgery ; thus, observation was continued. If aortic arch enlargement is seen in the future, surgical treatment such as total arch replacement with frozen elephant trunk will be planned.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_575_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_575_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a824ded1d659af0a75b9580a247b086076a53996
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_575_en.txt
@@ -0,0 +1,6 @@
+The patient was a 71-year-old woman. She did not keep any birds or animals, and had been treated for diabetes for over 30 years. She was on diet therapy and insulin therapy, but her diet appeared inadequate and her hemoglobin (Hb)A1c levels were within the range of 7.9%–8.5%. She was therefore admitted to her family hospital for dietary and lifestyle guidance in April 2019. During that hospitalization, she repeatedly developed pneumonia and bronchitis. In addition, findings of moon face, central obesity, and red skin lines led to a suspicion of Cushing's syndrome. During early morning fasting, plasma ACTH increased to 104 pg/mL (normal, 7.2–63.3 pg/mL) and serum cortisol increased to 23.5 μg/dL (normal, 6.2–19.4 μg/dL). In August 2019, at the time of consultation at our hospital (Fukushima Medical University Hospital), the patient showed: weight, 52.1 kg; height, 139.9 cm; body mass index, 26.6 kg/m2; blood pressure, 125/60 mmHg; and heart rate, 81 beats/min with regular rhythm. At this time, 24-h urinary free cortisol (UFC) was slightly increased to 128 μg (normal, 20–100 μg).
+We performed screening tests for Cushing's syndrome. No diurnal variation was seen in serum cortisol (values on 1 day: 8.15 μg/dL at 08:00; 12.30 μg/dL at 16:00; and 11.85 μg/dL at 23:00), and after a 0.5-mg overnight dexamethasone suppression test, serum ACTH and cortisol were not suppressed (ACTH: 67.80 pg/mL; cortisol: 11.28 μg/dL). Based on these findings, ACTH-dependent Cushing's syndrome was suspected and we performed testing to confirm the diagnosis. After 8-mg overnight dexamethasone suppression testing, serum cortisol was suppressed (ACTH: 31.79 pg/mL; cortisol: 4.12 μg/dL). No response to ACTH was seen in the corticotropin-releasing hormone (CRH) loading test (after CRH loading: basal plasma ACTH, 85.84 pg/mL; peak plasma ACTH, 87.18 pg/mL). Magnetic resonance imaging of the brain showed no abnormal enhancement of the pituitary gland.
+High-resolution computed tomography (CT) showed two pulmonary nodules in the left lung apex and lingual regions . The results of blood tests were normal, showing: white blood cell count, 5.2 × 103/μL; C-reactive protein, 0.04 mg/dL; carcinoembryonic antigen, 4.9 ng/mL; squamous cell carcinoma antigen, 0.5 ng/mL; cytokeratin 19 fragment (CYFRA 21-1), 3.09 ng/mL; and neuron-specific enolase (NSE), 208 pg/mL. Only NSE was elevated. Positron emission tomography/CT showed no significant accumulations of 18F-fluorodeoxyglucose in those lung nodules or other sites. SRS was performed using 111In-octreotide, and no positive lesions were found throughout the entire body.
+Although serum cortisol was suppressed in the high-dose dexamethasone suppression test, Cushing's syndrome due to an ectopic ACTH-producing tumor was suspected. However, the patient did not agree to selective venous sinus blood sampling from the cavernous sinuses or inferior petrosal sinus due to the invasiveness of the procedures. In addition, the possibility of ectopic ACTH-producing tumor could not be ruled out due to the presence of lung tumors. However, CT findings suggested these tumors would be difficult to sample by bronchoscopic lung biopsy and we therefore performed surgical biopsy in December 2019.
+With the patient under general anesthesia, two nodules in the left lung underwent wedge resection with free margins under thoracoscopy. Intraoperatively, the easily resectable pulmonary apex lesion underwent wedge resection first, and frozen section diagnosis revealed pyogenic granuloma. We therefore determined that the entire left lung was infected, and surgery was finished after adding only wedge resection of the lingual region.
+In the definitive diagnosis on histopathological examination of the resected specimens, the lesion in the left lung apex showed caseous necrosis, and no mycobacteria were observed on Ziehl–Neelsen staining. Grocott staining and periodic acid-Schiff staining showed numerous oval-shaped fungi positive for mucicarmine staining, indicating fungal infection by Cryptococcus. Lesions in the lingular segment comprised spindle cells proliferating in ribbons and foci , and immunohistochemistry showed strong positivity for chromogranin A, synaptophysin, CD56, and ACTH . No necrosis was present in the tumor, and the mitosis count was 1/2 mm2. The patient was diagnosed with ACTH-producing pulmonary typical carcinoid (p-T1bN0M stage IA2) with pulmonary cryptococcosis. Although this was before the diagnosis of ACTH-producing tumor, hydrocortisone was started at 50 mg/day immediately after surgery as a precaution. On postoperative day 4, basal plasma ACTH decreased to 6.67 pg/mL and serum cortisol levels decreased to 3.64 μg/dL. Although hydrocortisone might have had some effect, ACTH and cortisol remained at normal levels. Hydrocortisone dosage was gradually decreased to 20 mg/day, and the patient was discharged 15 days postoperatively. Subsequently, 24-h UFC levels were also normal, diabetes control was improved, and clinical symptoms resolved. Finally, at 6 months postoperatively and on hydrocortisone at 15 mg/day, the 0.5-mg dexamethasone suppression test suppressed ACTH and cortisol levels (ACTH: 14.55 pg/mL; cortisol: 0.288 μg/dL), confirming improvement of Cushing's syndrome. Furthermore, basal plasma concentration of ACTH was 20.05 pg/mL and cortisol was 10.32 μg/dL, so secretions were considered to be adequately maintained and hydrocortisone dose was further tapered and terminated 2 years postoperatively. Preoperatively, we did not test for cryptococcal antigen in the serum because we did not strongly suspect infection. Results for cryptococcal antigen in the serum examined 2 days postoperatively were negative. Cerebrospinal fluid was also examined after discharge, but no cryptococcus was found. The patient did not request additional lobectomy. As of July 2022, 18 months postoperatively, the patient was alive with no tumor recurrence and no clinical or laboratory evidence of elevated ACTH or Cushing's syndrome. She remains on insulin therapy for diabetes, but HbA1c is hovering around 7%. She patient is living independently and we will continue careful observation with laboratory data and CT.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_586_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_586_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a92655896883150400edc5c4c0ec7de296398fa1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_586_en.txt
@@ -0,0 +1,2 @@
+A 63-year-old man presented with hoarseness that continued for 6 months. Laryngoscopy revealed a white lesion in the right vocal cord . Biopsy of the right vocal cord was performed, and the patient was diagnosed with glottic squamous cell carcinoma. The patient reported drinking 1500 ml beer daily and had smoked one and a half packs of cigarettes per day for over 40 years. He quit smoking at the time of diagnosis. Computed tomography (CT) findings revealed no lymph node or distant metastasis. The patient's clinical stage was T1aN0M0, I (TNM classification, 8th edition). Definitive RT alone was planned. The RT dose was 63 Gy delivered in 28 fractions for the larynx using a three-dimensional conventional RT technique with a dynamic wedge. The radiation field size was 5.5 × 6 cm with a conventional rectangular field (no multi-leaf collimator) . At 3 days after RT initiation, laryngoscopy revealed that the primary tumor of the right vocal cord had slightly increased in size . At 2 weeks after RT initiation, the patient had resumed smoking, and laryngoscopy findings revealed a slightly changed bilateral vocal cord mucosa with a white lesion . He was instructed to quit smoking again. However, he continued drinking 1500 ml beer daily during RT. RT was completed on schedule with no pauses (total treatment time was 42 days). At the time of RT completion, laryngoscopy revealed that the primary tumor had disappeared . Acute toxicities included grade 2 dermatitis and grade 1 mucositis. The initial treatment response was complete response (CR), and the follow-up period was started.
+Monthly examination was performed, and no local recurrence or metastasis was observed at 1 year after RT . During the follow-up period, although the patient had quit smoking, he continued to drink 1500 mL beer daily. At 13 months after RT, he resumed smoking one pack per day of cigarettes. At 1 month after resuming smoking, laryngoscopy revealed a slightly changed bilateral vocal cord with a white lesion without recurrence . At 2 months after resuming smoking, he had severe sore throat and hoarseness. Laryngoscopy findings revealed a large tumor in the larynx . Unfortunately, we did not perform CT at that time. Eleven days later, surgical excision of the tumor was performed , and the patient was histologically diagnosed with radiation-induced laryngeal necrosis as a late toxicity without cancer recurrence . After surgical excision, the patient continuously experienced sore throat despite oral painkiller administration. At 3 weeks postoperatively, he suddenly developed dyspnea, and laryngoscopy findings revealed total laryngeal paralysis . The patient underwent an emergent tracheostomy. After tracheostomy, the lingering sore throat disappeared momentarily. Enhanced CT revealed bilateral vocal cord edema, and bilateral arytenoid cartilage showed atrophy and sclerosis . No cancer recurrence was observed on enhanced CT findings. Transvenous administration of steroids alone was performed. First, we injected hydrocortisone 500 mg per day for 2 days, with a gradually decreasing dose (300 mg per day × 2 days followed by 200 mg per day × 2 days). Laryngoscopy findings revealed a slight improvement in vocal cord movement and necrosis . Thus, we switched to oral prednisolone. We administered prednisolone 30 mg per day for 2 days, with a gradually decreasing dose (20 mg per day × 2 days followed by 10 mg per day × 2 days; then, 5 mg per day × 2 days). Steroid treatment further improved the laryngeal necrosis and laryngeal paralysis . After oral administration of prednisolone, the patient was discharged with tracheostomy. At 2 weeks after discharge (1 month after tracheostomy), laryngoscopy findings revealed that the bilateral vocal cord further improved the movement and necrosis similar to the pre-tracheostomy status . No respiratory distress was observed even when the tracheal foramen was blocked.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_596_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_596_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..096885b921f68ebe26b08c7e29b7aaed34f202cb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_596_en.txt
@@ -0,0 +1 @@
+A 29 year old Latina female with a history of papillary thyroid carcinoma was initially treated with a total thyroidectomy, central and bilateral neck lymph node removal and subsequently with radioiodine therapy. Following this, evaluation indicated locoregional progressive disease and micrometastatic involvement in both lungs. Therapy was then initiated with 200 mg of oral sorafenib every 12 hours. However, after 4 days the patient presented with cutaneous lesions in the sole of the foot and in the first finger of the left hand which was associated with a burning pain in soles and palms and an intolerance to contact with hot surfaces. She also had significant ambulatory limitations and patchy lesions were evident in several areas of the foot and yellow blisters on the lateral aspect of the foot, metatarsal region and on the proximal phalanx of the first finger of the left hand . Given these clinical findings the dermatological reaction was classified as Grade 3 and the Sorafenib treatment was discontinued. We then initiated treatment with a topical steroid, oral antihistamines and local management with ice packs around the lesions and observed the beginning of recovery seven days after the patient discontinued the drug therapy .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_599_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_599_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bc0b317fac548f33662f323989b3100294e2c544
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_599_en.txt
@@ -0,0 +1,4 @@
+A 46-year-old male cadaver was found to have an extra-hepatic biliary system with rare morphological anomalies. This was identified during a descriptive-prospective cross sectional study of the morphological characteristics of the extra-hepatic biliary system in humans.
+The anterior abdominal wall was opened longitudinally along the midline. The abdominal wall was separated on to the right side along the central margin up to the mid axillary line. Then the abdominal wall was divided from the right side of the pubic bone up to the anterior superior iliac spine. The anterior abdominal wall flap was reflected laterally. The stomach was retracted to the left side and the second part of the duodenum, free margin of the lesser omentum, epiploic foramen and gall bladder identified. Dissection was done to demonstrate the extra-hepatic biliary system and its vascular pattern.
+The right and left hepatic ducts were not seen extra-hepatically and the common hepatic duct drained directly into the gall bladder neck, with absence of the common bile duct. Further drainage of the bile away from the gallbladder and into the duodenum was provided by the cystic duct. The gall bladder was lying in the gall bladder fossa in the right lobe of the liver in a transverse plane. The width and the length of the gall bladder were 2.5 cm and 4.5 cm respectively. The length of the common hepatic duct was 2.6 cm and the cystic duct that drained the gall bladder to the duodenum was 6.9 cm .
+Apart from the anomalous extra-hepatic biliary morphology, a rare abnormal arterial pattern was observed. The cystic artery was anterior to the common hepatic duct and it was originating from the right hepatic artery. The division of anterior and posterior branches of the cystic artery was not noted. The right hepatic artery was found to be communicating with the left hepatic artery by a "bridging artery" after giving rise to the cystic artery. An accessory hepatic artery originated from the "bridging artery" forming a "cruciate" hepatic arterial anastomosis .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_604_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_604_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..97dc717b3ef5dce003f8a4dc31d2640e00bd1994
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_604_en.txt
@@ -0,0 +1,3 @@
+This case report has been written in accordance with the SCARE 2018 criteria .
+A 64-year-old female presented to the Emergency Department of our hospital with acute onset of a right-sided groin bulge that occurred earlier that day after doing heavy lifting. She had no significant past medical or surgical history. Her baseline functional status was exceedingly well. Her laboratory studies showed no leukocytosis or any electrolyte abnormalities. Initial radiologic studies included a transabdominal and transvaginal pelvic ultrasound, which showed a 2.4 × 2.6 cm fluid collection with some septations and absent visualized adnexal structures. A subsequent CT demonstrated a well-circumscribed 2.7 × 3.2 × 2.6 cm fluid collection containing echogenic debris. It did not have significant rim enhancement yet was noted to be most consistent with an abscess, complex seroma, or necrotic lymph node; its depth was amenable to percutaneous drainage. On further review with the radiologist, it was noted to contain the appendix, the tip of which was dilated and radiographically concerning for a cystic process, with mucocele remaining within the differential diagnosis.
+The patient was kept nil per os, intravenous fluid resuscitation was initiated, and antibiotic therapy was begun. She was brought to the operating room for emergent surgical intervention. The patient underwent laparoscopic appendectomy with open femoral hernia repair. Intraoperatively, the appendiceal tip was incarcerated within the hernia sac . Due to the preoperative radiographic appearance and the suspicion for mucocele, extreme caution was exercised to avoid rupture and not to provide excess tension in an attempt to reduce it laparoscopically. It was easily removed through the open inguinal incision after the appendix base was divided laparoscopically . The femoral hernia was repaired in standard McVay fashion. Final pathology showed inflamed non-perforated acute appendicitis without evidence for neoplasm. The patient recovered well without notable complications and was discharged on postoperative day number two without antibiotics.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_644_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_644_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6eb51dcad7d63009555cd180616619458c4b92ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_644_en.txt
@@ -0,0 +1,5 @@
+A 35 year old primiparous woman underwent an emergency caesarean section due to failure to progress in the second stage of labour. After a successful operative delivery, mother and child were discharged three days later, having had an uneventful recovery.
+Eighteen days post caesarean section, the mother presented to hospital with continuous vaginal discharge necessitating pad changes every hour. The discharge was clear, consistent with urine. She underwent a computed tomography intravenous urogram (CT-IVU) which suggested a diagnosis of a uretero-uterine fistula .
+Two days later, an examination under anaesthesia, and a cystoscopy and ureteroscopy, were performed. A small amount of blood was found on vaginal examination and cystoscopy revealed normal bladder and ureteric orifices. A guidewire inserted in the right ureter under imaging would only advance approximately 6 cm up the ureter. Retrograde ureterography was performed and showed the passage of dye from the right ureter to the uterus . The procedure was abandoned and a nephrostomy was inserted post-operatively to help divert urine away from the fistula.
+After a two months interval, the mother returned to clinic for follow-up and reported that she had not experienced any further vaginal leakage of urine. In order to assess the condition of the ureter and fistula, a nephrostogram was performed which showed complete blockage of the ureter . Following the nephrostogram, vaginal discharge of urine recurred indicating persistence of the fistula.
+Six weeks later she underwent re-implantation of the right ureter and JJ-stent insertion. A suprapubic and urethral catheter were inserted and the nephrostomy clamped. The urethral catheter was removed five days post-operatively and a cystogram performed 10 days post-operatively showed no evidence of an anastomotic leak. The nephrostomy tube was removed under radiological guidance, and was inadvertently accompanied by the JJ-stent. One week later, an IVU revealed both right and left ureters to be draining well with no evidence of obstruction or fistula . The patient went on to make a full recovery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_680_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_680_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..22715c19da18cd503c322e576941db5b5ee53ede
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_680_en.txt
@@ -0,0 +1,5 @@
+A 49-year-old French-Canadian male presented to our outpatient clinic with thick hyperkeratosis of the palms and soles. He reported that his paternal great-grandfather, two of his brothers, and his daughter had or have similar but milder lesions. This condition became apparent at the age of 6 months and gradually worsened over the years. The associated deep fissures made standing, walking and using his hands very difficult and painful. The pain and functional limitations were especially severe in the morning, when the patient had to crawl to the bathroom on his knees, leaning on the dorsum of his hands. Over the years, he had learned to regularly pare the thickened keratin off his soles and to use over-the-counter emollients that he found more effective than prescribed keratolytic preparations.
+Examination revealed compact, thick, and yellow palmoplantar hyperkeratosis with deep fissuring most prominent in the center of both palms. The keratoderma was surrounded with well-defined erythematous borders. The soles were diffusely thickened, while on the palms, the thenar and hypothenar areas were relatively spared. The hyperkeratosis involved the volar aspect of the fingers in a wavy linear pattern . The hyperkeratosis did not extend over the dorsum of the hands and feet, and no starfish keratosis was seen. Knuckle pads were noted over the metacarpophalangeal articulations, and the fingertips were pointed and sclerotic. The toes were twisted and swollen, and three of them were encircled at their base with constriction bands (pseudoainhum). The nails were grayish, grossly thickened, and showed a markedly increased longitudinal curvature described as ‘parrot-beaking’ . There was no involvement of the hair and teeth, the oral mucosa was normal as was the voice, no epidermal cyst was seen, and the general physical examination was normal.
+A 4-mm punch biopsy showed massive, compact hyperkeratosis with parakeratosis, prominent irregular acanthosis, and extensive epidermolytic hyperkeratosis (granulovacuolar degeneration of the keratinocytes; fig. ). The patient and his daughter, similarly affected, were referred for molecular testing and genetic counseling. Sequencing of exon 1 of the KRT9 gene and select exon analysis of the KRT1 gene failed to reveal mutations in keratin 1 and keratin 9. A final diagnosis of PC was established when whole exome sequencing was subsequently carried out and showed that both the patient and his daughter harbored a heterozygous mutation in KRT16 (L124R). No other pathogenic mutation was found.
+The patient was treated with acitretin 10 mg once a day for 1 month and tolerated the medication well. The dose was then increased to twice a day. He responded well, with a reduction of the hyperkeratosis in both palms and soles, healing of the fissures , loosening of the pseudoainhum, as well as with improved mobility and dexterity, which have been maintained over the last 5 years.
+The daughter is less severely affected, presenting with thickened nails, diffuse plantar keratoderma, and focal palmar hyperkertosis in a striate pattern reminiscent of her father's, although without fissuring or limitation in mobility. Given her desire to raise a family, she declined treatment with acitretin.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_71_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_71_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..159f9439b1580e7c19d41f5923ed2b4cfb2cfa9e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_71_en.txt
@@ -0,0 +1,7 @@
+A 48-year-old man with end-stage kidney failure, on maintenance dialysis since 2011, was referred in February 2020 with a 6-month history of general malaise and progressive evolvement of painless icterus and necrotizing skin ulcers.
+The patient’s medical history included diabetes mellitus (DM) type I with end-stage kidney failure, ischemic cardiomyopathy (obstructive lesions of left anterior descending coronary artery resolved by stent placement in 2018), and signs of predominantly diastolic heart failure (ultrasound of the heart prior to the occurrence of the symptoms referred to herein showed a 49% ejection fraction, mild mitral and aortic regurgitation, and moderate pulmonary hypertension with 47 mmHg). His official therapy consisted of lacidipine, furosemide, acetylsalicylic acid, calcium carbonate, bisoprolol, sevelamer, and pantoprazole, and was substantially unchanged in the last year.
+In December 2018, the patient underwent stem cell transplantation in Ukraine. The stem cell clinic NBS/ICH/Kiev/London promised––as cited from the brochure, with many grammatical errors»…it is expected strengthening of the regenerative abilities of the body, improving of all functions of organs and tissues and repairing of pathologically damaged tissues, rejuvenate body…« The patient explained he mostly hoped for restitution of his kidney function. Although the patient could not provide an exact operative report, he explained that the product was supposed to be stem cells of embryonal origin and was injected in a single infusion in his peripheral vein. The stem cell clinic claimed in their informative material that examination (including determination of normal heart, lungs, kidney and liver function, as well as ruling out infection) would be performed. However, the patient could not recall any preadmission testing.
+At the current referral, jaundice (bilirubin 142/116 μmol/l, increased alkaline phosphatase, slightly elevated alanine aminotransferase) and necrotizing skin changes predominated in the clinical picture . He described his skin wounds as aching and itching. The first skin lesions appeared 6 months after stem cell treatment, starting as bullae, which then burst, and a scab formed underneath. The wounds spread all over the body, the most severely affected being the skin on the arms and legs. A deep-punch skin biopsy disclosed segmental medial basophilic calcification with focal atrophy of smooth muscle in media, intimal fibroplasia of small- and/or medium-sized arteries and arterioles in subcutaneous adipose tissue consistent with calciphylaxis. Additional staining with von Kossa highlighted subtle calcium deposits also in the interstitium of the dermis and elastic fibers. Inflammation was relatively scant as well as extravasation of erythrocytes. There were no changes suggestive for graft versus host disease .
+However, the pathohistological diagnosis of calciphylaxis was not consistently supported by clinical findings, as there was no severe deterioration of phosphate/calcium metabolism on admission, parathyroid hormone was within limits, and, according to the angiologist's clinical assessment and ultrasound Doppler measurements of perfusion pressure in the lower extremity arteries, macrovascular peripheral arterial disease was not likely.
+The first laboratory signs of icterus were present in September 2019. Investigations of icterus included transabdominal and endoscopic ultrasound, which showed hepatosplenomegaly without signs of extrahepatic cholestasis. The most likely infectious, metabolic and autoimmune causes, as well as biliary obstruction (see Additional file 1: Table S1) were ruled out. Since the patient also experienced severe deterioration of heart function in the same time frame (heart ultrasound revealed a severe reduction of the left ventricular ejection fraction to 30%, segmental contraction disorders, right-sided heart failure, and moderate mitral regurgitation), the differential diagnosis included liver congestion due to heart failure of unknown etiology (acute coronary syndrome was ruled out). This was not, however, supported by the liver histology , which revealed subacute hepatitis with portal inflammation of mixed type (mainly neutrophilic and eosinophilic granulocytes) without convincing signs of chronic liver congestion. We concluded that the hepatic impairment was probably the result of combined liver defect: chronic congestive hepatopathy (dilated sinusoids and ultrasound dilated hepatic veins) and toxic injury of idiosyncratic type, which manifested as cholestatic hepatitis, revealed by liver biopsy. A reasonable trigger for this reaction was, however, unclear and difficult to identify.
+In accordance with assumed calciphylaxis, treatment with sodium thiosulfate, intensified dialysis, and hyperbaric oxygen were initiated. The inflammatory parameters decreased, and the patient was cardiopulmonary compensated, with better but not normal laboratory results (bilirubin 45/45 μmol/l) and with slight improvement in skin condition. He insisted on dismission and continued with regular dialysis thrice weekly at our outpatient service. Four days after dismission he was found dead in his apartment. An autopsy was not performed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_737_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_737_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..866a1d1632fd0f7425d90dbdaf9c9f6c633187f2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_737_en.txt
@@ -0,0 +1,2 @@
+A 60-year-old lady, presented with tremulousness of hands for 1 month and palpitation with excessive sweating for 3 months. She had a history of weight loss for 6 months, and gradually enlarging neck swelling for 3 years. She was nervous, irritable, and emotionally labile. Her weight was 46 kg, BMI 17, afebrile, pulse rate: 110/min/regular, blood pressure: 140/56 mm of Hg. Her thyroid gland was symmetrically enlarged, firm in consistency, nodular/lobular surface and mildly tender without any bruit. Palms were warm and sweaty with fine tremor in hands. All reflexes were exaggerated. There were no occular manifestations.
+Initial thyroid function tests (TFT) revealed high T3: 3.80 ng/ml (0.80-2.10), T4: 12.40 ug/dl (5.10-12) with a low TSH: 0.20 mU/L (0.70-5). Her TSH receptor antibody (TSAb): 25 U/L (Normal [nl.] <1), anti TPO antibody: 374 IU/ml (nl. <35) and thyroglobulin antibody: 268 IU/ml (nl. <65) were all strongly positive. Complete hemogram and ESR-18 mm/h (nl.-1-25) were normal. Ultrasonogram of thyroid revealed an enlarged gland with hypoechoic parenchyma with fibrous septa.99mTc pertechnetate scan (Tc99m scan) revealed enlarged thyroid gland with diffusely increased uptake of radiocontrast: 17% (nl. 0.4-4%) with some patchy defects in both lower poles. Thyroid FNAC showed sheets of Hurthle cells with abdunce of lymphocytes and sheets of regular follicular cells, indicating HT. She was observed on beta blockers. Repeat TFT, 3 months later showed: T3: 4.20 ng/ml, T4: 14.40 ug/dl, TSH: 0.001 μU. Repeat 99mTc pertechnetate scan was done, which again revealed enlarged thyroid gland with diffusely increased uptake of radiocontrast: 21% (nl. 0.4-4%) with same patchy defects in both lower poles. Antithyroid medication carbimazole was started.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_753_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_753_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbca3acb4095cfe017e24edbd7a2f81fd5234602
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_753_en.txt
@@ -0,0 +1,5 @@
+A 32-year-old male driver by profession presented to the cardiology department complaining of chest discomfort and a history of pain radiating to his back and left shoulder, which had gotten worse following four days of weight training. There are no comorbidities. History of similar complaints in the past with the first episode at the age of 10 years and similar such complaints are noted on lifting heavy weights, climbing uphill and on exertion. There is no history of concomitant surgical operations or substance abuse. There is no family history of ischaemic heart disease. Clinical assessment is normal. Routine blood tests and cardiac markers are normal. On presentations, vitals were heart rate of 164 beats per minute (tachycardia), blood pressure of 130/84 mmHg, and respiratory rate of 24 cycles per minute (tachypnoea), with normal blood glucose sugar level and showing normal ECG findings.
+The patient was directed to the radiology department for additional assessment. The chest X-ray indicated a normal apex and left heart border but a lucent region, as well as lung tissue between the left hemidiaphragm and heart base . The patient was referred for echocardiography, which revealed substantial cardiac mobility with a high degree of levorotation, normal left ventricle size, normal systolic function, and a 60% ejection fraction. The next day, the patient was suggested to undergo a cardiac MRI, which revealed significant levorotation of the heart and lung tissue interposition anteriorly between the main pulmonary artery and aorta. An analogous interposition of lung tissue occurs between the left ventricle and the diaphragm. The left atrial appendage protrudes outward along the lateral face of the aortic arch. A 6-mm defect in the middle atrial septum is seen, most likely of the secundum type with left-to-right blood shunting. Hence, a suspicion of pericardial agenesis was made.
+The left inferior pulmonary vein seems to have a restricted calibre as a result of compression between the descending aorta and left atrium, most likely caused by significant levorotation . On the left, the superior and inferior pulmonary veins measure 7 mm superior to the inferior and 4 mm inferior to the superior. On the right side, they were 18 mm and 12 mm.
+Investigations on the mobility of the walls of the left and right ventricles show excessive cardiac mobility is defined by a 1.5-to-2 mm displacement of the heart apex. The normal pulmonary artery diameter is 25 mm. The rest of the heart looks normal. Pleural or pericardial effusion is absent with normal ventricular walls .
+A chest HRCT was performed, revealing the absence of the pericardium on the left side. Lung tissue may be recognised between the aorta and the primary pulmonary artery . Lung tissue was observed between the left hemidiaphragm and the heart's base, as well as an abnormally expanded left atrial appendage. The following day, with the same concerns, a repeat chest X-ray revealed a leftward migration of the heart apex (wandering cardiac apex) . The patient was treated conservatively with regular follow-up in the outpatient clinic and is advised not to lift heavy weights.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_791_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_791_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e49124ff34654dded39b0d0c4bd0c1b6bb9ef72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_791_en.txt
@@ -0,0 +1,8 @@
+We report the case of a 66-year-old female patient suffering from acute heart failure due to severe aortic and mitral stenosis. She underwent a combined mitral and aortic valve replacement with bioprosthetic valves (respectively 29-mm Epic St Jude Medical and 21-mm Trifecta GT St Jude Medical) on October 7th, 2021 and was discharged after a 10-day hospitalization.
+4 weeks later, she was admitted to hospital for asthenia and fever. A paroxystic third-degree atrioventricular block was diagnosed on the electrocardiogram and blood cultures were positive to Enterococcus faecalis. Transthoracic echocardiography (TTE) confirmed the presence of a double supracentimetric endocarditis on the two prosthetic valves with an aortic root abscess. CT-scan did not find any sign of septic embolism. She received an antibiotherapy with Ceftriaxone and Amoxicillin.
+The patient underwent a replacement of the aortic and mitral prosthetic valves and the implantation of a leadless pacemaker on November, 07th 2021.
+Surgical examination confirmed the diagnosis of large vegetations of the two prosthetic valves and a massive destruction of the mitral annulus. The two prosthetic valves were replaced. A 21-mm Edwards Magna Ease valve was placed in aortic position. Nevertheless, because of the extensive deterioration of the mitral annulus, the 31-mm Edwards Magna Ease valve was inserted in supra-annular mitral position. Immediate post-operative transoesophageal echocardiography (TOE) was satisfying, with a good function of the new prosthetic valves. She was weaned from mechanical ventilation the next day.
+The postoperative course was marked by an acute kidney injury needing continuous renal replacement therapy. One week after the surgery, she developed a severe hypoxemic respiratory failure due to a pulmonary oedema needing mechanical ventilation.
+The TOE revealed a LA wall dissection and the creation of a new atrium cavity interpreted as a FA behind the LA posterior wall, squeezing the left atrium at every systole . The two new prosthetic valves were functional and unscathed without intra- nor para-valvular regurgitation. A severe left-ventricular regurgitant jet filled the FA pushing the LA posterior wall through the LA, probably causing pulmonary veins obstruction . No shunts were detected by the bubble test and the aortic wall and the interatrial septum were normal.
+Contrast-enhanced synchronized cardiac CT-scan (128-slice) was realized to perform a 3D reconstruction imaging to guide a potential surgery. It confirmed a FA measuring 65 × 40 x 30 mm behind the LA with a mass effect on it, communicating with the left ventricle outflow tract through a 23-mm defect, close to the mitral prosthetic valve . Pulmonary veins were correctly inserted in the right atrium.
+Unfortunately, weaning from mechanical ventilation was unsuccessful. Considering the high risk of a third surgery, the impossibility of a percutaneous treatment facing a very large collar and false aneurysm and the worsening of the clinical course, a palliative care support was collegially decided and the patient finally died.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_800_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_800_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..68770fd57a55d08b134366fdfc29e158d352c540
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_800_en.txt
@@ -0,0 +1 @@
+A 47-year-old man visited the emergency room due to two incidents of transient locomotor blocks. He had a past history of panic attacks. Recently, he had been under severe emotional stress. When he attempted to walk at the pedestrian crossing on the green light, his right foot was glued to the ground. He sat down and massaged his right leg with both hands. Several seconds later, he could walk normally again. Two hours later, when he attempted to run while walking, his right foot was again stuck to the ground for several seconds. During the attacks, there were no knee trembling of the frozen leg. He denied any motor weakness, sensory change, or dyskinesia of the arms or legs. On neurological examination, he had no motor, sensory, or cerebellar dysfunctions. T2 and diffusion brain magnetic resonance imaging (MRI) scans were normal . However, magnetic resonance (MR) angiography showed atherosclerosis in the proximal left anterior cerebral artery . Perfusion scans showed a delayed mean transit time in the left mesial frontal lobe, including the supplementary motor area and cingulate cortex . Routine laboratory tests were all normal, including CBC, liver function tests, renal function tests, urine analysis, electrocardiography, and chest x-ray studies. There was no hyperlipidemia. Screening tests for autoimmune disease (e.g. ANA, Ani-dsDNA antibodies, P-ANCA, C-ANCA, Anti-Cardiolipin antibodies Ig M andIg G) were all negative. Transthoracic echocardiography study showed no abnormalities. Interictal electroencephalography (EEG) studies revealed no abnormalities. During four months of follow up period, he had been treated with low dose aspirin, but he developed two more attacks when he attempted walking.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_818_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_818_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ce1e224c4f5e6ff10502b9f82d5e8b1d73277249
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_818_en.txt
@@ -0,0 +1,4 @@
+A 76-year-old man presented with a 12-month history of low back pain radiating down his right leg, without sensory dysfunction or motor weakness. Preoperative pain intensity was 8 on a 10-point scale and unresponsive to medication (i.e., continuous oral NSAIDs and 6 weeks of opioids). Preoperative MRI showed a paramedian, down-migrated, L3-L4 disc herniation (, B). Given the concordance between clinical symptoms and MRI findings, a right L3-L4 FETD was planned. From a prone position (, A), the patient underwent the procedure under monitored and local anesthesia (local infiltration with a 50/50 mixture of lidocaine 2% and physiological solution). Preoperatively midazolam 2 mg was intravenously administered for anxiety control. Propofol was administrated by continuous target-controlled infusion to achieve conscious sedation with spontaneous ventilation .
+The Joimax TESSYS® (Joimax® GmbH, Karlsruhe, Germany) transforaminal endoscopic surgical system was used. We established the paramedian skin entry point, under fluoroscopic guidance, at approximately 10−11 cm lateral to the L4 spinous process. Using intermittent fluoroscopic guidance, alternating between lateral and anterior-posterior views, an 18-gauge needle was advanced until reaching the lateral border of the right L4 peduncle (,1). Then it was replaced by a soft Kirshner wire that served as a guide for introducing sequential dilators. The smallest dilatator (green guiding rod, outer diameter: 1.8 mm) was hammered inside the right L4 pedicle (,2). The trajectory was forced towards the medial wall of the pedicle to access the intracanal space After radiographic confirmation of the trajectory, the hole in the pedicle was increased with subsequential dilatators and reamers (outer diameters: from 3 to 7 mm). The instrument position was kept under radiographic control while continuously switching from lateral to AP views (,3). The reamers were used to cross the pedicle and penetrate the full width of the bone. The breaking of the medial pedicle wall, and thus the access to the intracanal space, was confirmed by simultaneously feeling the loss of resistance by hand and real-time fluoroscopic confirmation.
+We then inserted the endoscope working cannula (8.0 mm in outer diameter) and the camera (,4). The herniated fragment was clearly visible (, A). We mobilized the disc fragment with the probe and the root retractor and then removed it with small forceps. The decompression was considered successful when we saw the nerve root pulsating freely in the epidural space (, B), after having checked the intraspinal space for additional fragments (, C). We closed with a resorbable suture.
+Late postoperative MRI showed satisfactory decompression (, C) and no sign of additional instability or fractures. Patient radiculopathy entirely resolved after the surgery – postoperative pain was negligible after the first 6 h and 24 h and at the 8-month follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_835_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_835_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2776f81dfa5248f7a6eb5b6d0ed217d19dd32a9d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_835_en.txt
@@ -0,0 +1,2 @@
+A 36-year-old pregnant woman (gravida 3, para 1) presented at our gynecological oncology department with vaginal bleeding after thinprep cytologic test (TCT) at 13 gestational weeks. She reported no abdominal/pelvic pain and no medical and surgical histories. Gynecologic pelvic examination revealed a cervical lesion 5 cm in diameter without involvement of vagina and parametrium. An ultrasound scan revealed an enlarged uterus for a pregnancy at the 13th week. Gadolinium-free pelvic magnetic resonance imaging (MRI) confirmed that no regional lymph node engagement was documented. Squamous cell carcinoma of invasive non-keratinizing type was confirmed by cervical biopsy. Human papilloma virus (HPV) DNA testing was positive for HPV 18. The case was diagnosed as stage IB3 according to the latest 2018 International Federation of Gynecology and Obstetrics classification.
+The patient strongly desired to maintain the pregnancy and refused to perform surgery. All the potential risks and complications of therapy were presented and the informed consent was signed. After thorough discussion in a multidisciplinary team (MDT) meeting, we decided for NACT with carboplatin (area under the curve of concentration × time [AUC]= 5 on day 1 every 21 days) and paclitaxel (175 mg/mq every 21 days), followed by caesarean section and radical hysterectomy with monitoring the evolution of the mass and pregnancy. The patient received 5 cycles of chemotherapy from 20 gestational weeks to 32 gestational weeks. The only toxic effects were slight nausea and vomiting. Concerning the advanced maternal age (36-year-old), prenatal screening for the common fetal autosomal aneuploidies was suggested. But malignancy among pregnant women could result in discordance between noninvasive prenatal testing (NIPT) results and the fetal karyotype . Therefore, an amniocentesis was performed and revealed no chromosome anomalies at 24 gestational weeks. Fetal and maternal Doppler readings demonstrated no intrauterine growth restriction through pregnancy. After careful MDT discussion and a review of literature , fetal lung maturity was achieved for babies at 35 weeks and 3-week-interval between the last cycle of chemotherapy (32 weeks) and delivery was recommended . Thus, a caesarean section at 35 weeks’ gestation was performed 3 weeks after the last cycle of chemotherapy to allow both maternal and fetal bone marrow to recover, followed by radical hysterectomy and pelvic lymphadenectomy. The caesarean section was performed under locoregional anesthesia, with conversion to general anesthesia for the hysterectomy and lymphadenectomy . The infant was a female, with an Apgar score at 1 and 5 min of 9 and 10, weighing 2060 g (21th percentile according to WHO growth curves). After placental expulsion, radical hysterectomy plus pelvic lymphadenectomy were performed. As no lymph node engagement was indicated by MRI and assessment during the surgery, para-aortic lymph nodes dissection was not considered. The patient and infant were discharged on the twelfth postoperative day in good general condition. The identifiable lesion was 3.5 cm in diameter during the surgery . Histologic report revealed a poorly differentiated cervical adenocarcinoma, locally adenosquamous carcinoma with 75% stromal invasion, invasion of the posterior vaginal wall, no lymphovascular space invasion, clear vaginal resection margins and negative pelvic lymph nodes. Postoperative radiotherapy was proposed. Extensive pathological examination of placenta and umbilical cord showed no metastasis of maternal malignancy. Neonate physical examination, blood count, biochemical analysis and auditory brain stem evoked potential test turned out to show no sign of abnormality. At last follow-up (4 months post-surgery) both the mother and infant are in good general condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_840_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_840_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9b28b88671e82e2271c64971be8781aeeed69875
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_840_en.txt
@@ -0,0 +1 @@
+Our patient is a 41-year-old white female with past medical history significant for psoriasis, temporomandibular joint pain, hiatal hernia, and migraine for which she received pitcher plant extract injections at multiple sites in her face and head every month for approximately 12 months prior to initial presentation. She was in her usual state of health when her identical twin sister noticed that her irides had changed color, prompting her to seek evaluation. She presented to our clinic with a best corrected vision of 20/25 in the right eye and 20/20 in the left eye. Intraocular pressures were 20 mmHg in both eyes. Eyelids, lacrimal system, and adnexa were normal in both eyes. Conjunctiva and cornea were clear in both eyes, and no keratic precipitates were seen. There was no anterior chamber cell or flare in either eye, and there was no posterior synechiae. Bilateral, symmetric, depigmentation of the peripheral iris stroma was present without transillumination defects (see Figs. and ). She had pigmentary sparing along the pupillary margin in both eyes with no pigment changes in the several overlying iris nevi and freckles. There was noted to be clump-like dusting of pigment throughout iris stroma of both eyes. Gonioscopy revealed open angles in both eyes without evidence of deep pigmentation, peripheral anterior synechiae or segmental pigment deposition. Dilated fundus exam revealed normal pigmentation in both eyes, and was otherwise unremarkable. The patient has been followed for approximately 5 years and her irises have remained depigmented. Her identical twin still has no signs of depigmentation of her iris and maintains brown irides at last exam 1 month ago (see Fig. ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_844_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_844_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0f0b327dde142b40243ef39d4b9e64290c7c2c98
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_844_en.txt
@@ -0,0 +1,6 @@
+A 28-year-old Asian female presented to accident and emergency department with 6 weeks history of intermittent left sided abdominal pain, which got worse over last 48 hours. Abdominal pain was associated with 2 episodes of watery diarrhea not mixed with blood and several episodes of vomiting. Drug history included nothing else apart from oral contraceptive pill. On examination she was comfortable and afebrile with pulse rate of 96 and blood pressure of 160/96. Abdomen was soft but tender in left iliac fossa and left lumber region with no guarding or rebound tenderness. Digital rectal examination was unremarkable. Full blood count showed white cell count to be elevated at 24.5 × 106/L. Urea, electrolyte, amylase and liver function tests were all within normal limits. Flexible sigmoidoscopic examination up to distal descending colon did not reveal any abnormality. Computer tomographic scan of the abdomen showed dilated large bowel up to splenic flexure along with dilated loops of small bowel. She was started on supportive treatment with IV Normal Saline, O2 inhalation, catheterization and antibiotics. However after treatment she failed to respond and progressively became more unwell. Gradually she developed hypotension and oliguria. Arterial blood gas analysis at 4 litre of oxygen showed compensated acidosis with following picture:
+Po2-10.7 kPa
+PCO2-4.04 kPa
+Hydrogen ion - 43.4 nmol/litre
+HCO3-17.5 nmol/litre
+On reassessment of abdomen it was more tender with both guarding and rebound tenderness. She underwent laparotomy which showed complete infarction of small bowel, Gall bladder and spleen. Large bowel was infracted up to splenic flexure. Liver also appeared ischaemic. No procedure could be carried out and abdomen was closed. She subsequently died after around six hours in the post operative period. An autopsy was requested in view of operative findings. Post mortem examination confirmed the presence of organized thrombus at the origin of celiac and superior mesenteric arteries. In the aorta there was eccentric intimal thickening with loss of smooth muscle and a proliferation of elastic tissue [Figure ]. The nature of the lesion was confirmed as intimal fibro muscular dysplasia and thrombosis causing stenosis and subsequent occlusion of the origin of superior mesenteric and celiac artery [Figure ]. Intimal fibro muscular dysplasia of aorta causing stenosis of the origin of superior mesenteric and celiac artery was rare in medical literature.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_845_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_845_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..98673ce86a330b1a57205a8549717de06900d87d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_845_en.txt
@@ -0,0 +1,6 @@
+The one-day-old Hispanic female baby was referred to the surgical team after an asymptomatic LUQ mass was detected. The baby was born at 39 weeks and two days via repeat C/S (two) to a 39-year-old G5P3 F with negative prenatals. The mother and father denied any alcohol, tobacco, or drug use. The mother, father, and siblings had no known past medical history. Her birth weight was 3.3 kg (7 lb 4 oz), and her length was 49 cm (1 ft 7 in). Apgar at 1 min and 5 min were 8 and 9, respectively.
+A prenatal scan revealed that the left kidney appeared enlarged, measuring 56 × 32 × 43 mm and with a heterogeneous texture. The baby was breastfeeding well, with no reports of hematuria or vomiting—normal bowel movements. Since birth, the baby has experienced multiple hypertensive episodes and was placed on Isradipine 0.15 mg every 8 h when systolic blood pressure was over 105. BMP, electrolytes, and blood pressure were monitored until a radical nephrectomy was performed. BUN and creatine levels were within normal limits. Calcium levels were noted to be elevated at 10.7.
+Ultrasound findings revealed that the left kidney measured 6.8 cm with a large heterogeneous solid mass infiltrating the hilum of the left kidney, demonstrating intrinsic flow and causing some dilatation of the renal collecting system. The tumor measures 5.8 × 3.6 × 5.3 cm. There is a normal-appearing adrenal gland superior to the left kidney. The MRI of the abdomen and pelvis w/ & w/o contrast in , revealed a large heterogeneously enhancing mass centered in the upper to the mid pole of the left kidney measuring 5.3 × 5 cm. There is a sparing of the lower pole of the left kidney.
+After a discussion with the patient's parents, a left radical nephrectomy was planned. The procedure was performed in the operating room under general anesthesia and lasted 68 min. Complete exposure to the lesion's anterior, lateral, and posterior surfaces was performed. The lesion was well-circumscribed without extending into the adjacent adrenal or retroperitoneal structures. The capsule appeared to be completely intact. The lesion was excised without any leakage or disruption of the tumor capsule. The lesion was mobilized upwards, and careful blunt cautery and sharp dissection on all lesion surfaces allowed it to be fully mobilized out of the retroperitoneum. The vascular pedicle was readily identified, as was the ureter. The artery and vein were carefully divided between clamps and tied off with #0 silk ties. The ureter was traced down to its entry into the bladder and excised, suture ligating the ureter at its entry into the bladder with 3-0 Vicryl suture.
+The lesion was submitted to Pathology as a fresh specimen. After a discussion with the pathologist, the frozen section diagnosis was confirmed to be mesoblastic nephroma. Further attention to the retroperitoneum for the presence of grossly abnormal lymph nodes revealed none. There were very few lymph nodes in the paraaortic region. These were all normal. The retroperitoneum was irrigated copiously with warm irrigation fluid. There was no bleeding of the tumor bed. The incision was then closed in several layers.
+Final pathology, seen in , , was consistent with congenital mesoblastic nephroma, classic type, although focal areas of hypercellularity were noted; the patient was diagnosed with stage I mesoblastic nephroma as it was utterly resected with an intact capsule and no renal vessel involvement. Therefore, no adjuvant chemotherapy was required for this patient. The patient will be followed-up with nephrology to monitor for the development of compensatory hypertrophy of the remaining kidney. In addition, the patient will undergo an ultrasound of the abdomen every three months for the first year of life and every six months during the second year of life.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_863_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_863_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..42368a8874757ea46e2dec151750682df270f518
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_863_en.txt
@@ -0,0 +1,4 @@
+A 63-year-old female patient presented with postmenopausal intermittent vaginal bleeding for 2 months. She denied other urinary, rectal, and gynecological symptoms such as abnormal vaginal discharge, abnormal defecation, and abdominal pain. Transvaginal ultrasonography showed a small amount of hemorrhage in the uterine cavity, endometrial thickness of 0.68 cm, and no abnormal echo in the bilateral adnexal area. The levels of relevant tumor markers were all within normal ranges as follows: CA125:15.4 U/ml (reference value:<35 U/ml), CEA:2.21 ng/ml (reference value:<5 ng/ml) and CA19-9:13.6 U/ml (reference value:<37 U/ml). The endometrial cytology examination hint to possible endometrial adenocarcinoma. No other neoplasms, hereditary diseases, or related family histories were self-reported. The multimodal PET/MR examination was recommended to provide further information about the depth of myometrial invasion and the assessment of metastases in endometrial carcinoma.
+The multimodal PET/MR imaging including the whole-body 18F-fluorodeoxyglucose (18F-FDG) PET and the multimodal MR images were performed with the hybrid PET/MR scanner (SIGNA TOF-PET/MR, GE Healthcare). The patient signed an informed consent form for the PET/MR examination and the publication of relevant images. On the pelvic sagittal MRI, there was no significant thickened endometrium and no high FDG uptake in the uterine corpus, but only a polypoid mass stretching from the lower segment of the uterine endometrium to the cervical canal . The polypoid lesion showed a slightly high intensity signal on non-contrast T1-weighted images (T1WI) and fat-suppressed T2-weighted images (fs T2WI), but no restricted diffusion signal in diffusion-weighted images (DWI) . Following gadolinium administration, a mild enhancement of the lesion was observed on contrast enhanced T1WI (T1WI+C) . The PET and PET/MR fusion images showed slight hypermetabolism in the lesion . Based on the pelvic PET/MR multimodal images and cytology examination, the polypoid mass in the cervical canal was suspected to be endometrial carcinoma.
+Unexpectedly, the maximum intensity projection (MIP) images of whole-body PET revealed an abnormal hypermetabolism in the left lower abdomen (SUVmax = 17.68 g/ml) . Thus, the coronal whole-body PET/MR images were reconstructed to evaluate the abnormal hypermetabolism. The coronal whole-body T2WI and PET/MR fusion images showed that the abnormal hypermetabolism on PET images was a mass in the intestinal wall of the descending colon . The thickened descending colon wall that showed markedly high signal intensity on either DWI (ADCmean = 0.75*10^-3 mm2/s) or T1WI+C and hypermetabolism on axial PET/MR fusion images was observed.
+Subsequent colonoscopy examination confirmed the presence of a descending colonic tumor on the corresponding location of PET/MR images. The patient underwent simultaneous laparoscopic radical hysterectomy and descending colectomy. Macroscopic analysis of the resected uterus confirmed that the polypoid mass stretching from the lower segment of the uterine endometrium to cervical canal. And the endometrial carcinoma (G2) categorized as superficial myometrial invasion and the poor-differentiated tubular adenocarcinoma invading the muscularis propria without serosa invasion were demonstrated by histologic analysis. Lynch syndrome was considered because the patient had both primary endometrial carcinoma and descending colon carcinoma, even though she had no relevant family history. Immunohistochemistry (IHC) analysis indicated that MLH1 and PMS2 proteins were negative expression in the resected tumor tissues derived from uterus . Molecular analysis identified no KRAS and BRAF mutations of primary colon tumor. Moreover, the gene analysis of both tumors was performed to identify microsatellite instability (MSI) for the diagnosis of Lynch syndrome. The results of endometrial carcinoma gene analysis included deletion mutations in exon 15 and exon 17 of MLH1 , replacement mutation in exon 16 of MSH-2 and duplication mutation in exon 5 of MSH-6 . And deletion mutation and replacement mutation of MLH-1 derived from the colon tumor were also confirmed . Therefore, post-operative adjuvant therapy and follow-up would be modified according to Lynch syndrome, and relevant genetic testing had been recommended for high-risk relatives.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_881_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_881_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3274cff9e978408e87ba5cef591333bdedb5bb7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_881_en.txt
@@ -0,0 +1,4 @@
+A 15-year-old Caucasian girl was referred to a laboratory in Goiânia, Goiás, Brazil, for genetic testing due to primary amenorrhea. Her medical history included removal of an abdominal mass as a newborn. The tissue removed was referred to as an umbilical hernia. Her G-band karyotype revealed a diploid set of chromosomes, including 22 pairs of homologous autosomes and one pair of sex chromosomes, compatible with a 46, XY male chromosome complement.
+The geneticists at our laboratory concluded that the mass withdrawal from the abdomen of our patient was, in fact, testes, and that our patient had a condition known as cryptorchidism; a reproductive change characterized by a failure of the movement of one or both testes from the abdominal cavity to the scrotum.
+We performed PCR and FISH to verify mutations of the exons 1, 4, 6, 7 and 8 of the AR gene and to detect the AR gene, respectively. We prepared a culture of T lymphocytes in RPMI 1640 medium, supplemented with 20% fetal calf serum and 2% of phytohemagglutinin. Metaphasic preparations were made by conventional methodology. The slides for FISH were prepared with a micropipette, with about 15 μL of the material set. Only slides of good quality (in terms of metaphase) were selected by phase contrast microscope, and were subjected to FISH using the LSI Androgen Receptor SpectrumOrange (Xq12) probe (Vysis, Abbott Park, IL, USA). For PCR, primers were used for exons 1, 4, 6, 7 and 8 of AR .
+In situ hybridization with the LSI AR probe indicated the presence of the gene in all analyzed cells. However, genomic DNA extracted from peripheral blood leukocytes assessed by PCR revealed coding sequence abnormalities for the AR gene, which lacked exons 1 to 7 indicating large deletion spanning the proximal region of the gene. Figure shows hybridization signals in both interphase and metaphase nuclei.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_905_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_905_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09218e46250357616e583b169029e95ae9d09354
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_905_en.txt
@@ -0,0 +1,7 @@
+A 65-year-old female patient (American Society of Anesthesiologists physical status II; height, 146 cm; weight, 44.2 kg) complained of an uncomfortable sensation in her back during postoperative chemotherapy for lung cancer. The only physical sign was slight focal tenderness on palpation, without evidence of inflammation. Blood test results were normal.
+The patient had a history of lung cancer, and had undergone left lower lobectomy at our hospital 2 years prior to this incident. Before the operation, ultrasound-guided TPVB was performed under general anesthesia, with the patient in a lateral decubitus position. With the aid of a portable ultrasound machine (M-Turbo®; FUJIFILM SonoSite, Inc., Bothell, WA), an 18-gauge Tuohy needle (Epidural anesthesia set; Hakko, Nagano, Japan) was inserted from the outer end of the ultrasonic linear array transducer via the fifth intercostal space. The needle was advanced in-plane with the transducer in a lateral-to-medial direction. After the needle tip had been reached into the thoracic paravertebral space, 5–10 mL of saline was injected via the needle, and expansion of the thoracic paravertebral space was confirmed by ultrasonography. A radiopaque catheter (1.0 × 950 mm polytetrafluoroethylene catheter; Hakko, Nagano, Japan) was inserted to a depth of 5 cm into the thoracic paravertebral space through the Tuohy needle. The catheter was fixed to the skin with 4-0 nylon sutures. For perioperative pain management, 0.5% ropivacaine (20 mL) was injected via the paravertebral catheter prior to the surgical procedure. At the conclusion of surgery, the patient received a bolus injection of 0.5% ropivacaine (10 mL), followed by a continuous infusion of 0.4% ropivacaine at 6 mL/h, via the paravertebral catheter. Intravenous administration of a nonsteroidal anti-inflammatory drug (NSAIDs) (flurbiprofen) and intravenous patient-controlled analgesia (iv-PCA) of morphine (bolus dose, 1 mg; lockout interval, 10 min) were used for rescue postoperative analgesia. Flurbiprofen (50 mg) was administered intravenously 1 h after surgery. A total of 18 mg of morphine was used during the 24-h period after surgery. On postoperative day one, the continuous TPVB infusion was discontinued, and the paravertebral catheter removed by the patient’s attending physician. Leakage of local anesthetic from the catheter insertion site was not observed.
+The catheter fragment was not identified on postoperative chest radiography. However, after identification of the fragment on computed tomography (CT), a radiopaque catheter fragment was retrospectively identified near the fifth thoracic vertebral body on the chest radiograph . The catheter fragment was also visible in the tissue of the back on CT . Radiologists detected the retained catheter fragment on CT a month and a half after the surgery; however, the attending physician and surgeon did not notice it until this incident.
+Two years had passed since insertion of the paravertebral catheter. The patient had neither neurological symptoms nor evidence of infection around the fragment. We considered that pancytopenia as a result of chemotherapy might increase the risk of hematoma or abscess formation around the fragment. Therefore, the catheter fragment was surgically removed. The cut side of the fragment was identified in the muscles of the back and the fragment was completely removed. Analysis of the fragment revealed that the catheter had been severed 100 mm from the tip. The catheter fragment was not stretched, and the cut surface was slightly crushed and smooth . We hypothesized that the catheter had been cut either by the Tuohy needle or the cutting edge of the needle used to fix it to the skin. The patient was in good general health and experienced no complications after surgical removal of the catheter fragment.
+Breakage or shearing of a catheter occurs rarely. Collier showed that the incidence of epidural catheter breakage is approximately 0.002% (1/60,000). There are no well-defined guidelines for the management of catheter fragments retained within the patient. Although surgical removal is recommended for patients with neurological symptoms due to a catheter fragment , leaving the fragment in place is considered acceptable in asymptomatic patients . However, neurological symptoms may develop if the retained catheter fragment causes late-onset hematoma [–]. A previous report from our hospital describes a patient with neurological symptoms related to late-onset hematoma formation around an epidural catheter fragment. The epidural catheter fragment had been in the epidural space for 18 years. In the present case, the paravertebral catheter fragment was retained in the tissue of the back for 2 years, and the patient experienced no neurological symptoms. If the catheter fragment had been left in the body, chronic inflammation might have occurred around the fragment with resultant vascular fragility. This condition, together with possible coagulopathy as a side effect of chemotherapy, might have resulted in hematoma formation around the fragment. In addition, the retained catheter fragment might have been a source of bacterial infection with resultant abscess formation, particularly if immunosuppression occurred as a result of chemotherapy. Therefore, we decided to remove the catheter fragment surgically.
+Breakage of a catheter usually occurs during insertion or removal procedures. In this case, analysis of the fragment revealed that the catheter had been severed by the cutting edge of the Tuohy needle or the suture needle. If a catheter is withdrawn during the insertion procedure, the catheter should not be withdrawn through the Tuohy needle, but be withdrawn together with the Tuohy needle . To prevent movement or removal, once the catheter is placed, it should be fixed to the skin with sutures, surgical tapes, or skin glue. Although secure fixation can be achieved with sutures, the suture needle may damage the catheter. Therefore, to reduce the risk of damage to the catheter, it is necessary to consider the method of catheter fixation. After removal of a catheter, its tip should be checked to ensure that the entire catheter has been completely removed. In this case, it is likely that the tip of the catheter was not checked after catheter removal.
+Thoracic paravertebral catheters may be inadvertently inserted into other spaces. Luyet et al. reported the position of the paravertebral catheter tip in human cadavers, inserted with ultrasound-guidance. Of the 36 catheters inserted, the catheter tip was located in the thoracic paravertebral space in 24 (66.6%), the prevertebral or mediastinal space in nine (25%), and the muscle in one (2.7%). No catheters were detected in the epidural space. In our case, the paravertebral catheter was displaced into the posterior mediastinum, and the tip was near the carina and esophagus. The ideal length of a paravertebral catheter and the ideal position of an insertion needle are unknown. Further studies are needed to determine the optimal insertion distance for a paravertebral catheter, and the optimal position of insertion needle into the thoracic paravertebral space.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_947_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_947_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..050fbbb62ac8437afbf91c129e64b1af9f21c457
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_947_en.txt
@@ -0,0 +1 @@
+A 57-year-old woman presented with intermittent gross hematuria for 2 years. She did not report any other symptoms. Physical examination indicated no abnormal findings. Blood cell counts and biochemical tests were within the reference range. Urinalysis displayed hematuria. Therefore, it was suggested that she should undergo a urinary system ultrasound examination. The kidney and ureter ultrasounds indicated no abnormal findings, whereas the bladder ultrasound revealed an avascular and homogeneous isoechoic polypoid mass with a maximum diameter of 6 mm at the right lateral wall of the bladder . She has no bladder tumors history or family history. So, the bladder of the patient was examined endoscopically and a polypoid lesion (6 mm in maximum diameter) was noted with a smooth surface, located in the right lateral wall . Subsequently, a transurethral resection (TUR) was performed and the lesion was easily removed. Microscopic examination indicated that the neoplasm was well circumscribed and composed of nests of monomorphic cells with bland nuclei and eosinophilic cytoplasm, clustered around dilated vessels. Atypia, mitoses, intravascular growth and necrosis were absent . Immunohistochemical staining revealed that the neoplastic cells reacted positively to the smooth muscle actin (SMA) and vimentin, whereas they were negative to desmin . A diagnosis of benign bladder GT was made. The patient remained asymptomatic and no recurrence was observed within a 2-year follow up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_964_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_964_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf27148d6477ef51b1df2468699b2f4c7c44c0c5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_964_en.txt
@@ -0,0 +1,2 @@
+In June 2020, a 21-year-old male was admitted to our department after 2 weeks onset of headache, mild paraparesis (right side worse than left side), tactile, and thermic hypoesthesia with a D2 level. A contrast-enhanced MRI scan of the brain and spine showed an intramedullary lesion extending from D1 to D5. The cranial portion of the tumor presented an apparently exophytic extramedullary component which extended on the right posterolateral side up to C7 . A diffuse craniospinal leptomeningeal thickening was also present . A total-body CT scan ruled out lesions outside the CNS and cerebrospinal fluid (CSF) analysis excluded infection. Corticosteroid therapy was administered with no clinical improvement. After a week, the neurological status deteriorated rapidly with paraparesis worsening and onset of hydrocephalus with headache, emesis, and lethargy. The patient, therefore, underwent external ventricular drain positioning, once again, cultural and cytologic CSF analysis was not diagnostic. A C7-D4 laminectomy was subsequently performed. Intraoperatively, the spinal cord appeared swollen and distorted, with difficult to identify the apparent exophitic nodule. The tumor was then approached with intraoperative ultrasound and functional mapping with direct electrical stimulation with a monopolar probe.[,] The procedure was interrupted due to sudden deterioration of the motor evoked potentials; then, to decompress the spinal cord, a duraplasty was completed using a dural patch and a pedicled multifidus muscle flap was performed to decrease the risk of CSF leakage.[,]
+Postoperatively, the patient showed an immediate mild worsening of the lower limbs deficit. After a few days, severe further neurological deterioration occurred with progressive motor deficit to the upper limbs and ultimately respiratory failure. Mechanical ventilation was necessary and the patient was, therefore, transferred to the Intensive Care Unit. During the following weeks, he developed tetraplegia and underwent surgery for ventriculoperitoneal shunt positioning. By the time, the histological diagnosis was available; the clinical status would not allow radiotherapy (RT) or chemotherapy (ChT). The patient deceased approximately 90 days after hospitalization due to respiratory complications.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_965_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_965_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c62208c868617e3411d371584de8b6d4134442b1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_965_en.txt
@@ -0,0 +1,3 @@
+A 52-year-old man arrived at the emergency department with a chief complaint of right-sided weakness since 3 h. He had a history of hypertension. Neurological examination revealed right-sided hemiparesis (manual muscle test grade of 3 in the right arm and 4 in the right leg; grade 0 meaning no strength, grade 5 full strength) and hypoesthesia. The National Institutes of Health Stroke Scale score was 4. His blood pressure was 166/109 mm Hg. To avoid delaying thrombolysis, we first chose non-contrast CT to exclude intracranial hemorrhage. Initial head CT revealed no intracranial hemorrhage and no early ischemic changes and an old lacunar cerebral infarction in the left putamen . The prothrombin time/international normalized ratio and the activated partial thromboplastin time were normal. Intravenous treatment with tenecteplase of 16 mg (0.25 mg/kg) was started 3.8 h after stroke onset. CTA of the head and neck was performed using 50 ml of intravenous iopamidol-370 and flow rate of 4.0 ml/s 0.5 h after IVT. The CTA showed bilateral mild to moderate atherosclerosis of the carotid and fenestration of the left proximal middle cerebral artery without any hemodynamically significant stenosis or occlusion of the carotid and major intracranial arteries . Then, he was transferred to the stroke unit for further evaluation.
+At about 1.5 h after CTA, the right-sided hemiparesis deteriorated with a manual muscle test grade of 1 in the right arm and 2 in the right leg, accompanied by drowsiness, aphasia, and urinary incontinence. Immediate head CT showed hyperdense lesions with mild space-occupying effect in the left basal ganglia and both lateral ventricles, which.
+had a mean Hounsfield unit (HU) of 55 (range from 24 HU to 79 HU) . He was transferred to our department for further treatment. The follow-up CT after 5 h showed that the hyperdensity in the left basal ganglia and lateral ventricles was reduced in size. A mild hyperdensity of the right posterior insular cortex was found . Two days later, CT showed that the hyperdense lesions in the lateral ventricles had almost completely disappeared and only a small amount remained in the basal ganglia and insular, without obvious surrounding edema and mass effect . The hyperdensity in the right posterior insular cortex remained, probably representing a mild HT . Only some scattered small petechiae could be seen in the left infarcted area on CT eight days after intravenous thrombolytic treatment . The patient was improving with physical, occupational and speech therapies during hospitalization and was eventually discharged to a rehabilitation center.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_96_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_96_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d0db23c2a9cd26d26e16992c92d3f0005f25143
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_96_en.txt
@@ -0,0 +1,2 @@
+A 64-year-old male initially presented with painless hematuria in September 2017 and was treated by a partial cystectomy as stage I BC. The patient showed local recurrence in August 2018 and underwent transurethral resection of bladder tumor (TURBT) followed by regular intravesical chemotherapy with epirubicin after TURBT. In March 2020, the patient approached to our hospital complaining about severe anorexia and fatigue. Subsequent FDG-PET/CT scan showed bladder recurrence with local invasion of the adjacent right lower ureter, resulting in the upper urinary tract dilation. Multiple lymph node metastasis, liver metastasis and lumbar metastasis (L5) were also identified . Ureteral stent placement was performed due to obstructive renal insufficiency and hepatic biopsy confirmed metastatic high-grade urothelial carcinoma with positive PD-L1 expression on 1% of the tumor cells. Then, next-generation sequencing (NGS) by a commercial laboratory (Genecast Biotechnology Co., Ltd, Jiangsu, China) identified ERBB2 p.V842I in both circulating tumor DNA (ctDNA) and biopsy sample with an allele frequency of 3.94% and 26.07%, respectively .
+The patient received one cycle of palliative reduced-dose albumin-bound paclitaxel due to elevated serum creatinine level (Scr 204μmol/L). The tumor biomarker CA199 was even higher after first cycle chemotherapy without any relief of his symptoms. Based on his NGS result, pyrotinib (400mg orally daily) was started from April 10, 2020. Within one month, his tumor markers dramatically improved with remission of clinical symptoms . Due to renal dysfunction, the patient performed FDG-PET/CT scan for treatment efficacy assessment, which showed significantly decreased FDG uptake of multiple metastatic sites in May 2020 . Even though the overall response was considered stable based on the RECIST 1.1 criteria, the decrease in FDG uptake and remission of clinical symptoms indicated the patient responded well to the HER2 targeting therapy. However, he developed G3 diarrhea and terminated the medication on May 20, 2020 (The pyrotinib treatment lasted for 40 days). The third-line treatment with the PD-1 inhibitor tislelizumab (200mg every three weeks) was next started but the disease progressed after 2 months . ctDNA was collected in August 2020 and ERBB2 p.V842I with an allele frequency of 2.06% was identified by NGS. Ureteral stent removal was performed with improved renal function. Four cycles of PD-L1 inhibitor durvalumab, oxaliplatin and gemcitabine were administered, but level of CA199 gradually increased. NGS was performed again showing the same ERBB2 mutation with an allele frequency of 1.58%. Reduced dose of pyrotinib (240mg orally daily) was added, the patient’s tumor again responded with significant improvement of CA199 within 20 days. Dynamic monitoring of the ctDNA again confirmed ERBB2 p.V842I by NGS with a lower allele frequency of 0.41% . The regimen was generally tolerated this time but the tumor marker gradually increased in this patient. PET/CT evaluation revealed disease progression in March 2021, and the treatment was then discontinued . The length of time for reduced pyrotinib therapy was 4.5 months. The patient passed away on July 1st, 2021, and the post-recurrence survival was 16 months.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_975_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_975_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1632c3db9fcd90403467ab055e26dbc920125b50
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_975_en.txt
@@ -0,0 +1,5 @@
+A 4-day-old full-term firstborn baby boy born to a 19-year-old mother was admitted to the neonatal ICU with complaints of bilious vomiting and delayed meconium passage. During clinical examination, we discovered forehead hair, eye, and right forearm discoloration. , and an erect abdominal X-ray revealed air fluid level, which is a radiological sign of intestinal obstruction, with suspected intestinal atresiawe as a periliminary diagnosis . Blood analysis revealed elevated coagulation parameters, urea and creatinine . Then started the correcting process: NG tube decompression and NPO.
+After correcting the laboratory findings, we went to Operation, believing the cause of the intestinal obstruction was intestinal atresia. We made an incision of the right supra umbilical transverse incision and externated the whole intestine and searched for the atresia site but could not find it. Instead, we found a normal caliber of intestine to the terminal ileum, where intestinal caliber diminished. We controlled the patency of the lumen and it was patent. We thought this was caused by mild malrotation. Then we checked the large bowel and it looked normal after that closed abdomen.
+For the following 8 days, we waited with the expectation of passing stool spontaneously, which unfortunately did not happen, and continued bilious drainage by NG tube. Then we did contrast clongraphy, which revealed a narrowed colon to the terminal ileum, which confirmed our suspicion of total colonic aganglionosis.
+By searching for causes of total colonic hirschsprung disease with eye, hair, and skin discoloration, we came across the syndrome called WAARDENBURG SHAH SYNDEOME (TYPE IV). Later, we discovered through a family history that the patient's mother had a variant of Waardeburge syndrome with only right eye iris hypopigmentation and her grandmother had forelok discoloration, which indicates that this disease is genetically inherited. The following day, we operated on the neonate, taking a full-thickness biopsy from the terminal ileum to the rectosigmoid junction, opening a loop ileostomy 10 cm above the where-seems transition zone, and taking a biopsy from the stoma's mouth before closing the abdomen . The pathology results revealed the presence of ganglion cells at the stoma site and an absence of ganglion cells from the terminal ileum to the rectum, which confirms total colonic Hirschsprung disease. Stoma started working on post-op day 3 and started oral feeding with a small amount and increased gradually until reaching full feeding regarding his age and being discharged. He was readmitted with.
+He was readmitted with severe dehydration due to excessive stoma output and passed away at the age of 2 months due to intractable sepsis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_98_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_98_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ff2eaa6e4092d4239ceda073974f264c3a0a1b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_98_en.txt
@@ -0,0 +1,3 @@
+A 61 year old man presented with progressive lower left abdominal pain and constipation since a few months. Colonoscopy showed a large obstructing tumour in the descending colon, and a hemicolectomy was performed. Histology showed an inflammatory reaction, possibly caused by a fungal or parasitic infection, but no definite identification of an organism was made. Postoperatively his complaints disappeared, but after a few weeks he developed abdominal discomfort in his right upper abdomen, and six weeks postoperatively a CT scan revealed a large mass with a diameter of 6 cm central in the right liver lobe. Treatment with metronidazole, directed against an amoebic liver abscess, was unsuccessful. A subsequent four-week course with fluconazole resulted in a small decrease of the liver abscess, without clinical improvement. He developed a marked eosinophilia (27.7%). A liver biopsy was performed and the patient was referred to a university hospital.
+A repeated CT scan showed a large mass with a diameter of 9 cm central in the liver, with extension to the right liver lobe . Review of the slides from the colonic mass and the liver biopsy showed similar features, with extensive necrosis and a mixed inflammatory cell infiltrate containing histiocytes, multinucleated giant cells and numerous eosinophils. In Grocott stained sections, many unusually large hyphae could be recognized which were surrounded by strongly eosinophilic material in haematoxylin and eosin stained sections (Splendore-Hoeppli phenomenon) .
+On the basis of this morphology, a presumptive diagnosis of infection with Basidiobolus spp. was made. A percutaneous cholangiodrain was placed to treat the cholestasis caused by the hepatic mass. A few days later, the patient developed a septic shock, probably of hepatic origin. Blood cultures yielded Escherichia coli and Clostridium perfringens. The patient was treated with broad-spectrum antibiotics. The presumed basidiobolomycosis was treated with amphotericin B intravenously, because the preferred therapy, intravenous itraconazole, was contra-indicated because of severe renal insufficiency. A few days after initiation of the antifungal therapy the patient died of multiple organ failure. Postmortem autopsy showed signs of extensive fungal infection of the liver , gallbladder and sigmoid colon. Culture of liver, gallbladder and sigmoid colon yielded Basidiobolus ranarum.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1414_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1414_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1d521816e59ac9091c13341bed641e923a41cb9f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1414_en_sum.txt
@@ -0,0 +1 @@
+A 19-year-old young lady presented with progressive shortness of breath, marked renal impairment, thrombocytopenia, and a highly oscillating huge right atrial mass. After she was admitted to the intensive care unit, she arrested in asystole and was resuscitated, and her electrocardiogram (ECG) showed evidence of acute anterior myocardial infarction. Urgent cardiac surgery to remove the right atrial mass was proposed by the heart team as the best option of management. Surgery was emergently performed with extra-corporeal membrane oxygenator (ECMO) as a support. Following surgery, mechanical support and vasopressors were successfully weaned and the patient achieved a good recovery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1416_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1416_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ed0f4b3d9c0aff78d873151626974d7fb9343bb5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1416_en_sum.txt
@@ -0,0 +1 @@
+A 27-year-old man presented to our hospital because of painless and progressive visual impairment of both eyes over two years. He was previously diagnosed with hypocalcemia but did not take calcium supplements regularly. He had no history of anterior neck thyroid surgery. After admission, the biochemical analysis indicated a serum calcium level of 1.21 mmol/L and an intact parathyroid hormone level of 0 pg/mL. Ocular examination revealed bilateral symmetrical opacity of the lens presenting as punctate opacity in the posterior subcapsular cortex together with radial opacity in the peripheral cortex (N1C2P3). Phacoemulsification with an intraocular lens was performed in both eyes sequentially. Postoperatively, the patient had a satisfactory recovery and greatly improved visual acuity.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1659_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1659_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3b229b583e9e4fb30e7c56c130d89f3a268e7afc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1659_en_sum.txt
@@ -0,0 +1 @@
+The medical history of a 30 year old woman diagnosed at 17 weeks gestation with an appendiceal mucinous tumor with large volume pseudomyxoma peritonei was presented. Her pregnancy was preserved and she had an early vaginal delivery of a healthy baby at 35 weeks. At 2 1/2 weeks postpartum the patient underwent extensive cytoreductive surgery and intraperitoneal chemotherapy. She remains disease-free 5 years after her initial diagnosis. A literature review of this clinical situation and a discussion of treatment plans were presented.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1730_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1730_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd70a137a4d938b47c57f3375f51d25a5cb99c1f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1730_en_sum.txt
@@ -0,0 +1 @@
+A 56-year-old HIV-positive Ugandan woman, with an undetectable HIV RNA viral load and CD4+ T-cell count of 766 cells per microlitre presented with signs and symptoms consistent with cryptococcal meningitis. Her serum and cerebrospinal fluid CrAg tests were negative despite having a positive cerebrospinal fluid India ink and quantitative culture. 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/summaries/multiclinsum_test_1904_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1904_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c30bff0219a926ced7be17f4282f8c1f46aa482
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1904_en_sum.txt
@@ -0,0 +1 @@
+We report a rare case presenting extensive penile glans and corpus spongiosum necrosis following catheter traction in a 71-year-old male patient who had a laparoscopic radical cystoprostatectomy for muscle-invasive bladder cancer. The patient has no preexisting diabetes mellitus or chronic renal failure. The case was successfully managed with penile preservation. During the procedure, it was observed that the necrosis was not limited to the glans. The necrosis had spread to the entire penile urethra and corpus spongiosum, and an excision of approximately 14 cm of corpus spongiosum was performed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1984_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1984_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..94678d0a6e0dd79f794539bcd05c2ebc7747b951
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_1984_en_sum.txt
@@ -0,0 +1 @@
+We present a case wherein a 62-year-old Japanese rheumatoid arthritis woman, with HSV uveitis, presented with hemorrhagic hypopyon in the anterior chamber and a fever with photophobia. Patient was treated with antiviral drugs which improved the hyphema and corneal lesions, but lesions recurred 3 months later. This rare presentation of HSV induced uveitis, and its subsequent recurrence, aroused suspicion of an additional hypopyon-inducing pathology. On account of previous history of lung opacities and elevated LDH, intravascular lymphoma was eventually diagnosed via lung biopsy. She was treated for the lymphoma which also completely resolved all ocular symptoms without any recurrence as of 1.5 years later.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2171_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2171_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5289b9cc6a4c22e7f90a3dec1ae8e920fb1871a3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2171_en_sum.txt
@@ -0,0 +1 @@
+We describe a 70-year-old male patient with PD, OS, and impulse control disorders, who presented with a six-month history of the delusional belief that his wife was having an affair with someone. He began to show an obvious increase in libido presenting as frequent masturbation. He had been diagnosed with PD ten years earlier and had no past psychiatric history. In his fourth year of PD, he engaged in binge eating, which lasted approximately one year. Both OS and hypersexuality were alleviated substantially after a reduction of his pramipexole dosage and a prescription of quetiapine.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2191_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2191_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..776c2e53eaae4181a4f2e032809f5ab256497868
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2191_en_sum.txt
@@ -0,0 +1 @@
+Perfluorodecaline was used as a temporary retinal tamponade. Three weeks after the surgery, a residue of heavy liquid was observed in the anterior chamber, even though the patient had an intact crystalline lens without any tilt or dislocation. The remnant of the heavy liquid was taken out of the anterior chamber immediately to avoid secondary complications.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2206_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2206_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f836c9455904cbb41407e0669832a3ec85aa5788
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2206_en_sum.txt
@@ -0,0 +1 @@
+The patient presented with acute upper abdominal pain and developed severe pyrexia and dyspnoea one day later. A chest computed tomography image revealed patchy consolidation in the left lung. The disease progressed rapidly, and the patient exhibited liver and kidney damage and type 1 respiratory failure within a short period of time. Metagenomic next-generation sequencing of alveolar lavage fluid revealed the presence of C. psittaci. The patient was administered doxycycline and moxifloxacin, after which the patient's abdominal pain and lung infection significantly resolved.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2354_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2354_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..49cd6dd3689ac0a15ff946b64a92bbbfbcba18ed
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2354_en_sum.txt
@@ -0,0 +1 @@
+A 26-year-old lady was admitted to hospital following routine echocardiography, requested for screening of pulmonary hypertension in the context of known hypersensitivity pneumonitis. This echocardiogram demonstrated severe right ventricular dilatation and impairment. She was also experiencing atrial fibrillation and non-sustained, symptomatic episodes of ventricular tachycardia. Endomyocardial biopsy revealed lymphocytic myocarditis. She was managed with azathioprine and prednisone, as well as sotalol and apixaban for her atrial fibrillation, and has had no complications in the 12 months since discharge.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2534_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2534_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..be5a3b036d4f20757ab41285abc144d9b16d31b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2534_en_sum.txt
@@ -0,0 +1 @@
+We hereby report a case of combined afibrinogenemia and congenital antithrombin deficiency manifested by recurrent life-threatening bleeding, as well as spontaneous severe arterial occlusion, such as acute coronary syndrome and stroke, and venous thromboses like pulmonary embolism.Secondary fibrinogen prophylaxis is recommended following any initial life-threatening bleeding episode in patients with afibrinogenemia, yet the high associated risk of thrombosis illustrates the complexity of choosing the most effective prophylaxis strategy combining fibrinogen concentrate with antithrombotic agent for optimal protection against the risk of both severe bleeding and thrombosis. For our patient, the thrombin generation assay objectively confirmed her prothrombotic tendency.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2786_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2786_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..de596181fba3f5529c35f3ca87df837317269b52
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2786_en_sum.txt
@@ -0,0 +1 @@
+A 27-year-old woman presented with a 6-year history of progressively worsening shortness of breath and chest tightness on exertion. She had cyanotic lips and clubbing of the fingers. A transthoracic echocardiogram revealed an enlarged heart and dilation of the main pulmonary artery. There was an abnormal 9 mm passage between the descending aorta and pulmonary artery. The ventricular septal outflow tract had a 14 mm defect. Doppler ultrasound suggested a patent ductus arteriosus and computed tomographic angiography showed the absence of the aortic arch. The diagnoses were ventricular septal defect, patent ductus arteriosus, and definite interruption of the aortic arch. Although surgical correction was recommended, the patient declined due to the surgical risks and was treated with medications to reduce pulmonary artery pressure and treat heart failure. Her condition has been stable for 12 mo of follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2831_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2831_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f9e07240753b8f58ceb0b81ad2e4b80e62506b2b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_2831_en_sum.txt
@@ -0,0 +1 @@
+We present a case of CRBSI caused by Mycobacterium wolinskyi, a rare RGM, in a 44-year-old female patient who received an umbilical cord blood transplant.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3087_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3087_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b94bbd7b2ea3a1c60b39170a7458942be7cb586b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3087_en_sum.txt
@@ -0,0 +1 @@
+A 6-year-old boy with newly onset psoriasis developed PHS with renal involvement, clinically manifested by nephrotic proteinuria and haematuria. A renal biopsy revealed glomerular fibrocellular crescents and mesangial deposits of IgA consistent with IgA nephropathy. Treatment with systemic corticosteroids led to control of haematuria, but as the nephrotic proteinuria persisted, cyclophosphamide was added, leading to a gradual decrease of proteinuria.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_31_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_31_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..152a75e319b8e28203372b92a28160cc5ef5f68a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_31_en_sum.txt
@@ -0,0 +1 @@
+This case involved a lesion compressing the origin of the external popliteal sciatic nerve of a 13-year-old Moroccan boy diagnosed with a neurofibroma. He developed functional impairment of his left lower limb during a football game, and examination revealed a steppage gait. The initial diagnosis was stretching of the peroneal nerve. The definitive diagnosis of a neurofibroma was revealed by imaging and confirmed by surgery and pathology. Treatment involved total removal of the tumor; however, our patient's steppage gait persisted.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3209_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3209_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a58e743927470ef88e86efa92e766064f46ae32
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3209_en_sum.txt
@@ -0,0 +1 @@
+5-year-old girl with a family history of HD and typical development until 3 years of age. She progressively presented language impairment with decreased age-appropriate expressive and receptive language skills, without impairment of pragmatic and social skills. Motor skills, gait and standing were unstable, and she showed rigidity, dystonia and choreic movements. She presented atrophy of the lenticular and caudate nuclei in the MRI, and later molecular diagnosis was performed with the expansion of CAG triplets (51 copies).
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3242_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3242_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fecc0436afd71e17fa033b2325544c8037611f73
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3242_en_sum.txt
@@ -0,0 +1 @@
+We present the case of a 66-year-old patient with a pulmonary nodule found during the oncological staging for prostate adenocarcinoma who underwent an anatomical pulmonary segmentectomy. The final pathological anatomy result was a perivascular epithelioid cell tumor (pulmonary PEComa or "sugar" clear cell tumor).
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3253_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3253_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..390fd4fca0b9fc9f0040ee25da67b01d1bd55a1a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3253_en_sum.txt
@@ -0,0 +1 @@
+Here, we present a case diagnosed with congenital hydrometrocolpos at 39 weeks of gestation during routine third-trimester ultrasound scanning. The newborn was delivered vaginally and huge hydrometrocolpos secondary to imperforate hymen was diagnosed postnatally, and a hymenectomy was done and the newborn was discharged and improved from the hospital.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3350_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3350_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9a8f601e2809ccbdf58726b50c4369d8ae852e7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3350_en_sum.txt
@@ -0,0 +1 @@
+We report the case of a 51-year-old male with a history of tuberculosis 11 years prior, who presented with left testicular pain, swelling, and an ulcer. Initial ultrasound findings suggested were unclear and only the histopathological examination ultimately confirmed a diagnosis of testicular tuberculosis. The patient was treated with complete clinical resolution.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3380_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3380_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0786923a1135ba06851a4f3e29b500c09d240f5d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3380_en_sum.txt
@@ -0,0 +1 @@
+A biopsy of a breast mass in a 60-year-old Caucasian man showed a morphologic-immunophenotypic profile with features characteristic of an ALK-positive (AKT+), anaplastic large cell lymphoma. Fluorescence in situ hybridization (FISH) analysis of fixed, paraffin-embedded tissue of this lesion was performed at our institution for IRF4/DUSP22 gene rearrangement. No rearrangement was detected. The patient presented with mutations in the following genes; BCOR_p.Q600X, DNMT3A_p.F609fs, NOTCH1_p.P2320fs, and IDH2_p.R140Q. However, the patient's consultation was complicated by the fact that he had been diagnosed with breast cancer at a local hospital and had come to our institution for further consultation. The histology findings were confirmed by immunohistochemistry and FISH. Computed tomography and positron emission tomography did not reveal nodules elsewhere in the body, which allowed the staging of the patient to be completed. However, although the patient had previously received the chemotherapy CCOP regimen (ie, cyclophosphamide, vincristine, prednisolone acetate) he did not go into remission in a timely manner and relapsed after six months, followed by a drastic deterioration in his condition after four months, resulting in his death in less than one month.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3395_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3395_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..48a9271db9f2b237318b7fbd594d76285153bfdf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_3395_en_sum.txt
@@ -0,0 +1 @@
+A 75-year-old man with body mass index of 30.5 kg/m2 and severe obstructive sleep apnea (OSA) with an apnea-hypopnea index (AHI) of 72 events/h was referred for upper airway stimulation (UAS) therapy. 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%. Following evaluation of clinical and polysomnographic data, he was an appropriate candidate for UAS and underwent uncomplicated implantation. Three months postoperatively, polysomnography showed a titrated AHI of 0 events/h. Follow-up cardiac evaluation revealed ejection fraction increase to 47% since implantation. No interval change in medical management or body mass index had occurred.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_50_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_50_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b275cc5587ec765c391a13c36fa601e8594ad65e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_50_en_sum.txt
@@ -0,0 +1 @@
+We present the case of a 32-year-old, 180 cm tall Caucasian woman with a predicted difficult airway who presented to our facility for an emergency cesarean section. After several failed intubation attempts via direct laryngoscopy, an airway was established with a laryngeal mask airway. After delivery of a healthy baby, our patient's condition necessitated tracheal intubation. A fiber-optic bronchoscope loaded with an Aintree intubating catheter (Cook® Medical Inc., Bloomington, IN, USA) was passed through the laryngeal mask airway into the trachea until just above the carina, but was too short to safely allow for the passage of an endotracheal tube.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_651_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_651_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8d3696c7f275a542ece32cf947445dfbde38579b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_651_en_sum.txt
@@ -0,0 +1 @@
+We recently reported the first case of acute lymphoblastic leukemia (ALL) from Egypt in a child with βTM, and we herein report the first case of ALL from Egypt in a child with βTI. In this report, literature was reviewed for cases of malignancies associated with βTI and the possible factors underling the relationship between the two entities.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_688_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_688_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18481f110d202cbfdcc98a219f6ab59f5d0ecef5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_688_en_sum.txt
@@ -0,0 +1 @@
+We report the case of a 48-year-old male who presented with cough, dyspnea, a history of recurrent pneumonitis, and therapy-refractory ulcerative colitis that completely subsided after the resection of a pulmonary carcinoid.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_831_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_831_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6fcbc42421758b6b02a53efa0b2fc60aa41535f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_831_en_sum.txt
@@ -0,0 +1 @@
+This report describes an atypical two-step spontaneous rupture of an asymptomatic parathyroid adenoma in a 56-year-old Caucasian woman who presented with a painful mass in the right side of her neck.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_860_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_860_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4bbbe6cd8af6977db1af806c21fd9b8a4dad49cf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_860_en_sum.txt
@@ -0,0 +1 @@
+The patient presented diffuse cutaneous erythematous plaques and nodules throughout the body. Skin lesions were biopsied and histopathological examination showed diffuse monomorphic lymphocyte infiltration in the dermal and subcutaneous layers, sparing the epidermis. Immunohistochemical staining revealed CD20, cyclin-D1, CD5, and SOX-11 expression. Fluorescence in situ hybridization showed CCND1/IGH gene rearrangement. Correct diagnosis of primary cutaneous MCL requires ensuring that no other parts are involved; these cases require close follow-up to monitor their possible progression to systemic disease and for treating relapsed cutaneous disease. In this case, positron emission tomography scanning and clinical staging revealed no systemic involvement, and follow-up examination at 20 mo after diagnosis showed no evidence of systemic disease. The prognosis of primary cutaneous MCL is relatively good. Our patient received six cycles of chemotherapy, and the cutaneous manifestations presented almost complete remission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_870_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_870_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ffd1bf1994c61f3fd833eae68c08be2d8a8b52f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_870_en_sum.txt
@@ -0,0 +1 @@
+This is a case report of a patient with a giant lipofibromatosis on the back that resembles an infantile hemangioma, which posed great difficulty in diagnosis due to atypical clinical manifestations. After the postoperative pathological and immunohistochemical examination and fluorescence in situ hybridization, the patient was finally diagnosed with lipofibromatosis.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_878_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_878_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5c9bf675579945e3439be0093412b1c05740f3e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_878_en_sum.txt
@@ -0,0 +1 @@
+A 73-year-old woman with dyspnea on exertion had a giant cyst (12 × 10 cm in diameter) on preoperative computed tomography. Compression of the left atrium and ventricle by the cyst was considered to be the cause of her symptoms. The cyst was diagnosed with an epicardial cyst intraoperatively. Although the cyst adhered to surrounding tissues, it was successfully resected with off-pump surgery by using a heart positioner and an ultrasonic scalpel.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_891_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_891_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..17cc7c34c5c487689bd483b5ee1aa5c231720617
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_891_en_sum.txt
@@ -0,0 +1 @@
+A 91-year-old Thai woman had undergone pterygium excision 26 years ago, with adjunctive mitomycin C, as well as an uneventful extracapsular cataract extraction in the same year. The patient developed a filtering bleb without glaucoma surgery or trauma approximately 25 years later. Anterior segment ocular coherence tomography illustrated a fistula connected between the bleb and anterior chamber at the scleral spur. The bleb was observed without further management, as no hypotony or bleb-related complications occurred. The symptoms/signs of bleb-related infection were advised.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_948_en_sum.txt b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_948_en_sum.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0f423ca10fc0bcec647adac4b14dec3cc27ee954
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/summaries/multiclinsum_test_948_en_sum.txt
@@ -0,0 +1 @@
+A 20-year-old woman presented with reduced vision (20/100) in her left eye (LE). Based on a complete ophthalmologic examination the patient was diagnosed with ASs and coincident MEWDS. Two weeks later best-corrected visual acuity (BCVA) improved up to 20/25 and the MEWDS findings almost disappeared. Two months later BCVA dropped again (20/100) due to the development of CNV which was treated by a single intravitreal injection of ranibizumab (0.5 mg/0.05 mL). One month after this BCVA improved up to 20/40, and there was regression of the CNV. There was no need for retreatment at the last follow-up visit, 1 year after the ranibizumab injection, when the patient showed further recovery of BCVA up to 20/25.
\ No newline at end of file