diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1003_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1003_en.txt
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index 0000000000000000000000000000000000000000..fd421feb3ba7639d919515468ed3f8153905327e
--- /dev/null
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+In this report, we present a 26-year-old male with a past medical history of Behcet's disease who developed progressive vision loss and severe hypotonia. He had received 15 mg of methotrexate weekly and 7.5 mg of prednisolone daily as well as multiple injections of subtenon triamcinolone acetonide (TA; 40 mg). He had also undergone phacoemulsification and posterior chamber intraocular lens placement for cataract in his both eyes. Pars plana vitrectomy with silicone oil injection was performed in his right eye for hypotony. Visual acuity was 20/400 in his right eye and “hand motion” in his left eye. Ocular hypotony persisted despite all these treatments in the absence of active inflammation. Corneal folds and band keratopathy were noted after few weeks. Fundus was poorly visible but it was remarkable for cystic changes in the macular region. B-scan showed a significant serous choroidal detachment due to severe hypotony in both eyes. To increase the IOP, multiple injections of 40 mg of subtenon and 4 mg of intravitreal TA were administered; however, no improvement was observed in vision, IOP status, and serous choroidal detachment. Visual acuity deteriorated because of persistent hypotony maculopathy. Ibopamine (a dopamine agonist) eye drops were used for three months with an increase in IOP of 2 mm Hg in both the eyes, but no change in vision was detected.
+We discussed the details of our experimental treatment based on published studies with the patient and proceeded with the treatment after obtaining a written consent. Subsequently, high-dose latanoprost eye drops (XALATAN, 0.005%, Pfizer) were administered every 6 hours in both eyes.
+One month later, IOP increased to 4 mm Hg, and at two months, to 7 mm Hg. After two months of latanoprost treatment, we performed a drug rechallenge test by discontinuing latanoprost for four weeks and then resuming the drug to prove its effect on IOP. After 6 months, IOP was stable at 7 mm Hg and remained unchanged even after 24 months. B-scan showed significant improvement in hypotony maculopathy and fluid resolved subretinally . The patient's vision improved to 20/200 in his right eye and “finger counting” at 1.5 m in his left eye.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1008_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1008_en.txt
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index 0000000000000000000000000000000000000000..ebdead8d02b5fb239c7b8174158b326eba82ebab
--- /dev/null
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+A 46-year-old male was brought to the emergency department (ED) with complaints of two weeks of cough, fever, generalized myalgias, sore throat, with progressively worsening of shortness of breath, and night sweats. He was initially treated with amoxicillin-clavulanate for pneumonia for seven days as prescribed by his primary care physician. On day eight he began to have tremors without fevers, which resulted in difficulty ambulating. He denied any nausea, vomiting, diarrhea, constipation, chest or abdominal pain. He had no other relevant medical history, denied taking any other medications, and denied history of alcohol use. Before going into self-quarantine he noted that some of his co-workers were having flu-like symptoms but he was unaware whether they had been tested for COVID-19.
+On physical examination in the ED his vital signs were blood pressure 130/87 millimeters of mercury, temperature 36.6° Celsius (97.9° Fahrenheit), pulse rate 108 beats per minute, respiratory rate 22 breaths per minute, and oxygenating at 96% on room air. On respiratory exam, he had clear and equal breath sounds bilaterally. Neurologic exam revealed intact mental status that was oriented to self, date, and place. He had no dysarthria, aphasia, or neglect. His cranial nerves exam was significant for saccadic intrusions with smooth pursuit. A generalized tremor was noted when the patient was lying down, which worsened with movement, and there was a postural tremor in all extremities. Heel-to-shin exam was non-dystaxic although tremulous, and there was a bilateral intention tremor. On motor exam, he had normal tone and five out of five strength of all muscle groups in the upper and lower extremities. He was noted to have a wide-based gait with unsteadiness, but there was no dysmetria, pronator drift or truncal ataxia. His sensation was intact to light touch. No other abnormalities were noted on physical exam.
+In the ED he was evaluated by neurology due to the constant tremors. Computed tomography (CT) of the head and CT angiogram did not reveal any significant findings, toxicology report came back negative, and thyroid-stimulating hormone, thiamine, and folate levels were normal. Chest radiograph showed clear lungs without any focal consolidation. Magnetic resonance imaging (MRI) done during his hospital stay showed hyperintense foci in the bifrontal subcortical and deep white matter on scattered T2-weighted, fluid-attenuated inversion recovery. These findings likely represent sequalae of microangiopathic ischemic changes. His hospital course was uncomplicated, and respiratory status improved with supportive measures. Final impression by neurology was that these were essential tremors, and the decision was made to treat with propranolol from which patient reported some mild improvement of symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1022_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1022_en.txt
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index 0000000000000000000000000000000000000000..6f7c506cb0f6c2436de4bd01ef7f823e99afe9dd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1022_en.txt
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+An 82-year-old lady was referred to gynaecology outpatients in June 2007 with a one month history of post menopausal bleeding. Her past gynaecological history included a negative hysteroscopy in 1998, and previous use of hormone replacement therapy. She had previously given birth to two children. The patient was fit and well, with no significant past medical history apart from hypertension for which she took bendroflumethiazide and atenolol.
+Physical examination revealed a bulky uterus with no adnexal masses. A pipelle biopsy demonstrated only tiny fragments of blood clot. A subsequent transvaginal ultrasound scan showed a large endometrial mass with calcification . The ovaries appeared normal. She underwent a hysteroscopy in July 2007 when a 6 cm uterine fibrotic polyp, which filled the uterine cavity, was removed.
+Microscopy demonstrated polypoid tissue with a variably cellular and fibrotic stroma, focal adipose and possible chondroid metaplasia, but no malignant features. The glands showed focal mucinous and keratinising sqaumous epithelial metaplasia. There was focal nuclear atypia, focal mitotic activity and occasional cribriform gland fusion. These features were in keeping with either atypical complex hyperplasia within an endometrial polyp associated with metaplastic changes, or a polypoid uterine teratoma.
+Immunohistochemistry showed positive staining of the small crowded epithelium for the epithelial marker cytokeratin (CK)-7 and the thyroid and lung marker TTFI. There was positive staining of the chondroid area for S100 protein, focal staining of dilated gland epithelium and stromal cells for oestrogen receptor and progesterone receptor, and staining of stromal cells for smooth muscle α-actin (SMA). Thyroglobulin, desmin, CK20 and CDX2 staining was negative. A diagnosis of benign teratoma with thyroid gland and cartilaginous elements was therefore made.
+Following hysteroscopy, the bleeding continued. A repeat ultrasound scan revealed that the teratoma had grown back almost completely filling the uterine cavity. A magnetic resonance imaging (MRI) scan in November 2007 showed the tumour filling and distending the endometrial cavity and extending down into the cervix . There was evidence of posterior wall myometrial invasion but there was no lymphadenopathy and the ovaries appeared normal. Tumour markers including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA) and Ca19-9 were within normal limits. Serum Ca125 was slightly elevated at 42 U/ml (normal range 0–35 units (U)/ml) and lactate dehydrogenase (LDH) raised at 372 IU/L (normal range 125–250 U/ml).
+The patient proceeded to a total abdominal hysterectomy and bilateral salpingo-oophorectmy in December 2007. At operation, the uterus was found to contain a haemorrhagic polypoid tumour (110 × 80 × 70 mm) arising from the posterior aspect of the endometrial cavity . Uterine size was equivalent to that of a 12-week gestation uterus.
+Microscopically the tumour was a teratoma containing mature and immature elements with mixed malignant transformation . The tissue types found included squamous and glandular epithelium, thyroid parenchyma, smooth muscle, connective and adipose tissue. In addition there were areas of immature bone, invasive adenocarcinoma, and papillary thyroid carcinoma. There was extensive lymphovascular invasion and deep myometrial, but not serosal, involvement. The omentum, cervix, fallopian tubes and ovaries were free of tumour. Immunohistochemistry showed that the malignant epithelial components were positive for CK-7 and TTF-1, but negative for CK20 and thyroglobulin. One area of the tumour stained positive for desmin but not for SMA, S100 or CD10, suggesting that this is likely to be a small focus of myogenic sarcoma.
+The histopathological conclusion was of a poorly differentiated adenocarcinoma and a focal myogenic sarcoma arising in a polypoid uterine teratoma with mature and immature elements. A post-operative computer tomography (CT) scan of the thorax, abdomen and pelvis found no evidence of distant disease giving an overall International Federation of Gynaecology and Obstetrics disease stage 1C.
+The patient recovered well from surgery and was referred for oncological follow up. Given her age and performance status a surveillance approach was taken with regular clinical examinations, serial tumour markers and routine CT scans. Initially in remission, six months post-operatively para-aortic lymphadenopathy was detected on CT although she remained asymptomatic with an Eastern Cooperative Oncology Group (ECOG) performance status of 0. In view of her age and wishes for a treatment with acceptable toxicity, the patient was commenced on an initial dose of cisplatin (20 mg/m2) and etoposide (100 mg/m2). This was well tolerated so one week later treatment was continued with a fortnightly alternating regimen of paclitaxel (135 mg/m2) and etoposide (150 mg/m2), followed by paciltaxel (135 mg/m2) and cisplatin (60 mg/m2). This treatment was chosen based on our experience of its effectiveness and tolerability in the treatment of relapsed germ cell tumours and gestational trophoblastic disease [,].
+After three cycles of chemotherapy there was a reduction in the size of the para-aortic mass, but an increase in the cystic component suggesting possible differentiation towards a mature teratoma. Consequently she underwent a retro-peritoneal lymph node dissection in October 2008. Histology from this confirmed the presence of metastatic teratoma. Unfortunately she had a turbulent post-operative course and, although she recovered well enough to return home a month later, she sadly died shortly thereafter.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1034_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1034_en.txt
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index 0000000000000000000000000000000000000000..523bdcbf575658379e14ef5a1815e50ca872542a
--- /dev/null
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+A 40-year-old African American female presented in 2014 with complaints of a right neck mass that was first appreciated 9 months earlier. The appearance of the neck mass coincided with a constellation of symptoms: frequent severe headaches, periods of lightheadedness, vertigo and tinnitus, hoarseness, dysphagia, blurred vision and tearing of the right eye. On physical examination, a non-pulsatile, non-tender mass was palpated, deep to the right sternocleidomastoid muscle. The patient underwent CT neck imaging, which revealed a 6.1 × 4.0 × 4.1 cm right neck mass extending to the base of the skull and encompassing the internal and external carotid artery . Upon further evaluation, the tumor was felt to be a Shamblin II lesion because there was some carotid arterial attachment, but the tumor did not entirely encase the carotid arteries, so the tumor was deemed as reasonable for resection. A cerebral arteriogram showed no intracranial arterial vascular abnormality, so an extracranial embolization was performed. Transcervical resection of the right carotid body tumor was performed the following day, and pathology showed a paraganglioma measuring 4.9 cm with areas of infarct and multiple vessels with intravascular thrombi, consistent with prior embolization procedure. The transcervical resection of the right carotid body paraganglioma was a gross total resection, but a microscopic surgical margin assessment on the surgical pathology was not performed. Following surgery, the patient continued to remain symptomatic with headaches, right neck and ear soreness, Horner’s syndrome symptoms, and right vocal cord paralysis. She received right vocal fold injection medialization. Over time, the patient reported improvement in most of her symptoms.
+The patient was routinely followed in office and via imaging. MRI in 2017 showed a small mass measuring about 1 cm in the vicinity of the carotid bifurcation, but it was unclear if this was recurrent disease, so the decision was made to continue to observe the mass. In 2018, a subsequent MRI showed interval enlargement of the mass from 1.4 × 1 × 1.2 cm to 2.5 × 1.7 × 2.4 cm. Due to the disease progression, the patient received Stereotactic Body Radiation Therapy of 25 Gy in 5 fractions to the presumed recurrent right paraganglioma in 2018. For the next two years, the patient’s imaging and clinical symptoms remained stable. In 2021, the patient re-presented with six months of new onset thoracic radiculopathy and weight loss, and one month of progressive bilateral lower extremity weakness, dysmetria, and paresthesias and numbness from the umbilicus down. Upon physical examination, the patient's strength was 4 + /5 in her bilateral lower extremities, she had decreased sensation to light touch and pin-prick from her naval to her distal bilateral lower extremities, she had intact sensation to light perineal touch, her bilateral patellar reflexes were 2 + , and her bilateral ankle reflexes had single beat clonus. She had a mildly ataxic gait with dysmetria on heel to toe walk and heel walk. While her finger to nose testing was intact, her heel to shin testing revealed dysmetria. During rectal examination, the patient demonstrated brisk voluntary anal contraction. MRI of the T spine showed a spinal mass arising from the posterior elements at T6-T7 with at least Bilsky grade 2 posterior to anterior cord compression as well as a mass in the T11 vertebral body . This compressive pathology localized to the patient’s acute symptoms, and it was determined that she would require surgical intervention. She underwent T6-T7 laminectomy, T5-T7 tumor resection, and T5-T9 posterior fixation in 2021 with pathology showing metastatic paraganglioma . She subsequently completed radiation therapy of 30 Gy in 10 fractions to the thoracic spine from T4 to T11 to encompass both the surgical field as well as the T11 metastasis in 2021.
+Following completion of radiation therapy to the thoracic spine, restaging DOTATATE PET in mid-2021 showed multifocal uptake in the right carotid body surgical bed as well as uptake in T4, T11, and the right iliac. Genetic evaluation showed no evidence of pathogenic mutations. The patient was evaluated for 131Iodine-Iobenguane but she was not felt to be a candidate. The patient was started on systemic therapy with sunitinib complicated by mucositis. The patient’s sunitinib dose was decreased to help alleviate the mucositis. Interval DOTATATE PET in late 2021 showed decreased size and uptake of the right neck masses and osseous metastases consistent with treatment response. The patient reported 2–3 months of dull, burning right hip pain. An MRI was obtained showing a well marginated lesion within the right iliac bone in the area of PET avidity consistent with metastatic disease. The right iliac lesion was treated with 8 Gy of radiation therapy in a single fraction for right hip pain attributed to bony metastatic disease. DOTATATE PET in mid 2022 showed two areas of focal uptake in the right carotid body surgical bed, small volume mild uptake in the C5 and T11 vertebral bodies and the right iliac, and a left adrenal nodule without PET uptake. Therefore, the patient’s systemic therapy was switched to capecitabine and temozolomide. At the time of her last follow up in 2022—a total of 13 months since completing thoracic spinal surgery and radiotherapy and 4 months since completing palliative right hip radiotherapy—the patient was ambulatory, her previously reported neurologic deficits had resolved, and she had no right hip pain. Upon physical examination at last follow up, the patient's strength was 5/5 throughout, her sensation was normal to light touch, and her reflexes were 2 + throughout. She ambulated independently with intact heel to toe walking, heel walking, and toe walking.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1039_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1039_en.txt
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index 0000000000000000000000000000000000000000..f15f69576bb916e136e718c1b607fed8512c64ca
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+A 31-year-old woman, gravidity three, parity zero, was admitted because of a suspected intramural pregnancy after IVF-ET.
+The patient was completely asymptomatic. She had regular menstruation, a moderate amount of menstruation and no dysmenorrhea. Her last menstrual period was November 17, 2020. The endometrium was prepared using hormone replacement therapy following 1.875 mg of subcutaneous gonadotropin-releasing hormone agonist (Leuprorelin Acetate, Livzon Pharmaceuticals, China) on day 3 of the menstrual cycle. In addition, 90 mg of vaginal progesterone (Crinone, Merck Serono, United Kingdom) once a day and 10 mg of dydrogesterone three times daily were administered (P + 0). A frozen day 6 embryo which had undergone preimplantation genetic screening was transferred on the 7th day of progesterone exposure (P + 6) under sonographic guidance.
+She received laparoscopic salpingotomy in 2014 due to a right tubal pregnancy. She had suffered secondary infertility since December 2015 and her hysterosalpingography results showed an obstruction in the right fallopian tube and adhesion of the distal end of the left fallopian tube in June 2016. As spontaneous pregnancy did not subsequently occur, she was referred to the reproductive center of our hospital for IVF-ET in June 2018. The patient underwent laparoscopic bilateral salpingectomy for bilateral tubal pregnancy after two frozen day 3 embryos were transferred in December 2018. Of the other three frozen-thawed embryo transfer cycles, a total of 5 embryos were transferred, but pregnancy was not achieved. In addition, the patient had a history of hysteroscopy three times to remove endometrial polyps and separate uterine adhesions.
+Her personal history and family history were unremarkable.
+The patient’s vital signs were normal. Physical examination revealed a 7-week sized uterus with no tenderness and no abnormalities in the uterine cervix and abdomen. There was no vaginal bleeding or fluid.
+At day 14 after ET, her serum β-human chorionic gonadotropin (β-hCG) level was 111.54 mIU/mL and then increased from 290 mIU/mL to 1759 mIU/mL. On day 32 after ET, her serum β-hCG level was 3819 mIU/mL.
+A transvaginal ultrasound examination revealed a suspected intramural pregnancy. When admitted on day 33 after ET, three-dimensional transvaginal ultrasound indicated a heterogeneous echogenic area measuring 1.40 cm × 1.26 cm in size arising from the uterine fundus which had a 0.48 cm × 0.37 cm anechoic region inside and was surrounded by myometrium . Color Doppler ultrasound showed abundant blood flow. This region seemed to have a slender and extremely hypoechoic area stretching to the uterine cavity . In addition, a hypoechoic structure with an indistinct boundary measuring 2.74 cm × 1.61 cm in size was observed in the anterior myometrium near the uterine fundus, which was thought to be a uterine adenomyoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1047_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1047_en.txt
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index 0000000000000000000000000000000000000000..6eef107e4eedef821aa91f40a560ef35891ac800
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1047_en.txt
@@ -0,0 +1,7 @@
+The proband (II-2 in Fig. ) is a 45-year old woman, who first presented to our university hospital at the age of 35 and was referred to us because of her pregnancy. She has congenital deafness, first experienced syncope at the age of 3, and was diagnosed with epilepsy. She was treated with anti-epilepsy medications; however, she subsequently experienced several instances of syncope. At the age of 13, she had a syncope event, and was suspected of having JLNS because of her congenital deafness and prolonged QT interval. Her syncope was diagnosed as an arrhythmic episode when she was aware of tachycardia and as epilepsy when she was not. She also had a subarachnoid hemorrhage at the age of 29.
+When she first presented at our hospital, she was not taking beta-blockers, because of a history of asthma, but was taking mexiletine in addition to phenytoin. Her QTc was found to be prolonged (584 ms) at presentation and administration of atenolol was initiated. She delivered her baby (III-1 in Fig. ) through Caesarean operation at our hospital at the age of 35. At 37, she delivered her second baby (III-2 in Fig. ) through Caesarean operation at our hospital. Despite administration of beta-blockers, her QTc remained prolonged (600 msec at the age of 37, 780 msec at 44) , which is not unexpected because treatment with beta-blockers in LQTS1 is not expected to overtly reduce QTc . However, she continued to experience occasional syncope and finally underwent an implantable cardioverter defibrillator (ICD) operation at 38 years of age. Subsequently, she is in a stable clinical condition. Because the proband was suspected of JLNS and both infants had a measured QTc of 500 ms or greater within 1 month after birth, beta blockers were initiated and both children remain in stable condition at ages 10 and 8 . QTc of the son (III-1 in Fig. ) was measured as 500 ms one month after birth, while the QTc of his sister (III-2) was 530 ms at birth.
+The father (I-1) and mother (I-2) of the proband were first cousins. There is no history of sudden unexplained syncope or death of children or adults in the immediate family members, despite the prolonged QTc of the children.
+Clinical evaluation and consultation of the proband and her family members were performed at Chiba University Hospital. Clinical phenotypes were deduced from the clinical history, physical examinations, and ECG. Blood samples were collected from the proband and her family members following genetic counseling, and written informed consent was obtained prior to sample collection.
+Genomic DNA was isolated from peripheral blood lymphocytes according to established protocols at our laboratory . Entire coding exons, including the intronic boundaries of the genes, of KCNQ1 (NCBI ref: NM_000218) and other LQT causative genes (KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, SCN4B, KCNJ5) were amplified by polymerase chain reaction (PCR), according to established protocols in our laboratory. Briefly, 30–100 ng of genomic DNA was subjected to PCR amplification with DNA polymerase (PrimeSTAR GXL DNA Polymerase; Takara Bio Inc., Kusatsu, Japan) and primer sets.
+The amplicons were subjected to conventional sequencing with Sanger sequencers (Applied Biosystems 3730/3130 DNA analyzers; Thermo Fisher Scientific, Waltham, MA, USA). The sequence data were processed with Gene Codes Sequencher Software (Takara Bio Inc.) and mapped to the human genome sequence (build GRCh37/hg19).
+Genetic analysis was performed to screen all coding exons and the exon–intron boundaries of the KCNQ1 gene (NCBI ref: NM_000218.2, NP_000209.2) with concurrent screening of other LQT causative genes (KCNH2, SCN5A, KCNE1, KCNE2, KCNJ2, SCN4B, KCNJ5). We detected a novel homozygous nonsense variant, NM_000218.2:c.115G > T (p.Glu39X, in exon 1a), in the KCNQ1 gene of the proband, as well as a homozygous common variant (NM_000218.2:c.1343C > G, p.Pro448Arg) (Additional file : Table S1). Genetic screening of her mother (I-2) and children (III-1 and III-2) revealed that they were heterozygous for the nonsense variant . Her husband (II-3) was also screened and found to be heterozygous for the common variant (NM_000218.2:c.1343C > G, p.Pro448Arg). The proband is a child from a first-cousin marriage, and we have concluded the homozygous nonsense variant in the proband is the cause of her JLNS1. The proband was negative for pathogenic variants in other LQT causative genes, including the KCNE1 gene (Additional file : Table S1).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1055_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1055_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8ae19f580e5bc86c182fa656f3bd1dd9b12024e8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1055_en.txt
@@ -0,0 +1,6 @@
+A 82-year old lady presented to the Department of General Surgery at the University of Heidelberg, Germany with recurrent attacks of hypoglycemia and a large abdominal mass. While diagnostic tests repeatedly documented glucose levels below 40 mg/dl (normal levels 80 – 120 mg/dl), a computed tomography (CT) scan of the abdomen revealed a large lesion of around 5 to 6 cm in relation to the pancreatic body and tail. There were also large masses of about 3–5 cm in the retroperitoneum and in the area of the celiac trunk and around the mesenteric artery. Furthermore, in the pancreatic body there was a hypervascularized area , that was suspicious for an insulinoma. Clinically this lady, who was not thriving, reported a weight loss of 12 kilograms over the previous 4 months. A somatostatin receptor scintigraphy showed an enhanced uptake in the region of the pancreatic body/tail as well as in the right axilla (a palpable mass was also noted there) and excluded the possibility of other involved areas.
+She gave a past history of an operation done on the right eyebrow 2 years prior for a 0.8 × 0.8 cm lesion that was reported as a Merkel cell carcinoma. Histopathology showed rather uniform tumor cells in a trabecular growth pattern with monomorphous pale-stained nuclei and many mitoses . There was invasion of dermal lymphatics and blood vessels . Immunohistochemistry revealed strong positivity for cytokeratin 20 and neurofilament (not shown) in the characteristic dot-like pattern and a weak expression of chromogranin A . After excision, radiation therapy was also administered only at the site of the primary lesion, the draining lymphatic vessels and the first lymph node station. A year later, a large abdominal mass was noted of uncertain origin and an ultrasound guided biopsy showed an unspecified small cell cancer. In view of the large mass with additional suspicious areas being noted in the spleen, left adrenal gland and axilla, she had been subjected to palliative radiotherapy of 30 Gray over 2 months. However no definitive diagnosis of metastasis in these areas was established. With a working clinical diagnosis of symptomatic insulinoma not responding to medical measures, a decision for surgical resection of this large lesion was inevitable, the age of the patient and the previous history of palliative radiation just 6 months prior notwithstanding.
+Surgical exploration revealed a large mass of about 5 cm in the tail of the pancreas, in close proximity to the spleen and the splenic flexure of the transverse colon. However there was no evidence of any metastatic disease to the liver, peritoneum and the adnexae. After a careful and meticulous mobilization, a distal pancreatectomy, splenectomy, and adrenalectomy along with resection of the splenic flexure of the colon were performed.
+Pathological examination revealed a tumor with manifestations in the pancreatic tail, the adrenal gland, the peripancreatic tissue, and the surrounding soft tissue. Grossly, the mass displayed a whitish and glassy cut surface, containing extended areas of haemorrhage and necrosis. Histologically, the tumor displayed endocrine architecture with mostly solid formations of rather monomorphic cells. The tumor was mitotically highly active (mitotic count >10 per high power field) and contained abundant areas of necrosis. Immunohistochemically, the tumor cells were strongly positive for the endocrine marker synaptophysin and for cytokeratin 20 while there was no expression of insulin. The proliferative activity (MIB-1) reached approximately 80% .
+Furthermore, gross examination of the resected specimen revealed a well demarcated, brownish tumor of the pancreatic body, measuring 1.2 cm in diameter. This tumor microscopically displayed endocrine architecture with trabecular arrangements of uniform tumor cells, showing no mitotic activity. Immunohistochemistry revealed strong positivity for synaptophysin as well as focal positivity for insulin. The proliferative activity (MIB-1) was approximately 1% . The diagnosis of a poorly differentiated endocrine carcinoma (Merkel cell carcinoma) along with that of benign pancreatic insulinoma was thus made.
+The patient had a smooth postoperative recovery, the bouts of hypoglycaemia completely disappeared, and she was discharged home within 3 weeks of surgery. She is presently asymptomatic and remains on regular follow up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_105_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_105_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..98431356fb4a5a06c4e4bbbfe1a5569d6d360a8f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_105_en.txt
@@ -0,0 +1,4 @@
+A 37-year-old Chinese woman presented to our department four years and 11 months ago with bilateral lower limb crush injuries sustained in a traffic accident. The lower limb injuries were at different anatomic levels . On the right side, her lower limb was crushed from her hip joint to 16cm below her knee joint, but the bones and soft tissues of the lower one-third of her leg were intact with only slight injury to the skin. On the left side, the distal portion of her leg was crushed. Our patient was in serious hypovolemic shock on arrival, with a heart rate of 150 beats per minute and blood pressure of 80/60mmHg.
+After rapid infusion of intravenous fluids, our patient rapidly recovered from shock and did not develop acute renal failure or acute respiratory distress syndrome. Emergency surgery was performed. Bilateral lower limb amputations were necessary. Her lower left leg was unsalvageable, but her lower right leg was suitable for replantation to the left leg stump after debridement. We decided to perform crossover replantation of her right lower leg to the left leg stump to provide our patient with a sensate weight-bearing extremity. Her amputated right lower leg was wrapped in sterile dressings, placed on a sterile tray and stored in the refrigerator at 4°C during fixation of the left leg fracture.
+After amputation and debridement of her right hip joint, her right lower tibia was fixed to her left upper tibia . The fibula was not fixed. The tendons, blood vessels and nerves of her left leg were anastomosed to the amputated lower right leg structures. The anterior tibial artery and posterior tibial artery were anastomosed crosswise, and the ends of the great saphenous vein, small saphenous vein and four deep veins were anastomosed without crossover. The sural nerve and saphenous nerve were anastomosed crosswise, and the anterior and posterior tibial nerves were anastomosed without crossover. Heterotopic replantation of her right lower leg to the left leg stump was thus completed. A stump was created on the right side at her hip joint. Routine antibiotic, anti-coagulant, and anti-angiospasm treatments were administered post-operatively. In a second operation, a soft tissue defect of the replanted limb was covered by a microvascular-free latissimus dorsi muscle flap. The post-operative anti-coagulation regime was as follows: dextran 40 (500mL) twice a day for seven days; aspirin (100mg) orally three times a day for three days; narceine (30mg) four times a day for seven days; and tolazoline (25mg) three times a day for seven days. Routine post-operative blood tests, including coagulation tests, were performed for seven days.
+The replantation was successful and our patient was discharged after two months . She was rehabilitated with a contralateral prosthesis and ambulates with a walking stick. One year post-operatively, X-ray examination showed perfect union of the tibia . There was no ulceration of the replanted extremity or the right-sided amputation stump at 39 months post-operatively. The sole of her foot on the left side regained complete protective sensation . Our patient described the functional result of the replantation as satisfying, and found that the prosthesis on the right side caused more problems than the replanted left lower limb. She had no complaints about the cosmetic result. In addition, she experienced restoration of perceived body height with the crossover replantation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1077_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1077_en.txt
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index 0000000000000000000000000000000000000000..f5d864606f47b288c50066a1fd06fa4c37433602
--- /dev/null
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@@ -0,0 +1,5 @@
+A 23-year-old male initially presented in our emergency department with symptoms suggestive of angina pectoris. The patient reported the sudden onset of chest pain radiating to the left arm as well as headache 1 day after vaccination with the second dose of the mRNA-1273 (Moderna) COVID-19 vaccine. Dyspnoea, fever, or excessive sweating were denied. Further examination revealed a relevant past-history of perimyocarditis in 2018 and 2019 (possibly post-infectious). The patient was not on medication at the time of presentation.
+The clinical examination of the patient was unremarkable. The body temperature recording was 37.5°C. The heart rate on admission was 96 beats/min and the blood pressure was 110/60 mmHg. The oxygen saturation was 99% on room air. An electrocardiogram (ECG) showed sinus rhythm with mild concave ST-elevations in II, III, and aVF. Laboratory data (see ) revealed leucocytosis, elevated levels of creatine kinase, C-reactive protein, and high-sensitivity troponin I levels. The nasopharyngeal SARS-CoV-2 PCR test was negative, and the patient denied any history of infection with COVID-19. The patient was admitted to our intensive care unit (ICU) for observation and further clinical management.
+The troponin I level peaked on the second day (10.923 μg/L; normal range 0–0.045 μg/L) and NT-proBNP levels showed moderate elevation (1,970 ng/L; normal range 0–125 ng/L). A thoracic CT revealed no obvious pulmonary infiltrates and no evidence of coronary plaques or significant stenoses in the coronaries. An echocardiogram performed in the ICU revealed a moderately reduced left ventricular ejection fraction (LVEF) with hypokinetic inferolateral and apical segments.
+The echocardiographic findings were confirmed using a cardiac MRI (CMR) (3T MAGENTOM SKYRA, Siemens Healthineers, Erlangen, Germany). Considering the medical history of the patient, images from the CMR scan during the earlier bout of myocarditis were compared to the present . The contrast enhanced images showed comparable subepicardial late gadolinium enhancement (LGE) in the lateral and apical myocardial wall during the qualitative assessment. A definitive diagnostic conclusion based on LGE alone could not be drawn due to inter-scanner and inter-study differences. Cine images from the current CMR revealed a dilated left ventricle (end-diastolic diameter-−64 mm) and a moderately reduced LVEF (38%) vs. a mildly reduced LVEF (51%) in the examination 2 years ago. Additionally, in the current CMR, native T1 maps revealed a diffuse increase in relaxation times in all myocardial segments [1,344 ± 74 ms; normal range <1,228 ms (1,181 ± 47 ms) for this 3T machine] . As example, the elevation of T1 mapping indices in the mid-ventricular myocardial inferoseptal segment has been shown in , although there is no evidence of any LGE in this segment. There was evidence of a mild pericardial effusion (3 mm). This could suggest renewed involvement of affected myocardium with spread of acute inflammation in other segments too. These findings support the diagnosis of acute myocarditis according to the updated Lake Louise criteria .
+The patient was started on a therapy with Ibuprofen 400 mg (twice daily), beta-blockers (Bisoprolol 2.5 mg once daily) as well as an ACE-Inhibitor (Ramipril 2.5 mg once daily). There was rapid improvement of clinical symptoms and a repeat echocardiogram performed on day 6 showed only a mildly reduced LVEF (52%) thus facilitating a timely discharge. The patient was stable throughout the course of hospital stay and no complications were documented. A follow-up CMR performed after 3 months revealed a markedly improved LVEF (57%). Videos documenting this improvement have been added as . LGE was comparable to the previous studies. T1 mapping indices had normalized (1,194 ms) except for myocardial segments corelating to chronic myocarditis (also evident in past CMR images) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1095_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1095_en.txt
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index 0000000000000000000000000000000000000000..38ae7641efb060eaad1a94e4cdc675d01e7bc3ae
--- /dev/null
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+A 56-year-old Caucasian male with a past medical history of hypertension, acute coronary syndrome and atrial fibrillation presented to the emergency department (ED) with acute epigastric pain. His complaints had started 2 weeks earlier and had worsened 1 day prior to ED presentation. The pain was associated with nausea and increased on inspiration. Defecation and micturition were normal. In addition to fenprocoumon and sotalol, he was on antihypertensives, a statin and a proton-pump inhibitor. There was no history of trauma. Physical examination showed a pale, sweating and obese man in pain. His blood pressure was 113/73 mmHg, with a heart rate of 72 beats/min, oxygen saturation of 95% on room air and a respiratory rate of 13 breaths/min. The abdomen was not distended, and there were normal bowel sounds. He had epigastric tenderness without muscular defence or hepato-splenomegaly. His initial haemoglobin was 8.5 mmol/l. White blood cell count was 8.5 × 109/l with a c-reactive protein of 26 mg/l. The international normalised ratio (INR) was 2.4. Abdominal ultrasound showed an inhomogeneous aspect of the spleen without free fluid. Contrast-enhanced computed tomography (CT) imaging of the abdomen revealed splenic haemorrhage with subcapsular hematoma .
+An acute operation was deemed unnecessary because his vital signs remained stable. Oral anticoagulation was reversed with 10 mg vitamin K. The patient was admitted to the hospital for observation and was discharged in good condition after 3 days.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1166_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1166_en.txt
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index 0000000000000000000000000000000000000000..e0aa2e07dc7d0ec8fc8a3e1380ec246a906b2c17
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+An 8-year-old Japanese boy presented with recurrent headache. He had a medical history of hypothyroidism and Down syndrome confirmed by a 47,XY, +21 karyotype. No thyroid peroxidase or anti-thyroglobulin antibody were detected . There was no family history of cerebrovascular disease. Magnetic resonance imaging and angiography showed old cerebral infarction in the left temporal lobe and bilateral occlusion of the terminal portions of the internal carotid arteries with development of collateral arteries consistent with moyamoya syndrome . Based on the asymptomatic stage and the lack of perfusion defects as revealed by 123I-iodoamphetamine single-photon emission computed tomography (SPECT) , we initiated antiplatelet therapy with aspirin, not revascularization.
+At 9 years old, he developed altered consciousness and slurred speech. Hypoperfusion was identified in the left cerebral hemisphere on 123I-iodoamphetamine SPECT . To prevent further stroke, the patient underwent left-sided indirect revascularization consisting of encephalo-duro-arterio-synangiosis and encephalo-myo-synangiosis. No perioperative complications were observed. After the bypass surgery, ischemic symptoms regressed. Postoperatively, 123I-iodoamphetamine SPECT and cerebral angiography demonstrated improved cortical perfusion . However, cerebral angiography showed left choroidal anastomosis and residual moyamoya vessels .
+At 13 years old, the patient was admitted to our center with sudden onset of severe headache and recurrent vomiting, with a Glasgow Coma Scale of 14 and blood pressure of 127/81 mmHg. Computed tomography (CT) of the brain revealed left thalamic hemorrhage with left intraventricular hemorrhage , considered as a cerebral hemorrhage attributable to the left dilated anterior choroidal artery . Aspirin therapy was discontinued and blood pressure was managed using an intravenous calcium channel blocker for 7 days to achieve a systolic blood pressure under 120 mmHg (<95th percentile for age and sex) . Four days after the onset of cerebral hemorrhage, he again complained of headache. Brain CT at this point revealed expansion of intracerebral hemorrhage to the right ventricle, suggesting rebleeding. Eight days after onset, clinical symptoms improved and magnetic resonance imaging demonstrated decreased intracerebral hemorrhage. The patient developed bacterial aspiration pneumonia and gastric ulcer and was therefore started on intravenous ampicillin and famotidine. Twenty days after onset, brain CT detected no findings of post-hemorrhagic hydrocephalus and he was discharged with no neurological deficits. Four months later, cerebral angiography showed spontaneous regression of the dilated left anterior choroidal artery .
+Genomic DNA was extracted from the peripheral blood sample of the patient and targeted Sanger sequencing confirmed a heterozygous RNF213 R4810K variant (GenBank accession number, NM_001256071.3), as a major susceptibility gene for MMD . Follow-up angiography detected the development of a contralateral right choroidal anastomosis and the patient therefore underwent right-sided direct revascularization to prevent future hemorrhagic stroke six months after onset of the left hemorrhagic stroke. Four months after revascularization, angiography showed regression of the right choroidal collateral vessels. No ischemic or hemorrhagic stroke was observed as of the time of writing, 22 months postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1173_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1173_en.txt
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index 0000000000000000000000000000000000000000..cf25a04b9ff7c1d3f54482d08b92a528d932cabd
--- /dev/null
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+In 2006, a 52-year old female patient was admitted to a neurological department due to sudden difficulties with swallowing and speech, ophthalmoparesis with a vertical and horizontal eye movement disorder, dysesthesia of the hands with a quality of “pins and needles” and a glove-like distribution, as well as generalized areflexia. Muscle strength was normal. A Miller Fisher syndrome was diagnosed. Under treatment with 150 g intravenous immunoglobulins the symptoms completely remitted within a few days. In the following years, the patient consulted the general practitioner and several gastroenterologists because of unspecific abdominal pain, from which she has been suffering since childhood. Diagnostics including computer tomography (CT), magnetic resonance imaging (MRI) and gastroscopy were normal.
+In October 2017 the meanwhile 63-year old patient was hospitalized with generalized epileptic seizures with prolonged postictal confusion. Cerebral MRI showed no pathological findings, and therapy with levetiracetam was started.
+In December 2017 the patient was admitted to our clinic for internal medicine because of persisting diarrhea, abdominal pain, renal failure and a reduced general state of health. Again, the patient had generalized epileptic seizures with postictal confusion and significantly reduced vigilance, accompanied from a lactic acidosis (serum-lactate 26.0 mmol/l (reference 0.55–2.2 mmol/l), pH 6.863), leading to admission to the neurological intensive care unit. Moreover, a slight, presumably residual ophthalmoparesis as vertical gaze palsy with conjugate, bilateral limitation of the eye movements in upgaze was evident. The anticonvulsive therapy with levetiracetam (3 g/day) was extended by lacosamide (400 mg/day). A mechanical ventilation was necessary due to the sudden and massive metabolic acidosis as well as a respiratory failure during an epileptic seizure (serum-lactat 14.7; 10.6; 16.0 mmol/l). In CSF, lactate (12.01 mmol/l (reference 1.12–2.47 mmol/l) and protein level (67 mg/dl (reference 15–45 mg/dl) were significantly increased. There were no signs for an infectious origin in CSF (polymerase chain reaction for neurotrophic germs, including Tropheryma whippelii). CT and MRI of the brain as well as abdominal- and thorax-CT were normal. The electroneurography revealed a slight mixed axonal-demyelinating polyneuropathy, the electromyography was normal. Besides a sinus-tachycardia with 140 bpm and a mild pericardial effusion, no signs of a Wolff–Parkinson–White syndrome, that would be common in mitochondriopathies, were present.
+Attempted extubation failed as another severe epileptic seizure occurred with life-threatening lactic acidosis and hyperkalemia (lactate 26.0 mmol/l; pH 6.925; potassium 7.8 mmol/l (referece 3.6–5.2 mmol/l). EEG showed an alpha rhythm, with intermittent slow waves and tendency to generalize. In cerebral follow-up MRI, multiple fat embolies were detected. CT-angiography of the lung revealed a pulmonary embolism. As a reason for the fat embolies, multiple vertebral fractures were verified in CT, presumably as a result of severe epileptic seizures. A surgical fixation of vertebral fractures was performed. Intensive care therapy including ventilation was necessary for more than eight weeks. Weaning was successful after dilatative tracheostomy and nutrition via percutaneous endoscopic gastrostomy (PEG) tube. Vitamin-B6 was supplemented. Subsequently, a rehabilitative therapy was performed. After five months, the patient returned to her normal life. Tracheostomy and PEG were removed.
+Taking into account all the symptoms (abdominal pain, relapsing remitting course, neurological deficits, epileptic seizures, peripheral neuropathy, lactic acidosis, cardiac disturbance), two main differential diagnosis were discussed: porphyria and a mitochondrial disease (MERRF syndrome). None of both diagnoses could be verified: Laboratory test revealed no hints of porphyria (Porphyria Specialist Center of the European Porphyria Network University Hospital Düsseldorf, Germany). A muscle biopsy gave no hint of a mitochondrial disease and revealed only a slight unspecific atrophy that was very likely due to immobility (Institute of Neuropathology of the University Hospital Essen, Germany). In terms of differential diagnosis, other metabolic diseases came into consideration. Comprehensive diagnostic for diseases of copper metabolism, lead poisoning or adrenoleukodystrophy remained inconspicuous. Finally, the analysis of the amino acids in the urine, CSF and serum showed a strong abnormality with ubiquitously increased amino acids, especially proline (proline in serum 3085 μmol/l (reference 90-342 μmol/l), in urine 46,531 μmol/g Crea (reference < 100 μmol/g Crea), in CSF 104 mg/dl (reference < 6 mg/dl), Hydroxyproline in urine 1395 μmol/g Crea (reference <100) Table ). Furthermore, vitamin-B6 was decreased with 3.3 μg/l (reference > 4.9 μg/l). We supplemented vitamin B6 with 200 mg/d.
+Therefore, a hyperprolinemia type I or type II was most likely. The targeted genetic analyses by Sanger sequencing revealed no pathogenic variant within the PRODH-gene (hyperprolinemia type I) but identified two novel variants within the ALDH4A1-gene . In combination, both heterozygous variants within the ALDH4A1 gene could lead to a compound heterozygosity (variants in trans), that would cause the described disease phenotype. Since the patient’s son had only one of the two heterozygous variants of his mother, the compound heterozygous state of both variants in our patient was proven.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1175_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1175_en.txt
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index 0000000000000000000000000000000000000000..222eed5274bb4ba64821a093471f9e4cc10b5ec3
--- /dev/null
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+A 38-year-old male complained of palpitation and exertional dyspnea on his first visit to a local hospital in February. He never had a fever, arthralgias, weight loss or fatigue, nor did he have a personal or relevant family history of cardiovascular disease or neoplasms. A grade II/6 pansystolic heart murmur was heard during physical examination. Transthoracic echocardiography (TTE) revealed a large mass in the left ventricle, attached to the anterolateral papillary muscle and chordae tendineae. The local doctor made a preliminary diagnosis of suspected intracardiac fibroelastoma or myxoma, and suggested surgical resection for this intracardiac neoplasm through conventional median sternotomy. However, the patient was deterred by the invasiveness of sternotomy, and refused to have surgery in his local hospital. In May, as he learned about our experience in minimally invasive cardiac surgery, he came to our center.
+We reexamined the patient. The TTE confirmed a mobile round cystic mass inside the left ventricle. The mass had a hyperechogenic wall and hypoechogenic content and was attached to the anterior mitral leaflet . In systole, the mass prolapsed into the left ventricular outflow tract (LVOT) with accelerated peak velocity (2.5 m/s), which led to mitral regurgitation . The LVOT appeared normal without subvalvular ridge or asymmetric septal hypertrophy. Complementary thoracic and abdominal computed tomographic (CT) scans did not show any evidence of the existence or potential spread of noncardiac neoplasms. All laboratory examinations including tumor markers were unremarkable.
+Non-invasively distinguishing aggressive from non-aggressive intracardiac tumors is an important clinical challenge. Preoperative biopsy for histopathological diagnosis is inapplicable to intracardiac tumors. In this case, fortunately, the TTE provided significant information on morphology, localization, biological characteristics, as well as tumor vascularity-perfusion. The mass had a smooth surface, clear border, and low echodensity. No imaging evidence showed any features of malignancy like vascularity-perfusion, invasion or filtration into the cardiac structure, permeation to the great vessels, or pericardial effusion. So, there was a fairly high probability that this mass would be benign. We made a diagnosis of a primary intracardiac cystic tumor according to the obtained information, and decided to resect the tumor.
+Generally, a benign intracardiac tumor in this location and size can be accessed via trans-aortic or mitral orifice approach through mini-thoracotomy. Since we have enough experience of totally endoscopic mitral surgery, we decided to perform the operation in a totally thoracoscopic approach, and manage the possible deformation and dysfunction of the cardiac structure if necessary.
+Tumor resection was planned and performed through a totally endoscopic, video-assisted approach with thoracoscopy and femoral cannulation (Supplemental Video). The cardiopulmonary bypass and the surgical approach were established as the conventional endoscopic mitral surgery . A 35-mm working port was made in the fourth interspace, lateral to the midclavicular line. After deflation of the right lung, two additional ports were then placed: a camera port through the anterior axillary line in the fourth interspace, and an 8-mm port in the lateral fifth interspace for a transthoracic Chitwood clamp (Scanlan International, Minneapolis, Minn). We used the Chitwood clamp to occlude the ascending aorta and administrated the antegrade cardioplegia. A left atriotomy was performed, and the atrial retractor was applied. The mitral orifice and the mass were then clearly visualized . The mass was oval and reddish, partly attached to the chordate structure of anterior papillary muscle and A1 area of anterior mitral leaflet via two pedicles . We completely excised the mass through the roots of the pedicles, and then carefully cauterized the margin of excision. The size and structure of the mitral leaflets and subvalvular apparatus appeared to be normal. No surgical injuries were found during further exploration . The saline test showed no mitral regurgitation.
+The excised mass was 25 mm*20 mm*20 mm in size . Pathologic diagnosis confirmed a simple blood cyst, consistent with blood-filled space lined with a single layer of endothelium. The patients had an uneventful recovery. He was able to walk on the first postoperative day and was discharged three days after the operation. The patient was symptom-free and working full time during follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_117_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_117_en.txt
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index 0000000000000000000000000000000000000000..c4a18faee3aa9f818fbeba25d9fee42f6800471a
--- /dev/null
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+A 70-year-old man, without any particular pathological history, referred by family physician, to emergency with a 48h evolving abdominal pain, important abdominal distension, nausea, vomiting, and a last bowel movement reported 2 days ago. On examination, his vital signs were: temperature: 37.3 °C, pulse rate: 110/minute, respiratory rate: 24/minute and blood pressure: 110/60 mmHg. The abdominal examination revealed an abdominal sensibility at the right illiac fossa, a distension of the abdomen and an empty rectal ampula on rectal examination. The biological checkup showed hyperleukocytosis at 15700/mm3, hemoglobin at 11g/dl, platelets count at 159,000/mm3 and C-reactive protein at 180 mg/liter, the hepatic and renal check-ups were normal. An abdominal X-ray revealed the presence of hydro-aeric levels at the ileum segments without pneumoperitoneum. The abdomino-pelvic CT-scan objectified a distension of the terminal ileum measured at 30mm, upstream of a transitional level in which seats a rectangular and plane foreign body (, ). Considering these findings, the patient was diagnosed with intestinal perforation caused by a foreign body. After optimization of his general condition with a Naso-Gastric tube suction and intravenous fluids resuscitation, a decision was taken to proceed with an emergency laparotomy, under general anesthesia with endotracheal intubation. Performed by a 5th year and a 4th year surgical resident. Preoperative prophylactic antibiotics were administered. The exploration revealed a sharp foreign body (fish bone) measuring 3 cm/2cm at the 15 proximal centimeters of the terminal ileum, which penetrated through the wall of the ileum. The foreign body was removed and we noticed that it is a fish bone (, ). The margins of the perforation were excised and primary closure was performed. The patient recovered well and was discharged on the 6th postoperative day. On interrogation, the patient acknowledged that he incidentally swallowed the fish bone 5 days ago. The postoperative course was uneventful: improvement of the general condition of the patient.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_118_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_118_en.txt
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index 0000000000000000000000000000000000000000..89ff145f7b2d46bff06a0e008de3230ba16adcc1
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+An 18-year-old man was referred for painful bilateral testicular tumors confirmed with scrotal ultrasonography. MRI revealed a 2.5 cm tumor and a 3.0 cm tumor in the rete testis regions of the right and left testicles, respectively . CBC, LH (4.9 mIU/mL, normal 1.5–9.3 mIU/mL), FSH (5.1 mIU/mL, normal 1.6–8.0 mIU/mL), and total testosterone (398 ng/dL, normal 249–836 ng/dL) were normal. Tumor marker beta-HCG, AFP, and LDH were also normal. Both tumors subjectively progressed in size during the time between initial evaluation and surgery. Bilateral partial orchiectomies were attempted . The right was converted to a radical orchiectomy with prosthesis due to intraoperative concerns regarding testis viability. A partial orchiectomy was successfully completed on the left. Intraoperative frozen sections were not conclusive for germ cell, Leydig cell, or another histology. Pathologic evaluation of both tumors revealed the proliferation of tumor cells throughout the testicular parenchyma and rete testis, with nodules ranging from <1 to 10 mm, a low proliferation index (Ki67 positive in 1% of cells) and negative p53. No features of malignancy such as necrosis, mitotic figures, or pleomorphism were present . A presumptive diagnosis of Leydig cell tumors vs TARTs was suggested.
+CT scans of the abdomen and pelvis revealed a soft tissue density measuring 2.1 × 1.7 cm in the left para-aortic region . Also noted were slightly enlarged inter-aortocaval nodes and a small left adrenal nodule. An image-guided biopsy of the para-aortic mass was nondiagnostic.
+A postoperative endocrine evaluation revealed markedly elevated ACTH levels (4322 pg/mL) yet normal cortisol levels. The patient’s clinical and radiographic findings, testis pathology, and elevated ACTH level, all supported a diagnosis of NCAH and the presence of TARTs. The postoperative endocrine evaluation also revealed an LH level of 21.5 mIU/mL, FSH of 22.9 mIU/mL, and a low testosterone level (81 ng/dL). Borderline adrenal insufficiency and moderate hypogonadism were effectively managed with hydrocortisone and testosterone supplementation. Larger than average doses of hydrocortisone were necessary to maintain the ACTH at a desired level (under 100 pg/mL).
+Follow-up scrotal U/S and CT scans 2 years post-surgery revealed a right testicular prosthesis, a partial left testicle containing no new masses, and a stable para-aortic soft tissue mass .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1253_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1253_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c8638fcc521c23d26282310fd1a1cb43a6c93eea
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+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1253_en.txt
@@ -0,0 +1,2 @@
+An immunocompetent 28-year-old male was empirically diagnosed with a primary tectal tumor at an outside hospital; his history was negative for intravenous drug use or significant systemic bacterial infection. He presented initially with progressive intermittent headache for more than 6 months. Initial magnetic resonance imaging (MRI) showed a 10 mm × 9 mm left midbrain tectum ring-enhancing lesion with associated surrounding edema and mild hydrocephalus . At the other hospital, he underwent placement of a ventriculoperitoneal shunt (VPS) for obstructive hydrocephalus.
+Eight weeks later, he started to have worsening headache, nausea, and intermittent vomiting. He was readmitted with a VPS infection and an abdominal pseudocyst. He was transferred to our institution where the VPS was removed, an external ventriculostomy was placed, and he was started on intravenous ceftriaxone and vancomycin. Cerebrospinal fluid (CSF) profile showed elevated white blood cell (WBC) count of 482 with lymphocyte predominance, suggesting a chronic infection; CSF culture revealed A. aphrophilus. His other workup including blood cultures and transthoracic echocardiogram were negative for infectious etiologies. He slowly improved with antibiotic treatment and was weaned off the ventriculostomy after 14 days, without any subsequent recurrence of hydrocephalus. Vancomycin was stopped after 10 days when the culture finalized A. aphrophilus sensitive to ceftriaxone. The tectal lesion completely resolved after 15 weeks of intravenous ceftriaxone . At the 4-month follow-up, he had no headache or any other clinical sequelae.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1265_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1265_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d14f93026b9c95cd18d72462229803ae9b2806df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1265_en.txt
@@ -0,0 +1,2 @@
+We report on an 81-year-old woman with no relevant comorbidities and a smoking history of 5 pack years. In 2006 she was diagnosed with a pT2a, pN0 (0/5), cM0, UICC stage IB squamous cell carcinoma of the left upper lung lobe, for which she underwent a double-sleeve lobectomy with lymphadenectomy. During 5 years of follow-up, no relapse occurred. In April 2019, the patient presented with a post-stenotic pneumonia. Computed tomography of the chest showed a mass in the left lung. Radiological staging with whole-body 18F-FDG-PET/CT and brain MRI showed metastatic disease with a strongly metabolically active primary tumor (SUVmax 16.7), pleural carcinomatosis on the left side (SUVmax 9.4), periclavicular lymph node metastases on the left side (SUVmax 9.9), and bone metastases in the 12th thoracic and 4th lumbar vertebra (SUVmax 5.0 and 4.6, respectively) . Histology of bronchoscopic biopsy specimens revealed squamous cell carcinoma, which could be interpreted as recurrence or as a second lung cancer, taking into consideration the 13-year-long disease-free interval. The immunohistochemistry for programmed cell death ligand 1 (PD-L1) revealed an expression in 20% of tumor cells and in < 10% of immune cells. In order to complete our internal lung cancer diagnostic algorithm (Treichler G, manuscript in preparation), we performed next-generation sequencing using the FDA-approved FoundationOne®CDx assay. We found a structural aberration on the long arm of chromosome 3 (3q) with amplifications of the genes , SOX2, and FGF12; mutations of TP53, ATRX1, RB1, and, subclonally, PIK3CA; a stable microsatellite state (MSS), and a low tumor mutational burden (5 Muts/Mb).
+Based on the recommendation by our multidisciplinary tumor board, a therapy regimen consisting of pembrolizumab, carboplatin and paclitaxel in analogy to the KEYNOTE-407 study was suggested. The patient declined systemic treatment. She was thus referred for radiotherapy in order to achieve local control, due to the central localization of the tumor with associated risk of post-stenotic pneumonia and bleeding. The patient underwent conventionally fractionated radiotherapy of the principal pulmonary tumor bulk with palliative intention with 3 Gy in 12 fractions, resulting in a total dose of 36 Gy, using Volumetric Modulated Arc Therapy (VMAT, RapidArc™). Radiotherapy was well tolerated, with esophagitis grade 2 according to the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Four weeks after the last day of radiotherapy, restaging was performed with 18F-FDG-PET/CT. A partial remission of the tumor bulk, the nodal metastases and, surprisingly, also of the vertebral lesions was shown . Of note, the supraclavicular lymph nodes and the two bone metastases in the spinal column had not been included in the irradiation field with scatter doses of 0.201 Gy, 0.093 Gy, and 0.021 Gy on the lymph nodes, vertebra Th12, and L4, respectively . Furthermore, no antiresorptive medication had been administered. Due to the remission and the lack of tumor-related symptoms, systemic treatment—although no longer refused by the patient—was withheld. The patient underwent radiological follow-up, during which further decrease in tumor size and complete metabolic remission of the bone, pleural and lymph node metastases was seen . Currently, 25 months after radiotherapy, the patient is still free of symptoms and has an Eastern Cooperative Oncology Group (ECOG) Performance Status of 0.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_126_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_126_en.txt
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index 0000000000000000000000000000000000000000..f1afbc6aa8e70a2bfd545e5307fa0ac8bf24a531
--- /dev/null
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+A 25 year-old Caucasian woman presented with a four-day history of acute onset of blurred vision in both eyes. She reported a viral upper respiratory tract infection for seven to 10 days, for which she had taken two Excedrin® Migraine (acetaminophen 250 mg, aspirin 250 mg and caffeine 65 mg) tablets. She used Midrin (acetaminophen 325 mg, dichloralphenazone 100 mg, isometheptene mucate 65 mg) as needed for her headaches concurrently. Additionally, she smoked half-pack cigarettes and consumed four to five 12-ounce cans of a caffeinated drink, Mountain Dew (caffeine 54 mg/can) per day.
+Her uncorrected Snellen visual acuity was 20/20 in both eyes and Amsler testing revealed bitemporal paracentral scotomas. She correctly identified 10 and nine out of 14 Ishihara color plates, in her right and left eye, respectively. No afferent pupillary defect was noted and the anterior segment was unremarkable. Fundus examination revealed bilateral hyperpigmentary changes in the papillomacular bundle . Fundus autofluorescence revealed a normal autofluorescence pattern. IR imaging disclosed classic wedge-shaped lesions with their apices oriented towards the fovea. SD-OCT exhibited changes at the inner segment-outer segment (IS-OS) junction, with a thickened OPL overlying these areas . Humphrey visual field (HVF) 30-2 demonstrated bilateral paracentral scotomas. Fluorescein and indocyanine green angiography did not demonstrate any perfusion defects or any other abnormality.
+Five months after initial presentation, her color vision improved to 14 of 14 Ishihara color plates correctly identified in each eye. Repeat HVF testing demonstrated interval improvement in the scotomas, more in her right eye than left. Similarly, SD-OCT showed a corresponding small improvement at the IS-OS junction in her right eye and no change in her left eye . Microperimetry using an MP-1 (Nidek, Japan) demonstrated focal elevation in threshold correlating with the wedge-shaped defects in both her eyes .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1283_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1283_en.txt
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index 0000000000000000000000000000000000000000..69e3933a9fd549071c3ec39cd02d3cde2e6a1a8d
--- /dev/null
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+A 79-year-old male presented to the dermatology clinic with a new rash. He had a past medical history of chronic kidney disease stage 3, gout, and papillary and invasive urothelial carcinoma, extravesical high-grade invading into the lamina propria and muscularis propria Stage IVA (pT4b, pN0, cM0) diagnosed by transurethral resection of bladder tumor 05/2020 on pembrolizumab. Of note, his urothelial carcinoma biomarkers were programmed death-ligand 1 negative (immune cell 5%, tumor <1%), Tempus XF (liquid) = IDH1 GOF, xT = ERBB2, RB1, TP53, CDKN2A, GATA-3, MTAP, TMB 4.2 m/MB, MS-S. He was treated with neoadjuvant Gemcitabine/Cisplatin ×3 cycles complicated by sepsis. The patient underwent cystoprostatectomy 09/2020. In 07/2021, he was found to have metastasis to the rectum after sigmoidoscopy biopsies show rectal mucosa and submucosa containing rare foci of malignant cells in lymphatic spaces. GATA-3 immunostaining was positive in these cells, compatible with a spread from the patient's known urothelial primary carcinoma. Surgery was offered at this time, but the patient declined. He was then started on pembrolizumab. Recent CT and sigmoidoscopy were concerning for the progression of rectal mass. After receiving 15 cycles of pembrolizumab, the patient was started on enfortumab vedotin plus pembrolizumab. On cycle 3 day 1, he presented to dermatology with a rash of the right inguinal region for 5 weeks which was painful and pruritic. He had previously been treated with oral valacyclovir and topical clotrimazole cream with no improvement. The patient denied a history of fevers or night sweats.
+His physical exam was notable for firm papulonodules, several of which formed confluent, hyperpigmented to violaceous plaques involving the right inguinal fold . Similar lesions also extended onto the proximal anterior thigh. A punch biopsy was performed which revealed a dermal proliferation of neoplastic cells in irregular nests with retraction artifact and focal glandular differentiation. The cells show high-grade nuclear features with background apoptosis. There was no involvement of the overlying epidermis. Immunohistochemistry revealed that the tumor cells were positive for CK20 and GATA3 and negative for CK7 . The presence of a glandular proliferation in the dermis, without overlying connection to the epidermis, and with a staining pattern consistent with the patient's known urothelial carcinoma, led to the diagnosis of cutaneous metastasis. Of note, the papillary dermis showed edema and perivascular inflammation that corroborated the clinical appearance of the rash and can be seen in metastatic lesions, adding to diagnostic challenge on clinical grounds. After confirmation of skin metastasis, the patient received one fraction of intensity-modulated radiation therapy to the right pelvis/groin. He was continued on enfortumanb vedotin plus pembrolizumab at that time. Significant decline in CA19-9 and ctDNA had stabilized. The newest CT imaging demonstrates a decrease in abdominal/pelvic lymphadenopathy with no new findings.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1289_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1289_en.txt
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index 0000000000000000000000000000000000000000..b72410b4634e90a6b0cc93faaf4e6fd34f3d125f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1289_en.txt
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+A 7-month-old Chinese boy was referred to the pediatric nephrology and immunology department of our hospital with eyelid edema for more than 2 months and limb swelling for 1 week. In the medical history, there had been recurrent cough that continued for some days. He had a pale complexion, with periorbital and bilateral pitting pedal edema on clinical examination, but no jaundice, petechiae, purpura, or lymphadenopathy. There was no history of tachycardia or tachypnea. There was no hepatosplenomegaly. His blood pressure (81/62 mmHg) was in the normal range at admission. The child had a history of amniotic fluid contamination at birth and no history of asphyxia. Neither the boy nor his family had a significant history of conditions such as kidney-related diseases or autoimmune diseases. However, the grandmother died of hematological disease.
+Investigations 3 days prior at clinics of another hospital showed a hemoglobin (Hb) level of 62 g/L without thrombocytopenia (platelet count 396 × 109/L). Serum lactate dehydrogenase (LDH) was elevated (579 U/L) (normal <382 U/L). An elevated serum cholesterol of 5.38 mmol/L was noted at that time, along with range proteinuria (1+) and hypoalbuminemia (serum albumin 28.8 g/L). There was no gross or microscopic hematuria. The serum C3 and C4 levels were normal. The laboratory values with reference values are shown in the . The boy was immediately referred to our hospital with a referral diagnosis of “nephrotic syndrome (NS)”.
+The patient presented with likely NS with anemia for five days after admission but no proteinuria or hypoalbuminemia. The direct Coombs test was negative. On hospital day 6, the patient presented with “hemolytic uremic syndrome (HUS)” following episodes of vomiting and diarrhea with fever. There were systemic pitting pedal edema, oliguria, petechiae, and soy sauce-colored urine at that time, along with hypertension (129/89 mmHg). Laboratory workup revealed normocytic hemolytic anemia with an Hb level of 62 g/L, mean corpuscular volume (MCV) of 86 fL, elevated reticulocyte count of 9.3%, schistocytes count of 3% on the peripheral smear, thrombocytopenia (platelet count 23 × 109/L), a serum creatinine (SCr) level of 0.62 mg/dl, blood urea nitrogen (BUN) level of 5.66 mmol/L, cystine (C) level of 1.57 mg/L, C3 level of 0.89 g/L, C4 level of 0.21 g/L, a markedly increased lactate dehydrogenase (LDH) level of 585.1 U/L, hematuria (red blood cells 4,627.9/µl), and proteinuria (3+). Coagulation function, including prothrombin time (PT), activated partial thromboplastin time (APTT) and fibrinogen, was elevated (36.2 s, 58.6 s and 4.26 g/L, respectively). The serum bilirubin, AST, ALT, and serum electrolyte levels were within normal limits. The activity of a disintegrin and metalloproteinase with a thrombospondin type 1 motif, member 13 (ADAMTS13), was normal. The stool rotavirus test was positive. Stool culture grew Streptococcus and Escherichia coli (E. coli), and stool multiplex polymerase chain reaction (PCR) showed that Shigella, Salmonella, E. coli O157, and pathogenic Vibrio were not detected. The infectious workup was notable for a negative respiratory viral panel, negative special viral panel (human parvovirus B19, EB virus, cytomegalovirus, rubella virus, herpes simplex virus, hepatitis virus), negative Mycobacterium tuberculosis, and negative blood culture. Antinuclear antibodies were negative. The chest x-ray was negative. B-ultrasound showed a small amount of abdominal effusion . Abdominal computed tomography (CT) showed that the kidney, liver and spleen increased in volume with a low-density image . The echocardiogram showed a central atrial septal defect (2.3 mm) with a normal ejection fraction (EF 66%). The 24 h urine protein quantification was not performed due to the difficulty in collecting 24 h urine. Moreover, due to his uncontrolled hypertension and thrombocytopenia, the patient could not undergo a kidney biopsy.
+Given the concern for HUS, broad-spectrum antibiotics and fresh frozen plasma infusions were given to treat his gastrointestinal infection and TMA. The following other treatments were employed: intravenous immunoglobulin (IVIg) infusions, human prothrombin complex infusions, albumin infusions (due to a decreased level of albumin), red blood cell infusions, platelet infusions, intramuscular injection of vitamin K1, low-dose methylprednisolone for anti-inflammatory treatment, antihypertensive treatment (nifedipine and metoprolol), and symptomatic treatment.
+The patient was diagnosed further with aHUS, had been administered plasma infusions (PIs) discontinuously and had required plasma exchange (PE) 2 times during the PICU hospital stay. Given the trend of acute respiratory distress syndrome (ARDS) with worsening pneumonedema and pneumorrhagia, mechanical ventilation (MV) was given for 7 days. There was a transient remission of respiratory symptoms. However, given the trend of worsening renal function [elevated levels of blood urea nitrogen (BUN)], progressing edema, and worsening hypertension, continuous renal replacement therapy (CRRT) and hemodialysis (HD) on alternating days were given to treat his acute kidney injury (AKI) for 13 days and 15 days, respectively. The patient's renal function and hematologic parameters (stage 3 AKI with gross hematuria) worsened during the 6th–7th week of the hospital stay while HD and PI therapy was continued, as depicted in . Subsequently, the patient developed a hypertensive emergency with features of intracranial hypertension leading to right temporoparietal hematoma and subarachnoid hemorrhage, as depicted in . He required multiple drugs (furosemide, nitrate, glycerin fructose) for the control of hypertension and intracranial hypertension. Ultimately, he still had a recurrence of ARDS and deteriorated to a stage of involuntary respiration requiring high ventilatory settings with pulmonary hemorrhage, gastrointestinal hemorrhage, and multiorgan dysfunction. Chest CT displayed both lung pneumonia and partial atelectasis of the upper lobe of the right lung . Head CT showed that the subarachnoid hemorrhage was more extensive than before . The patient's parents decided to withdraw the patient from further management. The patient died during the 8th week of his hospital stay.
+We obtained 2 ml of peripheral blood from the patient, his parents and older brother respectively. Whole exome sequencing was performed on the patient, his parents and brother. Sanger sequencing was used to verify the mutation site. CNVnator software was used for CNV analysis, and QPCR was used for family analysis. Two heterozygous variations in the DGKE exon region: NM_003647.2, c.610dup, p.Thr204Asnfs*4 and deletion of exons 4–6 were identified. The first variant was classified as de novo compared with the results obtained in the conventional in the Sanger sequencing of the parents and the older brother . The second variant was a deletion of DGKE exons 4–6, which was also detected in the asymptomatic father, but absent in both the mother and the older brother . The patient in this case had aHUS, consistent with recessive transmission with the 100% penetrance.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_129_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_129_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8e7ec25f7edd8937583e2096c38076d5973bae53
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_129_en.txt
@@ -0,0 +1,11 @@
+A 71-year-old female with a past medical history of undifferentiated connective tissue disease (UCTD) presented to an acute care hospital in December, 2020 after experiencing sudden onset of lower extremity weakness over 8-10 min, sensory loss from the lower trunk down, urinary retention, and worsening hypotension.
+This individual had recently been exposed to COVID-19 through a household member and subsequently tested positive, with COVID cycle thresholds suggestive of recent infection. She demonstrated cough and fever before hospitalization, but did not require supplemental oxygen beyond the first few hospital days. She was issued 5 d of IV methylprednisolone and remdesivir, followed by an oral prednisone taper of 5 additional days. Neurological exam in acute care found incomplete sensory deficits T3-8 but complete absence of sensation from T9 and below.
+During inpatient rehabilitation, we did acquire some key historical information about her UCTD, which to date had never progressed to a defined connective tissue disorder such as mixed connective tissue disease (MCTD). This condition is characterized by the presence of certain antibodies, particularly presence of the U1 small nuclear ribonucleoprotein particles (snRNP). Notes received indicate a negative titer for U1snRNP in 2020 when she had acute COVID-19, similar to her level when last tested in 2016. No lab quantification of U1-anti RNP titer was listed among lab results, other than a note stating it was not present. She had no clinical features of MCTD other than presence of sclerodactyly and stated history of Raynaud’s, which was not active during rehabilitation. She had myalgias but no evidence of synovitis or myositis that would prompt us to request a muscle biopsy. At the time of her admission to rehabilitation, this individual’s discomfort and spasms, as well as pain were in the middle and upper trunk and mid-back. However, during past UCTD exacerbations, she had endured aching and often sharp pain specifically in the posterior cervical spine and shoulders and during more significant attacks, pain and swelling in her fingers. Except during practice with wheelchair transfers, she reported no shoulder, arm, or hand pain with physical or occupational therapies.
+The possibility exists that some of the pain and spasms she was feeling was a different manifestation of her usual UCTD flare. In the past, such instances had always affected more proximal areas of the body, specifically neck, shoulders and hands. In her 2.5 years since discharge from her second inpatient rehabilitation stay, she has only experienced two significant UCTD exacerbations, both during an acute hospital admission for secondary complications of her NTSCI. The first occurred in the summer of 2022 when septic from a severe UTI. Her antibiotics for that condition included first intravenous cephalosporins and then ciprofloxacin. Both agents may have impaired absorption of hydroxychloroquine prescribed daily for chronic UCTD. In addition, several doses of this long-term medication were missed due to acute illness. During this hospitalization, she became weaker and had increased joint pain, neck pain, and hand swelling. However, the only serology that was abnormal among rheumatologic indices was an elevated ESR of 3 points beyond the upper limit of normal, which could have been outside the normal range simply due to the UTI. During this admission, the same labs as appeared in Table were performed and no findings revealed a change in her degree of UCTD.
+Upon arriving to rehabilitation, her exam demonstrated a C7 left, T3 right ASIA Impairment Scale A, with a zone of sensory preservation to T8 bilaterally and complete absence of sensory and motor function from T9-S5. Her first month of rehabilitation was marked by expected neurogenic bowel and bladder, moderate thoracic non-radiating back pain, and mild spasticity below T9. She also had a band-like tightness in the T4-5 dermatomes in the absence of imaging findings there. The pain continued to intensify during subsequent weeks in rehabilitation, progressively taking on more neuropathic features with relentless mid-back and chest tightness.
+She was discharged home after 8 wk but continued to experience unrelenting truncal pain between the T3-T8 dermatomes, above and at the level of the infarct, estimated to be located at T8. Several additional acute care and rehabilitation admissions for pain and urinary tract infections ensued during the subsequent two months. Her exam in this time now showed T3 complete SCI with partial preservation to T8.
+Table gives additional studies undertaken in the diagnostic workup, including the presence of viruses other than SARS-CoV-2 (enterovirus, Varicella zoster, Herpes simplex, and West Nile), and markers of inflammatory, autoimmune, and neoplastic disorders. Specifically, there was no evidence of Neuromyelitis Optica, based on absent aquaporin-4, and no evidence of myelin oligodendrocyte glycoprotein antibody, which is characterized by immune mediated demyelination of the spinal cord and other regions of the central nervous system. Moreover, immunoglobulin G synthesis of the cerebral spinal fluid (CSF) index was also negative, suggesting other inflammatory processes were not present. No oligoclonal bands were detected in CSF, a finding commonly seen in multiple sclerosis (MS) and in neoplastic processes such as multiple myeloma. Myelin basic protein was elevated but is a nonspecific finding, present in autoimmune disorders such as MS and ischemic conditions. including stroke. Lumbar puncture on presentation had serum and cerebrospinal fluid studies that were entirely unremarkable.
+Her managing team at the acute care hospital did not have access to her outpatient records about her rheumatologic condition from her community physicians. They did perform a comprehensive serologic workup during her acute COVID admission, but the specimens were sent to an outside lab. Her results were not finalized prior to acute hospital discharge and thus were never added to her inpatient record, nor subsequently forwarded to the rehabilitation team.
+Several weeks into her first inpatient rehabilitation stay, partial rheumatologic history and the labs drawn while admitted for COVID-19 were eventually obtained from her outpatient physician’s office. This individual’s initial diagnosis of UCTD occurred in 1993, prior to acute COVID-19, and was classified as non-antinuclear antibody UCTD. Her condition was based on the presence of CREST syndrome, the pneumonic of which represents calcinosis, Raynaud’s syndrome, esophageal dysmotility, sclerodactyly, and telangiectasias. This information was from her first available outpatient record dating back to 2004, nearly 20 years preceding this publication. In 1993, her predominant features were Raynaud’s affecting fingers and sclerodactyly. She began on disease-modifying medication hydroxychloroquine and a plan was made to arrange for oral prednisone as needed for any exacerbations. Outpatient records from 2004-2020 indicate patient reported feeling well, with a “stable UCTD presentation”, without changes in lab indices, recorded hospitalizations, or flares. Documents did note an exacerbation of symptoms of neck and shoulder pain in 2016 that was managed as an outpatient with a combination of hydroxychloroquine and nifedipine, a calcium-channel blocker. At that time a core panel of rheumatologic markers was drawn, identical to the panel drawn in December 2020 given in Table . No specific rheumatologic markers were concerning, with the exception of an elevated erythrocyte sedimentation rate that resolved using the above medications. Between 2016-2020, she continued with annual visits to rheumatology without a documented flare or change in medications. Although normal values vary from one lab to another, the purpose of each test and the ratio of positive to negative values is similar between institutions. The labs were selected by the referring facility where the acute care team made the decisions in diagnostic workup.
+Initial workup included magnetic resonance imaging (MRI) of the cervical, thoracic, and lumbar spine, which showed acute cord ischemia T9 to the conus medullaris. Thoracic cord expansion and increased intramedullary signal extending many vertebral segments were compatible with a spinal cord infarct, particularly in light of the CSF findings and her acute onset of weakness. The above helped to differentiate an infarct from transverse myelitis. The brain MRI was negative for optic neuritis or lesions suggestive of MS, features needed to diagnose those conditions.
+Figure demonstrates a lengthy region of T2 hyperintensity from T9 to the conus, yet absent imaging findings above T9, despite observed sensory abnormalities for many segments rostral to T9. She was diagnosed with a T8 spinal cord thrombotic stroke. Her infarct occurred approximately 7 d after acute infection with COVID-19, consistent with the timing reported by Zhang et al in relation to COVID cytokine storm.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1333_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1333_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0dfd8a3d88ad3bc4a1115c9c4cd2591c6556f86e
--- /dev/null
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+A 67-year-old man was referred for uncontrolled increased IOP in his left eye despite maximal tolerated medical therapy. He had previously been diagnosed with left secondary glaucoma related to idiopathic uveitis, which was diagnosed based on negative results in all systemic work-ups including serologic, radiologic test. His previous ocular history included laser iridotomy (LI) and trabeculectomy, which were performed three years prior to SLT procedure, as well as phacoemulsification with in-the-bag posterior chamber lens implantation which performed two years ago. His past medical history was unremarkable. Best corrected visual acuity was 20/20 in his right eye and 6/20 in his left eye. IOP measured by Goldmann applanation tonometry was 15 mmHg in his right eye and 28 mmHg in his left eye, with the latter being treated with a fixed combination of dorzolamide and timolol (Cosopt, MSD, Switzerland) twice daily, brimonidine 0.2% (Alphagan, Allergan, USA) twice daily and latanoprost 0.005% (Xalatan, Pfizer, Belgium) once nightly. Slit lamp examination showed deep anterior chambers in both eyes, as well as showing a shallow bleb, a patent LI hole at the 11 o’clock position of the iris, and an iridectomy site at the 12 o’clock position of the iris in the left eye. Gonioscopic examination of the left eye revealed peripheral anterior synechiae around the iridectomy site at the 12 o’clock position and hyperpigmented tissue within the trabecular meshwork in all quadrants . The patient was prescribed oral acetazolamide (Acetazol tab. 250 mg, Hanlim Pharm., Korea) twice daily for 1 week, reducing the IOP in his left eye to 17 mmHg as measured by Goldmann tonometry. Owing to drowsiness, however, the oral drug had to be discontinued. One week after discontinuing oral acetazolamide, the IOP returned to 30 mmHg. Therefore, it was decided to perform SLT while maintaining twice daily dosing of oral acetazolamide. SLT, rather than additional glaucoma surgery, was selected to reduce IOP because of following findings suggesting advanced glaucoma in the left eye , (1) a pale disc on fundus examination, (2) diffuse retinal nerve fiber layer (RNFL) loss on optical coherence tomography (OCT), and (3) severe field constriction on Humphrey visual field test .
+Proparacaine topical anesthetic solution was applied to the left eye, and hydroxypropyl methylcellulose (Hycell solution 2%, Samil Pharm Co., Ltd., Korea) was used with the gonioscopy lens. SLT was performed with 107 shots treating 360° of the trabecular meshwork with 1.1 mJ, which falls within the typical power range of 0.4–1.4 mJ . Thirty minutes after the treatment, the IOP in the left eye was 17 mmHg. The patient was instructed to apply fluorometholone acetate 0.1% (Flarex, Novartis Pharm., Switzerland) drops four times per day for 3 days and to return in a week for follow-up.
+One week after the procedure, the IOP in the left eye was 7 mmHg and there were no other symptoms other than foreign body sensation in the eye. Significant anterior chamber shallowing and inflammation were also not observed. Considering that the IOP decreased sufficiently, oral acetazolamide was discontinued and the patient followed-up 2 weeks later. At that visit, the patient reported ocular pain in the left eye when touched. The best corrected visual acuity and IOP of the left eye were 3/20 and 4 mmHg, respectively. Slit lamp examination showed a deep anterior chamber without evidence of marked inflammation. Fundus examination and B-scan ultrasonography revealed hypotonic maculopathy and choroidal detachment in the left eye .
+All anti-glaucomatous drugs were discontinued and the patient was started on oral prednisolone acetate (Solondo tab, Yuhanmedica, Korea) 30 mg per day. One week later, the IOP in the left eye was 4 mmHg, and the choroidal detachment did not improve. The patient was therefore started on additional atropine 1% (Isopto atropine, Alcon, USA) twice daily and prednisolone acetate suspension (Pred Forte 1%, Allergan, USA) four times daily. The IOP in his left eye was 7 mmHg 3 days later and 23 mmHg 10 days later, and the choroidal detachment had improved . One week after discontinuation of oral prednisolone acetate, atropine eye drops, and prednisolone acetate suspension, the IOP in his left eye was stable at 8 mmHg. Three months after SLT, the IOP in that eye was well maintained at 10 mmHg, with the patient being treated with only one anti-glaucomatous drug, brimonidine.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1353_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1353_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da076133e5ecd15aa9c8f110b7d4d3e164ca078e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1353_en.txt
@@ -0,0 +1,2 @@
+A 57-year old man with uremia on hemodialysis complicated by severe renal anemia, hypertension and heart failure, presented with a two-week history of recurrent fever and cough with purulent sputum. Chest pain, nausea, vomiting, abdominal pain, diarrhea and night sweat was denied. He had been diagnosed with end-stage renal disease (ESRD) nearly 2 months ago, and the etiology was primary glomerulonephritis. Hemodialysis with the central venous catheter started at that time. Two weeks before admission, he suffered from recurrent epileptic seizures, characterized by convulsions of the whole body, unconsciousness and fecal incontinence in other hospital. Shortly afterwards, fever and cough with yellow phlegm gradually appeared. His labs were notable for white blood cell count (WBC) of 11.6 × 10 9 /L with 87% neutrophils, hemoglobin (Hb) 61 g/L, and C-reactive protein (CRP) 74.06 mg/L. Blood and sputum cultures were negative. Computed tomography (CT) scan of the chest revealed pneumonia. Intravenous vancomycin (0.5 g three times a week) and meropenem (0.5 g Q8H) was administered empirically for suspected aspiration (given his lethargy after epileptic seizure). Then the symptoms improved gradually and indicators of infection dropped to normal during 1 week. Unexpectedly, the patient had fever again on the day of admission, with a temperature of 38.8 °C, accompanied by deteriorating general status. Therefore, he was transferred to our hospital for further treatment.
+Physical examination was significant for appearance of severe anemia, a temperature of 38.8 °C, decreased breath sounds at the lung bases bilaterally, a diffuse moist rale on respiratory exam and a slight exudation around the right jugular hemodialysis catheter. Initial laboratory investigations revealed WBC of 7.0 × 10 9 /L with 74.2% neutrophils, Hb 55 g/L, CRP 25.29 mg/L, procalcitonin (PCT) 3.02 ng/ml, Scr 557.1umol/L and B-type natriuretic peptide (BNP) greater than 5000 pg/ml. Chest CT demonstrated multiple exudation of both lungs, bilateral pleural effusion and atelectasis of both lower lobes . No valvular vegetation was found in echocardiography, and left ventricular ejection fraction (LVEF) was 43%. Initial diagnosis of admission was ESRD with hemodialysis, sever renal anemia, community acquired pneumonia, heart failure and suspected catheter-related infection. Treatment with intravenous piperacillin / tazobactam (2.25 g Q12H) for pneumonia and correction of heart failure and anemia were commenced. The dialysis catheter and urinary catheter were removed and peripheral blood cultures were collected. But his fever with a maximum temperature of 40 °C still persisted. Three consecutive blood, sputum culture and catheter cultures were negative. Additionally, thoracentesis and drainage were performed and hydrothorax culture was also negative. Laboratory detection of tuberculosis and fungi was all negative. Antibiotics were switched successively to cefoperazone sodium / sulbactam sodium (1.5 g Q12H) + moxifloxacin (0.4 g/day) + fluconazole (0.2 g/day), and vancomycin (0.5 g three times a week) + meropenem (0.5 g Q8H), according to consultation results of respiratory department. However, no apparent improvement was noted, and his general condition deteriorated progressively. Response of temperature and indicators of infection to antibiotic therapy was shown in Fig. and Fig. . A repeated chest CT showed increased multiple exudation of both lungs . Finally, fourth blood culture became positive for E. faecium at>105 CFU/ml (vanA genotype) on hospital day 13. At that point, antibiotic therapy was switched to intravenous linezolid (600 mg Q12H) based on the sensitivity pattern of isolates that were vancomycin, moxifloxacin, gentamicin, penicillin, rythromycin and ampicillin resistant, and linezolid, teicoplaninand and tegafycline sensitive. In the following days, the fever subsided gradually . And the CRP and PCT levels decreased steadily . The patient completed a four-week course of linezolid with complete resolution of chest CT abnormalities .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1361_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1361_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ce7e7c502442910ad66b42120317ee2c4408a46
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1361_en.txt
@@ -0,0 +1,9 @@
+The patient was a 79-year-old man with a history of methicillin-resistant Staphylococcus aureus infection (acquired during brain surgery), mitral regurgitation (MR), chronic atrial fibrillation for 9 years, and decreased left ventricular contractility.
+He had eight long-term hospitalizations during which he underwent multiple operations. Metal allergies to nickel (Ni) and cobalt (Co) were detected 8 years prior. The MR gradually worsened and became more severe. Dyspnoea on exertion appeared approximately 2 years prior and gradually worsened.
+One year prior, he was hospitalized for heart failure. Soon after discharge, he gained weight and experienced dyspnoea on exertion, accompanied by lower-leg oedema. Echocardiography showed severe MR, reduced ejection fraction (EF, 50%), and deterioration of pulmonary hypertension (pulmonary pressure: 37/16/25 mmHg).
+Because of recurrent heart failure, an elective surgery was planned after the previous hospital admission, following the successful management of heart failure. Preoperative echocardiography showed the following: left ventricular internal end-diastolic (LVEDD) and end-systolic diameters (LVESD) of 68 and 48 mm, respectively—EF of 45%, severe MR with central jet (tenting height, 12 mm) ( and ), moderate tricuspid regurgitation (TR) (tenting height, 8 mm) , a left atrial diameter of 66 mm, and progressive MR with increased diuretics. Using coronary angiogram and technetium-99m, cardiologists ruled out ischaemia and amyloidosis as the cause of LV dysfunction. Although the LV size was large, the LVEF was over 40% and the wall thickness was approximately 13 mm. Therefore, it was not a typical dilated cardiomyopathy (DCM); yet DCM could not be excluded as the cause of LV dysfunction.
+Prosthetic valves, rings, and TEER containing Ni and Co were contraindicated. Additionally, the sternal closure required a Ni- and Co-free sternal wire. We selected Ni- and Co-free rings for mitral and tricuspid annuloplasty. We used titanium wire for sternal closure as stainless steel can contain traces of nickel. Cardiopulmonary bypass was established through median sternotomy using standard aortic and bicaval cannulation. Antegrade blood cardioplegia was administered, and the left atrium was accessed via a transseptal approach.
+No chord rupture was observed. Left atrial ablation was performed using a modified maze procedure with cryoablation. The left atrial appendage was then resected. A 28-mm Ni- and Co-free Séguin Ring (Séguin Semi-Rigid Annuloplasty Ring; Abbot Medical, Austin, TX, USA) was chosen for mitral valve repair. After the annular mattress sutures were tied, they were passed around the annuloplasty ring again, taking additional bites of atrial tissue and tied again (the double-suture technique). The tricuspid valve was examined after the closure of the interatrial septum. The diameter of the annulus was 55 mm. In addition to annulus enlargement, tethering was also contributing to regurgitation.
+Subsequently, a pledgeted CV4 suture (GORE-TEX® Suture; W. L. Gore & Associates Inc., Newark, DE, USA) was placed at the base of the anterior papillary muscle (PM) and continuously sutured clockwise to the base of the secondary and then inferior PM. The CV4 suture crossed the interventricular septum and externalized the septal ring of the right atrium. After tricuspid annuloplasty using a 27-mm Ni- and Co-free ring (Duran Flexible Partial Ring; Medtronic Inc., Minneapolis, MN, USA) the CV4 suture was passed through the ring. Suture length adjustments were performed under a water test, and the sutures were tied (spiral suspension technique).
+Next, a pledgeted CV4 suture was passed through the head of the anterior and posterior PM via an aortotomy. It was passed from the left ventricular cavity through the mid-septal fibrous annulus and exteriorized through the aortic wall beneath the commissure between the non-coronary and left coronary aortic cusps (PM repositioning) ( and ). Aortotomy was closed with two layers of continuous sutures, and the sternum was closed with a pure titanium wire (Yokozuna wire; USCI Holdings, Tokyo, Japan). Transoesophageal echocardiography confirmed that the MR and TR had disappeared. Postoperative transthoracic echography revealed a trivial MR (tenting height, 8 mm) and disappearance of TR.
+After undergoing treatment for heart failure in the cardiology department, the patient was discharged from the hospital on the 26th postoperative day without dialysis intervention. Two years after surgery, MR and TR had not worsened on echocardiography .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1419_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1419_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6cc7bd14783d6089f87ff7519fefee188fae58dd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1419_en.txt
@@ -0,0 +1,2 @@
+A 62-year-old male presented to an outpatient ophthalmologist with a 5-day history of progressive binocular diplopia and was referred to our institution. On presentation, neurologic and ophthalmologic examination showed a right pupil-involving partial third nerve palsy with no other abnormal findings. Routine brain magnetic resonance imaging (MRI) and time-of-flight MR angiography (MRA) demonstrated an AVM located in the right frontal operculum extending to the anterior insula with venous drainage into the right basal vein of Rosenthal. There was no subarachnoid or intraparenchymal hemorrhage to suggest AVM rupture. A diagnostic cerebral angiogram was performed next and demonstrated a 1.9 cm × 2.2 cm AVM fed by the right middle and accessory meningeal and sphenopalatine arteries and opercular branches of the middle cerebral artery (MCA). The venous drainage followed a deep pattern into a dilated and tortuous right basal vein of Rosenthal to the vein of Galen and ultimately into the straight sinus . The patient underwent staged embolizations of the feeding pedicles using Onyx-18 embolic material (Medtronic, Minneapolis, USA) to facilitate planned surgical resection. In the first stage, superselective catheterization of the right middle meningeal, accessory meningeal, and sphenopalatine arteries was performed using a Marathon microcatheter (Medtronic, Minneapolis, USA) and a Synchro 10 microwire (Stryker, Kalamazoo, USA) . In the second stage, the next day, the feeding branches of the opercular segment of the MCA were accessed with a Scepter balloon-guided microcatheter (MicroVention Inc., Tustin, USA) and a Synchro 2 microwire . On the following day, the patient underwent a right pterional craniotomy for resection of the AVM. An intraoperative control angiogram confirmed complete obliteration of the AVM [ and ]. The pathologic tissue examination was consistent with AVM.
+At the 4-week follow-up, the patient reported complete resolution of the diplopia. Neurologic examination demonstrated no deficits and isocoric pupils with intact extraocular movements bilaterally. There was no recurrence of the diplopia 6 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1427_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1427_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6bef6afd916a22b2c999c5f30cb3cc247f751c79
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1427_en.txt
@@ -0,0 +1,7 @@
+She was 3 years old at the time of her first visit and presented on 16 September 2020 due to language delay. She is 5 years old now.
+Since age 6 mo, she had had obvious slow growth in height and weight. Language development was delayed. Her response to name calling was normal but there was no communication with people. Her eyes could not be met and there was no social smile. There was no autonomous language, However, the child had rich gesture language and body language, she could understand instructions, had a short temper, and when she wants to achieve something, she starts crying or shouting. She was thin, with a weight of 9 kg and height of 83 cm.
+There was no obvious abnormality at birth, weight 3 kg, height 50 cm. She raised her head at 3 mo, crawled at 7 mo, and walked at 15 mo. She had a history of febrile convulsions twice, each lasting about 2 min, which resolved spontaneously, and a 1-year history of ulcerative colitis.
+Both parents were healthy.
+Body temperature was 36.2 °C, heart rate 96 beats/min, breathing 24 beats/min, blood pressure 100/60 mmHg, height 83.0 cm and weight 9 kg. There was no special sick face, and cardiopulmonary and abdominal examinations showed no obvious abnormalities. Bilateral muscle strength and muscle tone were symmetrical and slightly decreased. Physiological reflexes were present but pathological reflexes were not elicited.
+Routine blood and urine examinations, myocardial enzymes, lactic acid, liver function, renal function, electrolytes, blood glucose, thyroid function, and hematuria showed no obvious abnormalities. The peak growth hormone challenge test was 5.77 ng/mL.
+Video electroencephalography showed no abnormalities. Magnetic resonance imaging (MRI) of the brain showed mild atrophy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1436_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1436_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5997334ec826b494c28acbf0a026bc52bfb0e640
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1436_en.txt
@@ -0,0 +1,5 @@
+A 31-year-old black Congolese female patient, P3G3, who had a pregnancy of 38 weeks and four days, was transferred from a district hospital to a tertiary facility in Kinshasa, Democratic Republic of Congo, for severe preeclampsia with acute on chronic fetal distress. Her past medical history was notable for eclampsia during her first pregnancy in 2011 and preeclampsia in 2013 during her second pregnancy. She had had two cesarean sections for her pregnancies, and she had her antenatal care for her third pregnancy at a referral hospital. She was diagnosed with preeclampsia during her third pregnancy for which she received 250 mg alpha-methyl-dopa twice a day. ​​During the 30th week of gestation, the patient’s systolic blood pressure became labile, oscillating between 140 and 150 mmHg, despite her antihypertension medication. The patient consulted at a district hospital where she underwent a fetal wellbeing ultrasound which did not find anomalies.
+The patient was the 7th of 9 children, and her father was hypertensive. She weighed 72 kg for 155 cm, and upon arrival at the authors’ hospital, her blood pressure was 217/152 mmHg. Her heart rate was 101 bpm, her respiratory rate was 24 cpm, and SpO2 was 96% free air. The patient was in pain, she was lucid and coherent, her palpebral conjunctivae were colored, and she had bilateral pitting edema. The fundus height was at 30 cm, the presentation was cephalic, the fetus was bradycardic at 88 bpm, and there were no signs of genital bleeding. The cervix was median, soft, 80% effaced with a 2 cm dilation. Urine deep stick revealed 3+ proteinuria. She had 1.5 mg/dL of creatinine (normal: 0.5–1.5 mg/dL), 22 mg/dL of urea (normal: 10–50 mg/dL), 15,000 white blood cells/ml, 213,000 platelets/ml and 14 g/dL hemoglobin. Based on these findings, we indicated an emergency cesarean section for acute fetal distress, which resulted in the extraction of a dead infant.
+Postoperative suites were marked on day two by decompensated anemia (hemoglobin at 7.8 mg/dL) for which the patient was transfused two units of packed red blood cells. On postoperative day three, the patient presented an abdominal effusion, exacerbation of the bilateral pitting edema, blood pressure increase, hematemesis, melena, petechiae, hematuria, and oliguria. Her blood pressure was 215/120 mmHg and she had signs of renal failure (creatinine = 6.9 mg/dL (normal: 0.84–1.21 mg/dL); urea 132.5 mg/dL (normal: 5–20 mg/dL); hyperkalemia at 6.4 mmol/L (normal: 3.5–5 mmol/L); hyponatremia 109 mmol/L (normal: 136–145 mmol/L); hypocalcemia 0.88 mmol/L (normal: 1.12–1.32 mmol/L)), and signs of hepatic failure (AST 135 IU/L, normal: < 33 IU/L; ALT 325 IU/L, normal: < 33 IU/L; prothrombin ratio 100% (normal: 80–110%). PTT was 39 s (normal: 24–35 s), LDH was 1398 IU/L (normal: 120–280 IU/L), and total bilirubin was 0.35 mg/dL (normal: 0-1 mg/dL)). She equally had neutrophilic leukocytosis at 22,180 cells/mm3 and low platelets at 44,000 cells/mm3. Additionally, schistocytes were identified in the peripheral thin smear.
+The team excluded TTP and HELLP syndrome as possible causes of the postpartum microangiopathic hemolytic anemia (MAHA). This decision was based on the history, clinical presentation, and laboratory findings. Atypical hemolytic uremic syndrome was retained as the final diagnosis, and in the absence of anti-complement therapy, the patient underwent four sessions of hemodialysis. Hypertension was treated with Nicardipine, 5 mg/hr. IV with a 2.5 mg/hr. increase every 15 min without exceeding 15 mg/hr., and the goal was to lower the systolic blood pressure below 160 mmHg. Hyperkalemia was corrected with insulin and glucose (10 units of insulin dose with 25 g of glucose per each 1 mmol/L of potassium above the normal). A favorable clinical and biologic evolution was observed, and the patient was released for outpatient follow-up on postoperative day 18 .
+Laboratory tests could not be obtained more frequently due to their financial burden to the patient and her immediate family. The patient had a normal kidney function at postoperative day 160 (urea 24.2 g/dL, creatinine 0.8 mg/dL) and postoperative day 202 (urea 16.9 g/dL, creatinine 0.8 mg/dL). She did not present new episodes of microangiopathic hemolytic anemia.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1457_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1457_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6a281f48442c186354f9c10bbc8f3b3c5bfec653
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1457_en.txt
@@ -0,0 +1,9 @@
+A 31-year-old Egyptian male with American Society of Anesthesiologists (ASA) I physical status, with history of polytrauma since 1 week, had a left arm and right leg fracture. A complete trauma survey was done at the time of admission, with no other injury and acceptable laboratory and radiological investigations.The operation was done first to the fracture on left hand under general anesthesia with no complications. Then after 1 week, the patient was scheduled for an operation on the right leg. While sitting in the L3–L4 interspace, a 22-gauge needle with a Quincke tip was used to deliver spinal anesthesia to the patient. About 120 seconds after receiving an injection of 20 mg (4 ml) of hyperbaric bupivacaine 0.5%, the patient had significant back and gluteal discomfort, followed by myoclonic movements in the lower limbs and a generalized convulsion.
+The arterial blood pressure of the patient was elevated to 170/100 mmHg, and his heart rate increased to 120 beats per minute. Immediate intravenous sedation with midazolam (5 mg) and fentanyl (50 μg) was delivered with no response in seizure termination. Phenytoin (1000 mg) was given by intravenous infusion and we subsequently applied the airway, breathing, and circulation (ABC) protocol. General anesthesia was induced by a thiopental sodium (250 mg) and atracurium (50 mg) infusion, the trachea of the patient was intubated, and respiratory parameters on mechanical ventilation were as follows: tidal volume (TV) 500 m/minute, respiratory rate (RR) 16 cycles/minute, fraction of inspired oxygen (FIO2) 100%, positive end-expiratory pressure (PEEP) 0 mmHg.
+Maintenance of anesthesia was attained by isoflurane 1.2 minimum alveolar concentration (MAC) and atracurium 10 mg every 20 minutes, and subsequent doses of thiopental sodium (100 mg) to control seizures. Although with the above interventions, the patient developed focal seizures in the hand and leg. The attending anesthesiologist had suspicions regarding intrathecal administration of the incorrect medicine after discovering a used TXA ampoule (500 mg/5 ml) in the trash. So, cerebrospinal fluid (CSF) lavage was done by inserting two spinal 22-gauge Quincke tip needles on level L2–L3 (drainage) and the other on L4–L5. Intrathecal normal saline infusion (150 ml) was done in 1 hour by passive flow. During CSF lavage, vital signs were as follows: blood pressure (BP) 140/85 mmHg, pulse 140 beats/minute, and the patient was on mechanical ventilation (MV) with FIO2 100 and oxygen saturation (SO2) 98%. Arterial blood gases (ABG) were pH 7.42, PaCO2 37, PaO2 157, and HCO3 24 after CSF lavage. The patient was stabilized, and he was transferred to the intensive care unit (ICU).
+About 2.5 hours after the injection, the patient was transferred to the ICU and with volume-controlled ventilation mode, the MV was continued. The patient was put on MV, and thiopental sodium infusion was continued, with 100 mg/hour increased to 300 mg/hour, but the patient developed multiple generalized myoclonic seizures so atracurium was started by loading 50 mg then 5–10 μg/kg/hour as apart of complete general anesthesia. However, the seizures were not controlled so we put the patient on an anesthesia machine and continued MV with isoflurane 1.2 MAC, with thiopental sodium 300 mg/hour and 10 μg/kg/hour atracurium.
+A central venous catheter was inserted on the right subclavian vein. The initial postoperative ABG examination showed pH of 7.44, PaO2 of 170, PaCO2 of 47, and HCO3− of 27. The MV parameter was adjusted to produce hyperventilation to target PaCo2 of 35–40 mmHg with continuous monitoring with capnogram. A complete blood test indicated no evidence of hepatic, renal, or hematological malfunction. Six hours postoperatively, the patient suffered tonico–clonic seizures of the upper limbs and face, which were managed by a continuous infusion of sodium thiopental (3–5 mg/kg/hour), atracurium 10 μg/kg/hour, isoflurane 1.2 MAC, and 150 mg phenytoin every 8 hours.
+Cranial computed tomography revealed no abnormality and fundus examination revealed papilledema, so protective brain strategies continued with mannitol 20% 150 ml every 8 hours for 2 days and isoflurane 1.2 MAC and mild fluid restriction and lasix 20 mg every 12 hours. To avoid ventricular arrhythmia, amiodarone was administered prophylactically at a dose of 10 mg/kg/24 hours for 24 hours. The patient developed sinus tachycardia and his heart rate increased to 150 beats/minute, which was controlled by an amiodarone infusion. After 3 hours from admission to ICU, the patient’s blood pressure decreased, with mean arterial blood pressure below 50 mmHg, and investigations showed normal electrocardiogram (ECG) sinus rhythm. Central venous pressure (CVP) was 10 cm H2O, so norepinephrine infusion was started at 0.05 μg/kg/minute to maintain tissue and cerebral perfusion. The mean arterial blood pressure then improved with norepinephrine and maintained above 75 mmHg.
+On the second day postoperatively, the sedation began to decrease: first isoflurane to reach 0.6 MAC, then isoflurane was stopped, and thiopental sodium was decreased to 200 mg/hour. The patient developed one-time seizures on the face and upper extremities, so sedation was continued for another 24 hours with decreasing thiopental sodium to 200 mg/hour only. Also, the patient became feverish (39 °C) in the second day so, 1 gm intravenous acetaminophen was given every 6 hours.
+Norepinephrine was stopped after 24 hours as mean arterial blood pressure was maintained over 75 mmHg without support.
+On the third day after surgery, sedation was discontinued. As the patient’s degree of consciousness improved, he moved his head and upper extremities in response to painful stimuli and absence of deep tendon reflexes in the lower limbs. On the fourth day postoperatively, he opened his eyes in response to voice instructions, followed simple directions, and breathed on his own. The trachea was extubated, and all neurologic examinations were acceptable. The patient was discharged from the ICU on the sixth day and transferred to the ward after 48 hours from weaning from MV. The patient was discharged home with recommendation to follow-up with neurology and to be fully evaluated after 6 months. The patient was monitored at 6-month and 1-year intervals and found to be in excellent condition with no neurological symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1460_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1460_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ff631f883cbdced2a2a757936c30dd02c8e87393
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1460_en.txt
@@ -0,0 +1,3 @@
+The patient is a 33-year-old female patient with personal history of NF1 (without any family history in the two previous generations) characterized by multiple Café au lait macules and multiple neurofibroma nodules in distinct regions of the skin which involve the scalp, neck, back, abdomen, and all the extremities.
+The patient has a normal evolution of her disease with no incidents; she is an independent professional and refers no other symptomatology. Eventually, she complains of pain due to the mechanical compression of one of the neurofibromas. After considering the genetic counseling, the patient decides to get pregnant. During the second trimester of her pregnancy, she started to note gradual and progressive growth of one of the neurofibromas located in the anterolateral left portion of the neck, in the angle formed by the thyroid gland and the common carotid artery. Such growth gradually increased to the point where by the end of the pregnancy it had a diameter of approximately 10 cm × 15 cm, it made swallowing difficult, dysphonia, and generated local pain (nonneuropathic pain) . The consistency was smooth in the peripheral contours, but firm in the center, mobile, and no skin changes were noted. She has an uneventful full term pregnancy with a C-section delivery.
+After neuroimaging evaluation, a surgical approach is decided 3 months after the C-section using general anesthesia and microsurgical dissection. A tumor mass was identified, with a superficial wall, free from vascular or cervical major nerve structures, with a clear serous liquid content that after decompression, modifies the tumoral morphology immediately, allowing identification of the layers of the cystic lesion. The visceral portion of the capsule was found attached to the external plane of the thyroid gland and to the carotid artery adventitia, which was preserved. The postsurgical evolution was normal, without any complications. There were no alterations regarding phonation or deglutition, and there was a normal recovery of the external anatomy of the neck without any evidence of tumoral mass. The analysis of the fluid reported no cytological alterations and culture was negative for infection. The hematoxylin and eosin stain shows the presence of neoplastic cells, nuclear and diffuse cytoplasmic positivity to S-100 protein .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1471_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1471_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3387e4e33fb251a453f6fb41506f5a41be93b987
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1471_en.txt
@@ -0,0 +1,2 @@
+A 30-year-old Japanese man was referred to our clinic complaining of pain, tenderness, and swelling on the left side of his palate for the past several months. Our initial clinical examination found that his left palatine mucosa was significantly swollen compared with his right side. The swelling was diffuse, and its borders were unclear . The swelling was especially pronounced in the left molar region of his palate, and his pain was exacerbated with the application of direct pressure to the lesion. The swelling exhibited increased signal intensity on T2-weighted magnetic resonance images (MRI, Fig. ). All of his left maxillary teeth were healthy, and no specific abnormalities in his left maxilla and maxillary sinus were observed on panoramic X-ray and computed tomography (CT) images. His medical and familial histories were unremarkable, and he was not aware of any history of trauma or inflammation of his head or neck. We administered antibiotics orally (cefcapene pivoxil hydrochloride hydrate 100 mg tablet every 8 hours) and non-steroidal anti-inflammatory drugs (loxoprofen sodium hydrate 60 mg tablet every 8 hours) for 7 days because we suspected that his symptoms were due to inflammation secondary to an infection. However, his symptoms did not improve.
+Based on his clinical and radiographic examinations, our initial diagnosis was a soft tissue tumor. An incisional biopsy was performed and histopathologic examination of the lesion revealed haphazard nodes and inflammatory cells in a fibrous stroma . Immunohistochemical analysis revealed significant staining for the neural marker S-100 in the bundles within the node . Factor VIII staining was positive in the fibrous stroma, but not in the bundles . These findings led to the diagnosis of a traumatic neuroma. The patient underwent resection of the tumor with a 5-mm margin using an electric scalpel under general anesthesia. Although the border of the mass was unclear and diffuse, the extent of the tumor could be determined based on the MRI images. As the tumor was conglutinated with a part of his palatine bone, we saucerized the bone surface including the overlying mucosa and the periosteum. His left greater palatine nerve was resected as the possible origin of the tumor. The open surgical wound was covered with a collagen-based artificial dermis (Terudermis, Olympus Terumo Biomaterials Corp, Tokyo, Japan) and a surgical splint. The size of the specimen was approximately 6×3 cm . The pathologic findings of the surgical specimen were the same as those of the incisional biopsy specimen, and the patient’s greater palatine nerve exhibited no pathologic changes. The tumor was not entirely encapsulated and some tumor cells were observed within the surgical margins. We decided to continue strict clinical follow-up without additional surgery because the traumatic neuroma is not a true neoplasm, and his pain subsided immediately after the surgery. No clinical evidence of a recurrence has been observed in the 3 years since the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1474_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1474_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..04c72a04ac1f4f7d4c64707ad70271b03434df4b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1474_en.txt
@@ -0,0 +1,2 @@
+The patient was 76-year-old male, right-handed, living by himself, and fully able to walk independently. His chief complaint was right shoulder pain, limited range of motion (ROM) in the right shoulder. He fell on his right shoulder while walking and injured it. He visited another hospital 3 days after the injury where he was diagnosed with dislocation of the right shoulder and received manual reduction followed by immobilization with a sling. Due to persistent pain and limited ROM of the right shoulder, plain magnetic resonance imaging (MRI)was performed and revealed a massive rotator cuff tear. He was then referred to our hospital 2 months after the injury. Physical findings on initial examination were markedly limited ROM and decreased abductor/external rotator muscle strength were observed, with an active flexion angle of 10°, active abduction angle of 10°, active external rotation angle of 0°, and manual muscle test (MMT) for abductor and lateral rotator (at a hanging position) muscle strength of 2 . Visually discernible atrophy of the deltoid, supraspinatus and infraspinatus muscles and hypoesthesia (5/10) in the axillary nerve region were also observed. At this point, the patient was given an American shoulder and elbow surgeons (ASES) scoring system of 10/100, University of California at Los Angeles (UCLA) shoulder scaling system of 4/35, and Japanese Orthopaedic Association (JOA) scoring system of 37/100. The plain X-ray findings were irregular glenohumeral joint surface and subacromial osteophytes, diagnosed as Grade 3 on the Hamada classification , were observed. The plain MRI findings were massive tear of the supraspinatus and infraspinatus muscles, which were withdrawn back to the glenoid fossa, diagnosed as Stage4 atrophy of supraspinatus muscle and Stage3 atrophy of infraspinatus muscle on the Goutallier classification was observed. The subscapular muscle was completely torn with bone fragment formation and diagnosed as Grade 3 on the ide classification . Electromyography was performed at the neurology department of our hospital to evaluate the degree of axillary nerve palsy. A motor nerve conduction study of the axillary nerve showed a marked decrease in compound muscle action potential in the deltoid muscle. An electromyogram showed a denervation potential suggestive of neurogenic changes in muscles innervated by the axillary nerve, leading to a diagnosis of axillary nerve palsy, leading to a diagnosis of neuropraxia in axillary nerve. However, muscle contraction was maintained in the axillary nerve region, suggesting the possibility of restoration. Therefore, a treatment plan was developed to conduct an outpatient rehabilitation program to improve the ROM and enhance the muscle strength of the shoulder until the palsy is improved, and then perform the surgical treatment. Hypoesthesia improved to 7—/10 with a reduced affected area. Furthermore, noted was an improved ROM, with active flexion, abduction, and external rotation angles of 20°, 20°, and 40°, respectively, and gradual improvement in muscle strength, with an abductor and external rotator (at a hanging position) muscle strength of 2 and 3 by MMT, respectively ( and ). Given these findings, ASCR was performed 6 months after injury.
+The operation was started with the patient placed in a beach chair position under general anesthesia. Two portals were made in the posterior and lateral aspects of the shoulder, and the posterior portal was used to perform intra-articular locking. Arthroscopy revealed no injury in the tendon of the long head of the biceps brachii muscle, but its origin was detached along with the labrum. The rotator cuff was extensively torn, involving the tendons of the subscapular, supraspinatus, and infraspinatus muscles, with the stumps withdrawn back to the glenoid fossa. Osteoarthritic changes were observed in the joint surface but were mild in severity. Mild injury of the glenoid labrum was observed, but it was not associated with joint dislocation under anesthesia. The subscapular muscle tear was repaired as it was considered reparable. In contrast, the supra/infraspinatus muscle tear was considered irreparable; therefore, the contralateral fascia lata was collected, folded in half and used as a graft for ASCR. Although it was initially planned to repair the humeral head side of the graft using a bridging suture, it was difficult to place four anchors due to poor bone quality. Therefore, the graft was fixed using single-row interrupted sutures. Finally, to complete the operation, the graft was attached to the residual teres minor muscle by interrupted sutures . After surgery, the patient wore a shoulder abduction pillow for 3 weeks, followed by immobilization with a sling for 2 weeks. On the day after the operation, the patient started shoulder girdle relaxation, passive ROM, and periscapular muscle training. An ultrasonography performed 4 weeks after operation showed coverage of the torn portion by the graft. External fixation was removed 5 weeks after the operation, and active ROM training was started. Hypoesthesia in the axillary nerve region was almost completely resolvedat 3 months after operation, with no bilateral difference. Pain and deltoid muscle atrophy were resolved by 4.5 months after operation. During the first 2 years after operation, improvements were observed in both the ROM and muscle strength of the shoulder, with an ASES shoulder score of 96, UCLA shoulder rating scale of 34, and JOA score of 95. An MRI performed 2 years after operation also showed adequate coverage of the torn portion by the graft ( and ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1492_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1492_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..94c7e00782b2e29aab46add7996fc5d07ba4f5b9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1492_en.txt
@@ -0,0 +1 @@
+A 70-year-old man was diagnosed with lung adenocarcinoma (clinical T4N0M0) involving a right upper lobe mass of 4.0 cm in diameter and a metastatic nodule in the middle lobe. He underwent right upper and middle bilobectomy and systematic lymph node dissection through a posterolateral thoracotomy. On the second postoperative day, 1750 mL of white turbid fluid was drained through the chest tube and the effusion was diagnosed as chylothorax. During the first 24 h following implementation of a fat-free dietary regimen, the color of the discharge became transparent, but another 630 mL of discharge was observed. Although the amount of discharge reduced gradually, it was persistent. Chemical pleurodesis was performed on the sixth postoperative day for which 5 KE of OK-432 (Picibanil; Chugai Pharmaceutical, Tokyo, Japan) and 300 mg of minocycline were administered into the thoracic cavity. The discharge began to progressively diminish. Three days thereafter, the amount of discharge had decreased to 150 mL/day, and on the ninth postoperative day, the chest tube was removed. On the 14th postoperative day, the patient complained of dyspnea and dysphagia, and an upper mediastinal mass was detected on chest radiogram . Chest computed tomography revealed a large mediastinal fluid collection 6 cm in diameter surrounded by a thick capsule that was compressing the trachea and esophagus . The mass was suspected to be a mediastinal chyloma. Since the patient’s symptoms were gradually progressing, we performed surgery on the 15th postoperative day. Thirty minutes before the surgery, ice cream was given to the patient to help confirm the leakage point in the thoracic duct. Thoracoscopy revealed a small amount of chylous effusion in the thoracic cavity and an elastic mass in the upper mediastinum. When the thick capsule was incised, chyle began to spill out . Once the chyle had drained completely, we confirmed the point of leakage and repaired it using a Z-suture with 4–0 Prolene (Ethicon, Somerville, NJ) . The postoperative course was uneventful and the patient was free of any symptoms. He remained asymptomatic 12 months after discharge from the hospital.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1508_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1508_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..53e770ae3f863e55572f249bf2b26394593a64eb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1508_en.txt
@@ -0,0 +1,6 @@
+A 68-year-old Peruvian man had been suffering from lumbar pain for several days. His CT scan revealed a mass compressing his right ureter and iliac vessels. He underwent exploratory laparotomy with radical resection of a retroperitoneal tumor (10 cm × 8.3 cm × 8 cm), as well as ileocecectomy and ileocecal anastomosis. Pathological analysis showed that the tumor was a DDL (T2 N0 M0, FNCLCC grade 2, stage IIIA, <50% necrosis, R0). This diagnosis was corroborated by immunohistochemistry markers (ie, the positivity of D33 and NSE and negativity of h-CD and S100). One month after the surgery (for details of the disease course, see ), his initial postoperative scan showed the absence of disease. However, 2 months later (3 months after the surgery), his new CT scan revealed a 1.6 cm × 2.3 cm mass anterior to the right iliac vessels (first recurrence). He received neoadjuvant chemotherapy with doxorubicin plus ifosfamide (6 cycles). Then he underwent resection of the retroperitoneal tumor (R0) and right ureterectomy. The patient further received 3 cycles of doxorubicin plus ifosfamide postoperatively. Eight months after chemotherapy (11 months after the second surgery), a control imaging revealed 2 anterior psoas masses measuring 1.5 cm × 1.5 cm and 1.3 cm × 1 cm (second recurrence). The biopsy of one of the lesions revealed a malignant spindle cell neoplasm compatible with DDL. Two months later, the CT scan showed that the masses had enlarged to 3.0 cm × 1.9 cm and 2.1 cm × 1.6 cm. However, CT scans and a chest x-ray revealed no evidence of metastatic disease. The patient underwent a third surgery wherein the 2 masses and a right pelvic mass were resected entirely (R0). At this point, the patient sought for different treatment options involving an integrative approach. Three months later, he came to the Centro Médico Antroposófico (CMA) and became our patient.
+The recommended treatment was subcutaneous injections of VAE obtained from the host tree ash (AbnobaVISCUM® Fraxini); the injections were given thrice per week in increasing doses. The application of VAE Fraxini in the periumbilical area started at 0.2 mg; after 6 months, the dose was increased to 2 mg, which was then maintained for 7 months. The subcutaneous VAE injections occasionally induced self-limited local erythema and swelling of the skin around the application site, which could be tolerated by the patient. Nine months after the VAE treatment was initiated (12 months after the third surgery), a retroperitoneal mass measuring 4.1 cm × 3.0 cm was noticed (third recurrence). After 5 more months, the dose of VAE was increased to 20 mg thrice per week. Three months later, the patient underwent resection (fourth surgery) of a right iliac fossa tumor (a mass measuring 4.7 cm × 3.5 cm with a moderate amount of surrounding fibroadipose tissue) and a right juxtarenal psoas tumor (a well-encapsulated, focal fibro-fatty soft tissue measuring 8.7 cm × 6.5 cm with central areas of probable necrosis). Both tumors were DDLs (FNCLCC grade 3, pT2b). The patient had a negative margin resection (R0) for the larger sarcoma, and the other exhibited focal involvement by the tumor. A cholecystectomy (mild chronic cholecystitis and cholelithiasis) and appendectomy were also performed, and both organs were negative for tumor. Additionally, he received 12 cycles of three-dimensional conformal radiotherapy post-surgery.
+As a result of the previous surgeries, which involved a partial right ureter resection with psoas bladder hitch, the patient developed obstructive renal failure as evidenced by the right ureteral obstruction and abnormal serum creatinine levels. The patient then underwent a right percutaneous nephrostomy with stent placement.
+Throughout this time, the patient continued to receive VAE Fraxini. Follow-up magnetic resonance imaging was performed periodically post-surgery. Three-month breaks without VAE Fraxini application were set twice per year after obtaining the first negative follow-up magnetic resonance imaging result. The frequency of subcutaneous VAE Fraxini application was reduced to twice per week from month 54 on. The patient reached a recurrence-free interval of 69 months; however, the magnetic resonance imaging performed on month 86 of VAE Fraxini treatment showed a mass in the right iliac fossa. The tumor measuring 8.1 cm × 4.8 cm (FNCLCC grade 3, pT2b) was resected. The tumor showed areas of well-differentiated liposarcoma, which were mixed with areas of intermediate to highly dedifferentiated myxoid fibrosarcoma and high-grade undifferentiated pleomorphic sarcoma. The tumor was relatively well-circumscribed and mostly surrounded by fibroconnective and fibroadipose tissues of variable thickness. However, the resection margins were involved by the sarcoma. One month after the surgery, the VAE treatment was resumed. The patient started receiving intravenous infusion of 100 mg VAE obtained from pine as host tree (Helixor® P); the injections were administered in 500 mL of standard saline solution over 2 hours thrice a week. The dose was increased by 100 mg per application until 400 mg was reached which was maintained until 12 applications were completed. Then, the patient was subjected again to subcutaneous injection with 20 mg VAE Fraxini thrice per week. Five months after the surgery, multiple abdominal and retroperitoneal nodular tumor implants were detected, and their number and size increased within the following 9 months. For 2 weeks, the patient received intravenous infusion of VAE (Helixor® P, maximum dose: 400 mg) followed by subcutaneous infusion of 20 mg VAE Fraxini. One of the implants caused urinary tract obstruction, and the patient developed renal and abdominal pain, which was treated with buprenorphine 20 mg/25 cm2 transdermal patches and with anthroposophic remedies (Wala® Solum Inject, Wala® Plexus coeliacus D15, Wala® Bryonia/Stannum, Weleda® Formica comp injections, thrice per week). Weleda® Equisetum sulfuratum tostum D3 was applied (thrice a day) to support the urinary function. When the pain was relieved and controlled, intravenous infusions of VAE were resumed. He also received 1 cycle of eribulin (1.65 mg IV infusion). In month 103 of the VAE treatment, the patient underwent pleurodesis due to pleural effusion; however, he died 2 weeks later. Altogether, the patient received a total of 103 months (8.6 years) of VAE treatment and achieved 10.5 years of survival.
+Within approximately 2 years during which the first 3 surgeries were performed, the patient’s weight decreased from 84 kg to 71 kg. Since the VAE treatment started, the patient’s quality of life progressively improved as seen in his increased appetite, resulting in weight gain (up to 77 kg) during the low-dose VAE treatment. After the fourth surgery, his weight was 70 kg to 74 kg. After the fifth surgery, his weight decreased to 66 kg and then increased again to 70 kg . The ideal body weight based on his height (172 cm), gender, and age is 54.7 kg to 74.0 kg.
+The patient was married and had 3 grown-up children. He had a history of tobacco use, but he quit after being diagnosed with DDL. He consumed alcoholic beverages occasionally. His medical history included diphtheria and hemorrhoidectomy. His father died of leukemia, and his paternal uncle had an unknown cancer of the lower extremity. Further medications included allopurinol tablets for high blood uric acid level and a combination preparation of hydrocodone 10 mg and bitartrate and acetaminophen 500 mg tablets for left lumbar region pain. The patient stopped taking these medications on month 18 of VAE treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1518_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1518_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..176ed807a28b1255877a18bc343327d5a57376b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1518_en.txt
@@ -0,0 +1 @@
+A 62-year-old man with no history of eye surgery underwent 25G+ pars plana vitrectomy for proliferative diabetic retinopathy. After retrobulbar anesthesia, a vision system was used to view the surgical field, and an inferotemporal sclerotomy was created using a 25G+ trocar. The trocar obliquely punctured the bulbar conjunctiva and sclera at an angle of 45° (sclerotomy), approximately 4 mm from the limbus and parallel to it. The trocar was twisted into the eyeball, and its orientation was gradually changed perpendicular to the limbus. After confirming that the cannula was inside the eye, we pulled out the trocar and inserted an infusion cannula into the port. Two more sclerotomies were created in the superotemporal and superonasal quadrants. However, when we pulled out the superonasal trocar, the collar of the cannula fell off and the cannula tube was missing . Therefore, a bulbar conjunctival incision was placed to search for the missing cannula. No cannula was found in the subconjunctival space. We used a scleral depressor to look for the missing cannula tube along the peripheral retina and found the broken cannula tip in the ciliary body corresponding to the superonasal sclerotomy site. We created a new sclerotomy 2 mm above the original incision and 4 mm from the limbus and subsequently performed vitrectomy around the broken cannula to mobilize it for extraction. The new scleral incision was extended to 3 mm parallel to the limbus and allowed entry of a foreign body forceps . The broken tip of the cannula was brought into view by indenting the sclera adjacent to the original sclerotomy. We used the foreign body forceps to clamp and pull the fractured cannula toward the central vitreous body . With the help of the light probe, the longitudinal length of the cannula was aligned with the foreign body forceps and retrieved through the enlarged incision . No leakage occurred from the original sutureless scleral incision. The extended scleral incision was sutured with 7-0 polyglactin 910 suture.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1519_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1519_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e191ebd456d19fff11d499473e11760eef90d0c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1519_en.txt
@@ -0,0 +1,12 @@
+A 64-year-old woman with increased lethargy, generalized weakness, and shortness of breath on exertion was found to have pancytopenia on a routine blood count; hemoglobin 80 g/L, white blood cells 3.2 × 109/L, platelets 98 × 109/L. After bone marrow examination a diagnosis of refractory anemia with excess blasts (RAEB) was made. The symptoms were attributed to anemia and she received 5 units of packed red cells.
+Approximately 2 months later, she developed a 4-day course of intermittent chills and sweating but was afebrile when she came to the local emergency department. The CBC at admission demonstrated 6.9 × 109/L white blood cells with left shift and 0.21 × 109/L blasts, 76 g/L hemoglobin and 65 × 109/L platelets. During her hospital stay the white blood cells increased to 16.9 × 109/L with increasing left shift; anemia and thrombocytopenia persisted. There was central bronchial wall thickening and interstitial prominence in the chest radiograph suggestive of an early viral infectious process. The cardiomediastinal silhouette was within normal limits . The electrocardiogram (ECG) showed normal sinus rhythm. The patient was started on oral levofloxacin.
+Four days later, the patient became febrile (38.8 degrees) and developed increasing shortness of breath and retrosternal chest pain that radiated to both arms. There were bilateral crepitations and decreased breath sounds. Repeat chest radiograph demonstrated bilateral pleural effusions, basal consolidation of the left lower lobe and left ventricular enlargement. There was no evidence of cardiac failure . Right bundle branch block (RBBB) with sinus tachycardia was identified on ECG. An echocardiographic study identified a moderate pericardial effusion with no cardiac tamponade; the left ventricular ejection fraction was 66% and there were no regional wall motion abnormalities. The next day, a repeat echocardiographic study identified a 33% ejection fraction with left ventricular global hypokinesia and a moderate sized pericardial effusion without tamponade. The patient was treated for pneumonia, hypotension, acute renal failure, and anemia but developed heart block and cardiorespiratory compromise. Her condition deteriorated rapidly and she died five days post-admission.
+Peripheral blood and bone marrow, ante-mortem : In the peripheral blood there was dysplasia in the leukocytes (pseudo Pelger-Huet cells and hypogranular neutrophils), platelets (hypogranular platelets and large platelets) and red cells (macrocytic red cells and dimorphic red cells) was associated with a left shift and circulating blasts. The bone marrow was hypercellular with trilineage dysplasia (pseudo Pelger-Huet cells, erythroid precursors with nuclear bridging, irregular nuclear contours, irregular hemoglobinization of the cytoplasm and mononuclear and multinucleated megakaryocytes). There was abnormal localization of immature precursors (ALIP) in the core biopsy. The bone marrow aspirate differential count showed increased blasts (18.2%) while the erythroid precursors were less than 50% of the nucleated cells.
+Post-mortem examination was limited to heart and lungs at the request of the family. The heart lay free in the pericardial sac, surrounded by 300 mL of straw-colored pericardial effusion. There was fibrinous pericarditis. The free wall of the left ventricle and the interventricular septum had soft and hemorrhagic areas scattered throughout, with no definite transmural focus. The major coronary arteries (right coronary, left anterior descending, and left circumflex arteries) were involved to only a minor degree by old eccentric atherosclerotic plaques (maximum stenosis of 25 to 30%) with no evidence of an acute event (thromboembolus, hemorrhage, rupture). There was bilateral pulmonary edema and left lower lobe congestion and consolidation.
+Microscopic examination of the heart revealed a diffuse interstitial infiltrate of immature dysplastic hemopoietic cells involving the myocardium, endocardium and the pericardium. Cells of myeloid, erythroid and megakaryocytic lineages were present. These infiltrates were associated with single fibre myocyte necrosis as well as larger foci of necrosis. A majority of these cells were immunopositive for myeloperoxidase consisted with myeloid lineage.
+Pancytopenia associated with peripheral blood features including dysplastic changes in the granulocytes, <1% blasts and < 1 × 109/L monocytes coupled with multilineage dysplasia and 18.2% blasts in the bone marrow was in keeping with the diagnosis of refractory anemia with excess blasts-2 (RAEB-2) . Clinical presentation and clinical course of RAEB is typically related to the symptoms of decreased counts of one or more cell lineages and blast count [,]. The symptoms of lethargy, shortness of breath, and generalized weakness in this patient may be attributed to both anemia and cardiac infiltration by malignant cells, although the former is much more common clinically . Her cardiac symptoms were not due to drugs sometimes used in patients with myelodysplasia, since the patient had not received cytotoxic, immunomodulatory, putative differentiating agent, or hemopoietic growth factor therapy [-].
+Although cardiac involvement in leukemic extramedullary spread is relatively common (ranging from 37–44%) [-], clinical signs are found in less than 1% of cases [-] and leukemic cardiac involvement antemortem is usually not suspected . The most likely reason for this is the subclinical nature of the symptoms and signs in cardiac leukemic infiltration . This is in keeping with the observation that gross infiltrative disease at the time of initial diagnosis in patients with acute leukemia is rare [,,]. In the patient reported here extramedullary (cardiac) infiltration by dysplastic hemopoietic precursors by itself is not a reason to upgrade the diagnosis to acute leukemia. Extramedullary infiltration at other sites has been reported in patients with myelodysplastic syndromes [,], more frequently in patients with chronic myelomonocytic leukemia compared to RAEB and refractory cytopenia with multilineage dysplasia [,]. Although it may herald transformation to acute leukemia , this transformation may not be observed for some time [,] and sometimes not at all during follow-up [,]. Granulocyte-macrophage colony stimulating factor overproduction may lead to autonomous colony formation in the bone marrow of patients with myelodysplastic syndrome ; this may partially explain proliferation of malignant hemopoietic cells in the heart infiltrated by malignant cells.
+Although cardiac infiltration is usually associated with high WBC count (mostly due to blasts) and advanced disease , the presence of a high circulating white blood cell count is not a necessity for developing cardiac infiltration as infiltration has been shown to be present in aleukemic leukemia as well as in patients with very low white cell counts . The development of cardiac infiltration in our patient with myelodysplasia and pancytopenia would be consistent with this observation keeping with this pheneomenon; the rising white late in the course of the disease was was predominantly due to neutrophilia and left shift and not due to a large blast population.
+The effects of hemopoietic cell infiltrate in the heart are varied. Leukemic deposits may form mass lesions or thrombi . Pericardial involvement may lead to pericardial effusion contributing to restrictive myocardial dysfunction [,]. Reports of heart block in extramedullary cardiac leukemic involvement are few [,,]. Heart block has been observed in patients with both very high and very low peripheral blood white cell counts and may be reversible after local radiotherapy to the heart despite persistence of leukemic infiltration . However, infiltration of the conduction system is a potentially serious complication that may be fatal . Leukemic infiltration is a rare cause of restrictive cardiomyopathy . An antemortem study of 18 patients with acute leukemia (6 ALL, 12 AML) demonstrated no significant difference from controls in LV systolic function parameters including LV ejection fraction, similar to what was observed in our patient at initial echocardiography . However, LV diastolic dysfunction has been observed in 38 percent of leukemic patients, independent of age and heart rate. It is likely that cardiac compromise in our patient was due to a combination of restrictive cardiomyopathy due to leukemic infiltration, concomitant anemia, cardiac dilatation, conduction blocks and myocardial necrosis. Myocardial necrosis was most likely due to a combination of, a) ischemic damage secondary to anemia and prolonged hypotension and b) extensive leukemic infiltration. Markedly rapid decrease in ejection fraction from 66% to 33% also suggests the role of ischemia, since leukemic infiltration is not expected to cause this degree of systolic dysfunction over a 24-hour period.
+Usual causes of death in patients with myelodysplasia are related to bone marrow failure and transformation to acute leukemia [,,], however, in this patient, death was attributed to cardiac failure. It is likely that the rising white blood cell count during second admission, although predominantly due to neutrophilia and left shift, was associated with early transformation- in view of increased peripheral blood blast percentage – the limited autopsy did not permit evaluation of the bone marrow.
+Cardiac involvement in by malignant hemopoietic cells is of more than just academic interest, since cardiac function has been shown to improve following therapy directed against malignant infiltrate [,]. Incorrect diagnosis during life and the fatal outcome highlight the clinical importance of considering myocardial infiltration in patients with myelodysplasia and cardiac symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1525_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1525_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3d3ef535fc556ea9de1049ffc63acf4c2630c283
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1525_en.txt
@@ -0,0 +1,7 @@
+A 22-year-old Sri Lankan man presented with acute onset diplopia, progressively worsening over one week. He had noted that his eyelids were drooping, especially towards end of the day. He did not experience dysphagia, dysarthria or limb weakness. He had been diagnosed with end stage renal failure (ESRF) due to obstructive uropathy one year ago. Although his serum creatinine had been 16.4 mg/dl (normal: 0.7 – 1.3) five months ago, he had not consented for renal replacement therapy.
+On examination, he had a fatigable bilateral asymmetrical partial ptosis (additional file 1) and a positive curtain sign (manually raising the more ptotic lid causes increased ptosis on the opposite side), but the Cogan’s lid twitch and peek signs were negative. There was a complex external ophthalmoplegia without nystagmus . The pupils were normal. Limb power was 5/5 (modified medical research council score) in all four limbs, no cerebellar signs were noted and the sensation to pin prick and joint position sense was intact. The rest of the examination were normal apart from severe pallor. The blood pressure was 130/80 mmHg. The bedside ice-pack test for ocular myasthenia gravis was negative.
+The biochemical parameters on admission are given in the Table .
+After correcting the hypocalcaemia, haemodialysis was commenced because of the severe acidosis and continued on an alternate day frequency.
+In the evaluation for the cause of the patient’s complex ophthalmoplegia and fatigable ptosis, the following investigations were done .
+Acetylcholine receptor antibodies were not tested due to resource constraints.
+The patient’s ophthalmoplegia improved completely by the end of the first week after initiating haemodialysis and the ptosis resolved by the end of the second week . The MRI of the brain repeated after two weeks demonstrated marked improvement in the previously noted brainstem abnormalities with residual mild T2W/FLAIR hyperintensities in the midbrain. T2W hyperintensities in the internal capsule and cerebellar peduncles had completely resolved .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1533_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1533_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..528dfa54b1fd0139c41330bdc070d2b4caa6e2c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1533_en.txt
@@ -0,0 +1,2 @@
+A 5-year-old Asian boy presented with decreased visual acuity in his right eye . He was born with CL/P at 40 weeks of gestation. However, he had no family history of CL/P. His mother received a measles, mumps, and rubella vaccine during the first trimester of pregnancy. No relevant history of smoking, alcohol consumption, folate deficiency, exposure to ionizing radiation, or any severe infection during pregnancy was found. Prenatal fetal ultrasonography showed unilateral CL/P on the right side without brain lesions. Postnatal renal ultrasonography of the child revealed mild hydronephrosis in the right kidney without dysfunction. Follow-up examination at 4 years of age confirmed that both the kidneys were normal. He underwent several cardiological and endocrinological investigations for the evaluation of congenital rubella syndrome, which revealed no abnormal findings. Neurological examination revealed no midline defect of the vertebral bodies. At 9 months of age, he underwent successful surgical repair of his unilateral CL on the right side . He experienced two episodes of febrile seizures at the age of 2 years with no sequelae. Electroencephalography after the seizures revealed no remarkable findings. Although genetic analysis was recommended, his parents refused to undergo chromosomal evaluation. Magnetic resonance imaging showed no other midline defects or neurological anomalies. He did not have any intellectual or psychomotor developmental delays.
+At initial presentation, his best-corrected visual acuity (BCVA) was 20/60 in the right eye and 20/25 in the left eye. Slit lamp examination revealed iris coloboma in the inferonasal quadrant of the right eye . Fundus examination showed optic nerve and chorioretinal colobomas in the inferonasal quadrant of the right eye . Spectral domain optical coherence tomography showed preserved foveal anatomy without retinoschisis or neurosensory detachment in the right eye . No evidence of microphthalmia, scleromalacia, congenital cataract, or ocular motility disorder was found. The left eye had no remarkable findings. He was prescribed glasses based on his cycloplegic refractive errors (Right eye: − 2.00 Dsph − 2.00 Dcyl × Axis 180°; Left eye: + 1.50 Dsph − 1.00 Dcyl × Axis 180°). We recommended daily occlusion therapy in the left eye for 4 h. After 3 months, BCVA in the right eye improved to 20/30. In addition, the patient was referred to the otolaryngology department for otological and audiological assessments, which revealed no relevant abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1543_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1543_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8308f73b2e2311db230be8e23a9a1c23496d07e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1543_en.txt
@@ -0,0 +1 @@
+A 56-year-old female military officer was referred to the Colorectal Surgical Department for mid-rectal cancer 8 cm from the anal verge. The patient had no past medical history. Her physical examination and routine laboratory studies were unremarkable. Her carcinoembryonic antigen level was 5.93 ng/ml, and an abdomino-pelvic computed tomography (CT) scan showed no intra-abdominal metastasis. Pelvic magnetic resonance imaging showed a clinical T2N0 tumor. The patient underwent laparoscopic low anterior resection and diverting loop ileostomy. The operation time was 310 min. The pathologic results showed that the adenocarcinoma had infiltrated the proper muscle layer (T2) with no lymph node metastasis (0/17). On postoperative day 3, the patient complained of vomiting and abdominal pain, and a follow-up abdomino-pelvic CT scan showed an ileo-ileal type intussusception . Two days of surgical observation were unsuccessful, and her nausea and abdominal pain continued. The patient then underwent exploratory laparotomy. On exploration, intussusception was found 40 cm proximal to the loop ileostomy site. The proximal ileum (P, intussusceptum) had invaginated into the distal segment (D, intussuscipiens), and segmental resection of the ileum was carried out . There was no pathological leading point on the resected ileum . The patient recovered uneventfully and was discharged on postoperative day 14 after the second operation. The patient has remained in good health for two years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1551_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1551_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a20dff0ae6a5c0866acc8ff9823289a279ea4d55
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1551_en.txt
@@ -0,0 +1 @@
+A 52-year-old previously healthy woman with no family history of endocrine disease was admitted to our hospital with suspected PA based on high blood pressure (193/105 mmHg), spontaneous hypokalemia (potassium [K], 3.4 mmol/L), and a high aldosterone-to-renin ratio (ARR 71 ng/dL per ng/mL/h [plasma renin activity (PRA) 0.2 ng/mL/h and plasma aldosterone concentration (PAC) 14.2 ng/dL]). On admission, the patient showed no clinical features of Cushing syndrome, and no catecholamine excess symptoms other than hypertension, such as headache or excessive sweating. Before the initiation of antihypertensive drugs, PA was confirmed by the positive captopril challenge test (PRA: 0.2 ng/mL/h, PAC: 9.6 ng/dL, ARR: 48 [> 20]; Table ) according to the Japan Endocrine Society Clinical Practice Guidelines for PA and the Japanese Society of Hypertension Guidelines for the Management of Hypertension . Abdominal computed tomography (CT) revealed bilateral adrenal masses (right, 16 × 11 mm; left, 13 × 9 mm), with baseline CT attenuation values of 30–60 Hounsfield units (HU) on the left and 10 HU on the right , and contrast-enhanced CT showed a stronger contrast effect in the left adrenal mass than in the right adrenal mass . Although overnight 1mg dexamethasone suppression test (DST) showed mild autonomous cortisol secretion (2.25 µg/dL [< 1.8]; Table ), plasma level of ACTH in the early morning before DST was not suppressed (52.1 pg/mL [> 7.07]; Table ), and the diurnal variation of serum cortisol was preserved . Based on the Japanese Endocrine Society criteria , adrenal subclinical Cushing's syndrome was ruled out. The 24-h urinary catecholamines (epinephrine, 23.7 μg/day [< 41]; norepinephrine, 151.6 μg/day [< 160]; dopamine, 582.1 μg/day [< 1100]) were within normal limits, and the urinary fractionated metanephrines (metanephrine, 0.47 mg/day [< 0.19] and normetanephrine, 0.46 mg/day [< 0.33]) were slightly elevated but did not reach 3-fold of the upper limit of normal range . Adrenal vein sampling (AVS) was performed because she requested surgical treatment at that time and the results were interpreted according to previous guidelines . The findings confirmed that the right adrenal gland was responsible for aldosterone hypersecretion (post-cosyntropin stimulation lateralization ratio 24.67 [> 4], contralateral ratio 0.575 [< 1]; Table ). She refused right adrenalectomy at the last minute, and medical therapy with the mineralocorticoid receptor (MR) antagonist, eplerenone (50 mg) was initiated; however, she abruptly discontinued treatment and the follow-up visit. Five years after the first AVS, she visited a local clinic with complaints of headache and high blood pressure (208/109 mmHg) and was administered a calcium blocker (cilnidipine 10 mg). At this time, she requested surgery for PA and was readmitted to our hospital. On admission, her blood pressure was 127/96 mmHg, and she was taking oral cilnidipine 20 mg/day. No symptoms of catecholamine excess or Cushing's signs were observed. Repeated abdominal CT showed no significant change in the right adrenal mass (16 × 11 mm); however, the left adrenal mass was enlarged to 26 × 13 mm . At the surgeon's request, AVS was performed a second time to confirm PA localization. The second AVS confirmed the right unilateral hyperaldosteronism (post-cosyntropin stimulation lateralization ratio: 12.60; contralateral suppression index: 0.40) had not changed. . Repeated 1mg DST showed mild autonomous cortisol secretion, but the diurnal variation of cortisol was preserved (11:00 pm cortisol: 4.46 µg/dL). The 24-h urinary excretion assay revealed that norepinephrine (142.3 μg/day), epinephrine (26.5 μg/day), and dopamine (644.0 μg/day) levels were normal; however, metanephrine (0.81 mg/day) and normetanephrine (0.60 mg/day) concentrations were higher than those measured 5 years earlier . 123I-MIBG scintigraphy showed a tracer-avid left adrenal mass but no metastatic lesions . Based on these findings, a left pheochromocytoma was diagnosed preoperatively. After the temporary discharge, we had a conference with the department of urology of our institution, and we decided to perform partial adrenalectomy for the left pheochromocytoma and medical treatment for the right unilateral PA. The patient was started on α-blocker (doxazosin, 2 mg/day), a non-steroidal MR antagonist (esaxerenone, 5 mg/day), and continued cilnidipine 20 mg/day. Two months later, she was readmitted to our hospital. After preoperative administration of saline (1 L/day) for 7 days and an α-blocker (doxazosin, 2.0 mg/day) for 2 months, laparoscopic left partial adrenalectomy was performed. No intraoperative or postoperative hemodynamic instability occurred. Histologically, the tumor cells were arranged in diffuse sheets or nests and were large with prominent nucleoli . The pheochromocytoma of the adrenal gland scaled score was 0 indicating a low grade pheochromocytoma. Immunohistochemical examination of the tumor showed that chromogranin A and synaptophysin were positive , leading to the final diagnosis of left pheochromocytoma; Succinate dehydrogenase subunit B (SDHB) was positive ; cytochrome P450 (CYP) 11B2 was negative, Ki 67 was weakly positive , and ACTH was negative . The left adrenal gland tissue adjacent to the tumor was normal . Although we could not perform genetic analysis, as consent could not be obtained from the patient, the positive immunostaining for SDHB, suggested against SDH-related paraganglioma syndromes. Doxazosin was discontinued after surgery and esaxerenone (5 mg) and cilnidipine (20 mg) were continued. One month after surgery, the patient’s blood pressure was 126/84 mmHg, and her serum K (4.27 mmol/L), PAC (47.38 ng/dL), active renin concentration (ARC) (36.57 μU/mL), and random fractionated urinary metanephrines (metanephrine 152 ng/mg Cr [29–158], normetanephrine 363 ng/mg Cr [122–500]) were normalized. One year after surgery, blood pressure and serum K levels remained well controlled. No surgical treatment for the right adrenal mass has been performed, and pheochromocytoma has not recurred.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_156_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_156_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d633d99bf123f07c254a46af90d7c757f0a0917
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_156_en.txt
@@ -0,0 +1,7 @@
+A 25-year-old African American female presented to the Emergency Department (ED) complaining of diffuse abdominal pain, non-bloody diarrhea, nausea, and non-bloody emesis.
+The patient’s symptoms started the day prior to arrival to the ED. She described the abdominal pain as sudden onset, sharp and stabbing in quality, 10 out of 10 in intensity, and located in the suprapubic region with radiation to the right and left flanks. She denied any rash (including malar erythema), aphthous ulcers, hematuria, pleuritic chest pain, shortness of breath, or fever. Of note, several months prior, the patient had developed left eyelid swelling non-specific arthralgias (without swelling) of her wrists, fingers, and ankles. Her workup, including autoimmune laboratory tests, was inconclusive at the time. No diagnosis was made. Her arthralgias resolved spontaneously after a few days. She denied any arthralgias at the time of examination. The rest of her review of systems was non-contributory.
+Her past medical history was significant for seasonal allergies. Her family history was significant for discoid lupus in her father, rheumatoid arthritis (RA) in one of her paternal cousins, and SLE in another paternal cousin.
+On presentation, the patient’s vital signs were normal: 36.7 °C, heart rate of 92 bpm, blood pressure of 110/70 mmHg, respiratory rate of 18, and oxygen saturation of 100% on room air. Her abdominal exam revealed normal bowel sounds, mild abdominal distention but no lesions, scars, or hernias. There was significant lower abdominal tenderness without guarding or rigidity.
+Initial laboratory testing included a complete blood count (CBC) and comprehensive metabolic panel (CMP) . The patient had leukopenia with a WBC count of 3.25 k/uL, lymphopenia with an absolute lymphocyte count of 740, and anemia with a hemoglobin level of 11.7 g/dL. The CMP revealed a low albumin of 3.1 but was otherwise normal.
+A contrast computed tomography of the abdomen and pelvis done in the emergency room revealed marked circumferential wall thickening and edema of the proximal and mid small bowel loops predominantly involving the submucosa .
+At this point, the main differential diagnoses were intestinal angioedema and mesenteric vein thrombosis given the radiographic findings. However, the mesenteric vessels were patent, and there was no evidence of thrombosis. Laboratory testing for hereditary angioedema showed a normal C1 Esterase inhibitor level, low C3 (48 mg/dL), and low C4 (4 mg/dL) . Autoimmune work-up revealed elevated ANA of 13.6, normal double stranded DNA antibody of 25 IU/mL (anti-dsDNA ab), high anti-Smith antibody (>8 AI), and high anti-ribonucleic protein of 6.9 AI (anti-RNP) antibody . A urinalysis to screen for concomitant lupus nephritis did not show hematuria or red blood cell casts, and a urine protein to creatinine ratio was negative (0.1).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1577_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1577_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c41eac264342da56787029be638708ae775a5cbd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1577_en.txt
@@ -0,0 +1,5 @@
+A 33-year-old male presented to our institute with pain in the left elbow on extending the elbow. He had limited extension of 10–15 degrees. Patient had developed painful elbow on throwing the cricket ball from the periphery of the ground. This pain started to increase on repeated throws. He had conservative treatment for the same. Over the span of 18 months, he developed loss of terminal extension.
+On clinical examination, he had tenderness in the posterior aspect of elbow along with crepitus and extension lag of 15 degrees and painful passive and active terminal extension. He did not have any instability of the medial and lateral ulnar collateral ligament.
+Roentgenogram showed no radiological abnormality. Magnetic resonance imaging MRI revealed posterior fat pad hypertrophy withimpingement between olecranon and olecranon fossa whichwas the primary cause of pain and extension lag. After getting informed consent patient was posted for arthroscopic excision of posterior fat pad. Patient positioned in right lateral position and left elbow scrubbed, painted, and draped under aseptic precautions. Standard anterolateral portal was made and the anterior joint was visualized. Later on standard posterior and posterolateral portals were made revealing posterior fat pad hypertrophy locked and preventing complete olecranon extension.
+The fat pad was shaved off using 3.5 mm shaver and no impingement of soft-tissue was evident. An incidental finding of small foramen was found in the olecranon fossa. It was found that the rent in the olecranon fossa got the fat pad locked into it, causing impingement on elbow extension.
+Portals were closed and postoperatively dressings were changed and active complete elbow mobilization was started on post-operative day 1and 2,respectively. Patient was advised against heavy usage of elbow such as lifting heavy objects for 3 weeks. Patient was on regular follow-up and was symptom free. He got back to contact sports in 1 month duration. His last visit was 1year following surgery; he was comfortable with full range of movements.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1586_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1586_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f109ce8586c64295d00dc20b18efce25194c46cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1586_en.txt
@@ -0,0 +1,2 @@
+Without significant previous medical history, a 67-year-old Caucasian man developed spinal symptoms with temporary hypesthesia and hypoalgesia in both legs. These symptoms spontaneously resolved without any specific diagnosis at that time. At the age of 73, our patient suffered from bilateral optic neuritis and he was diagnosed with MS at an outside hospital. His expanded disability status scale (EDSS) score was at that time 2.5. Magnetic resonance imaging (MRI) studies of the spinal cord revealed a diffuse cord swelling and longitudinally extensive T2 hypertensive lesions extending from C2 to T3 (see Figure depicting a T2-weighted MRI scan, which shows residual longitudinal myelitis with extensive cord atrophy). A cranial MRI scan displayed few periventricular and cerebellar lesions without contrast enhancement and without fulfilling the Barkhof criteria. Moreover, analysis of the cerebrospinal fluid (CSF) presented oligoclonal bands. At that time, anti-AQP-4 antibody testing was not performed. A therapy with interferon beta 1a was started for six months and was replaced by interferon beta 1b at the discretion of the treating outside neurologist. Our patient developed two further spinal relapses during the treatment with interferon beta preparations. They were treated with corticosteroid pulses without any success and his EDSS score worsened from 2.5 to 4.0. Although a subsequent therapy with natalizumab was initiated at an outside clinic, our patient continued to present another three relapses. The first relapse occurred four months after starting natalizumab, the second after six months and the third relapse after eight months. All relapses repeatedly affected both optic nerves and the spinal cord each with increasing visual and motor impairment. Thus, our patient developed a high-grade spastic tetraparesis as well as impaired visual acuity of both eyes and his EDSS score progressed from 4.0 to 8.0. At that point, NMO was discussed after referral to our hospital and natalizumab therapy was discontinued after nine courses. After repeated cycles of plasma exchange, the disease course stabilized and a therapy with rituxan was started. Although B cells were completely depleted, our patient experienced another severe myelitis relapse upon further follow-up three months later. Consequently, an additional immunosuppressive therapy with cyclophosphamide at a dosage of 600mg/m2 was initiated. In the meantime, we performed repetitive anti-AQP-4 antibody tests in an approved external laboratory employing an immunofluorescence assay (IFA) cell-based analysis. Negative anti-AQP-4 antibody tests were obtained via IFA analyses upon first admission and then in six-monthly intervals after first contact at our hospital. It was only after 18 months that anti-AQP-4 antibodies became positive after three negative results. At that time, the anti-AQP-4-immunoglobulin (Ig)G antibody titer was 1:1000 while IgM and IgA titers were negative. There were no other autoantibodies and no signs of other autoimmune diseases or malignancy.
+Under combination treatment with cyclophosphamide (13 cycles every six weeks, cumulative dosage of 8300mg/m2) followed by another cycle of rituxan, our patient developed no further relapses over an observation period of 2.5 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1593_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1593_en.txt
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index 0000000000000000000000000000000000000000..ce20d01c6e64a1fa32a3210b8901352cfdf31564
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1593_en.txt
@@ -0,0 +1,3 @@
+A previously healthy six-year-old girl was admitted with fever, dyspnea, abdominal pain, and pain in the right arm and shoulder. Four days before admission she had fallen from a tree while playing. Shortly after admission she was transferred to the ICU because she acutely developed signs of shock, anemia and progressive abdominal pain. Splenic rupture was suspected and confirmed by ultrasound showing sub-capsular spleen hematoma and free intra-abdominal fluid. During the ICU stay she developed an abscess on the right shoulder, for which antibiotic treatment was started. The culture of the aspirate, taken before start of antibiotics, from this abscess was positive for Staphylococcus aureus. After 1 month she was transferred to our center under the suspicion of pericarditis, because of persistent fever and cardiomegaly on the chest X-ray. Echocardiography revealed pericardial effusion, located mostly behind the left ventricular (LV) posterior wall (Additional file ), with a to and fro blood flow through a fistula between the left ventricular lumen and a cavity in the pericardial space, and echogenic densities suggestive for fibrin strands and clots (see Fig. ). Cardiac function was good with mild mitral valve regurgitation. Findings were suggestive for advanced purulent bacterial pericarditis complicated by covered left ventricular perforation (pseudo-aneurysm).
+High doses of intravenous cefotaxime and flucloxacillin, already started in the referring hospital, were continued. She developed arthritis of the left knee and right elbow which were both aspirated but with negative cultures. Two weeks after admission her clinical condition did not improve with persistent leukocytosis and high C-reactive protein levels. A pericardial abscess with ongoing bacteremia was suspected and surgical intervention was scheduled.
+A median sternotomy was performed, leaving the pleural space closed. The patient was placed on extracorporeal circulation using standard bicaval cannulation. The operation was performed on a beating heart. On opening of the pericardium multiple small abscesses and adhesions were identified and removed, as were thick vegetations on the left ventricular posterior wall. The fistula in the LV myocardium connecting the LV lumen with an abscess on the posterior-lateral wall of the LV was found and closed with prolene sutures with felt (see Fig. ). The pericardial space was irrigated multiple times with a solution of sodium-chloride and iodine. Cultures of the abscesses were negative. Post-operatively she had a quick recovery without fever episodes. She was discharged from the hospital in good condition 2 weeks after surgery. Antibiotics were continued for almost 4 months because of persistent osteomyelitis of the right upper arm and a septic arthritis of the right elbow. Echocardiograms during follow-up revealed no abnormalities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1596_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1596_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8f3ee0ae771627734a1bbf85dea52defd4718d04
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1596_en.txt
@@ -0,0 +1,7 @@
+A 4-year-old boy was admitted because of persistent lower limb pain and claudication in the left lower limb over the past 9 mo.
+The patient had mild persistent lower limb pain and claudication without any inducement. Claudication worsened in one day. The child had no fever, urinary frequency or urgency, numbness, fatigue, or lameness. For further assessment and treatment, he was admitted to our joint hand surgery department.
+The child had no history past illness.
+The child had no history of family illness, and his medical history was unremarkable.
+Pressing pain and local swelling were present in the left shank. The results of sensation and strengthening test, and tendon reflex test were normal in both lower limbs. No pathological signs were observed upon physical examination.
+Laboratory examinations were normal.
+Preoperative imaging examinations, including X-ray photography, computed tomography, and magnetic resonance imaging, showed erosion-like changes with bone expansion of the left middle and lower fibular segment . No invasion of circumferential soft tissue or pathological fracture of the lesion site was observed. Initial pathological examination revealed fibular fibrous dysplasia . Postoperative photography showed that an allograft bone was implanted into the fibular medullary cavity . Recurrent fibular fibrous dysplasia was observed at the age of 6 years .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1601_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1601_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..73492af11090d9d60532e69e8539c00940a8cca4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1601_en.txt
@@ -0,0 +1,6 @@
+A 40-year-old pregnant woman at 28th week of pregnancy was admitted to an obstetric emergency department in Isfahan, Iran, with chief complaints of epistaxis and gingival bleeding that were manifested about a week before admission.
+She had no previous family history of bleeding disorders. But in her past medical history, it is highly notable that she had several hours of bleeding after eyebrow tattooing about 5 years before admission and two episodes of abortion in the first pregnancy trimester, 4 and 2 years before the current pregnancy. Moreover, her first pregnancy was successful. There were no abnormal data pertaining to her first labor.
+Her medications were aspirin due to previous pregnancy losses, daily perinatal multivitamins, and iron supplements. She did not smoke or drink alcohol. Considering the patient’s condition, aspirin administration was discontinued and her symptoms reduced in intensity.
+On admission, her vital signs were blood pressure 120/70, pulse 82, temperature 37 degrees C, respiratory rate 17. A detailed physical examination was performed but all findings were normal and no evidence of bleeding was found.
+In her laboratory data, platelet count was in the normal range but prothrombin time (PT) and partial thromboplastin time (PTT) were both significantly elevated, so a mixing test was done. In the mixing test, both PT and PTT corrected instantly and after two hours of incubation at room temperature. Based on these results, the patient was suspected of having a deficiency of one or more coagulation factors. Thus, the activity level of coagulation factors were tested . Laboratory results showed that the activity level of factor V was decreased significantly and the patient was diagnosed with factor V deficiency. In accordance with the mixing test result, the congenital form of FVD was approved.
+The patient had a history of two unsuccessful pregnancies and some complications were possible due to significantly elevated PT and PTT. Thus, the patient was started on fresh frozen plasma (FFP) every three days -two units each time (15–20 ml/kg bodyweight)- from week 30 of pregnancy until the parturition and she responded well with increase in FV activity to the normal range. At 40 + 2 weeks gestation, the vaginal delivery was done successfully and the baby was born with 3820 gr weight and Apgar score of 9 and 10 in 1st and 5th minute respectively. The newborn was tested for bleeding disorders and diagnosed with congenital FVD. As the patient and her husband were cousins, the infant was a case of congenital FVD with parental consanguinity.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1623_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1623_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0126ddd2c758d845ff88ff05acb153c57bfce3ac
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1623_en.txt
@@ -0,0 +1,6 @@
+A 46-year-old man had been diagnosed with a clear cell carcinoma with rhabdoid differentiation (World Health Organization grade 4) of the left kidney in May 2018 through a renal biopsy. The tumor was locally invasive, associated with metastases to retroperitoneal lymph nodes, the liver and the lungs. Because of the widely metastatic disease, nephrectomy was not performed. At initial diagnosis, the thyroid function tests showed a discrete elevation of his thyroid-stimulating hormone (TSH) at 4.5 mU/L (reference range 0.27-4.2 mU/L), with normal levels of fT4 (16 pmol/L, reference range 12.0–22.0 pmol/L) and fT3 (4 pmol/L, reference range 3.1–6.8 pmol/L) . He was subsequently started on systemic therapy with the tyrosine kinase inhibitor sunitinib in May 2018, pending approval for immunotherapy with nivolumab and ipilimumab. Therapy with nivolumab was initiated in June, and ipilimumab was added in August. The therapy with sunitinib was definitely stopped in October after completion of the mutational analysis of the primary tumor (next-generation 400 gene sequencing panel), which showed mutations in the TERT promoter and the MET gene (exon 15: p.V1088A), and amplification of SETD2 (SET domain containing 2, histone-lysine N-methyltransferase) and MET. Moreover, the tumor showed significant expression of programmed death ligand 1 (80%).
+Shortly after the introduction of ipilimumab, he developed transient thyrotoxicosis secondary to immune checkpoint inhibitor-associated thyroiditis, with subsequent hypothyroidism (October 2018: TSH 26.3 mU/L, fT4 9 pmol/L, fT3 2.0 pmol/L). At this stage, levothyroxine substitution was introduced (100 µg/day, corresponding to about 1.3 µg/kg/day). However, the TSH levels further increased to 72.7 mU/L after 4 weeks of therapy. The situation remained unchanged in the following months; in January 2019, the TSH was 81.5 mU/L, the fT4 was decreased at 9 pmol/L, and the fT3 was particularly low at 1.5 pmol/L. On February 18, 2019, the levothyroxine dosage was increased to 300 µg/day (corresponding to 4.3 µg/kg/day). Despite that, the fT4 and fT3 levels remained at similar levels after 2 weeks with 10.4 and 1.1 pmol/L.
+The patient was hospitalized in March 2019 with a diffuse atopic eczema and was found to be severely anemic. He was hypotensive and tachycardic, and the dermatologic exam revealed dry skin and eczema eruptions with erythematous and squamous papules and plaques.
+At that time, endocrinology was consulted for the first time. The patient reported profound weakness, a weight loss of 14 kg during the last 8 months, constipation, and a generalized pruritic rash. He plausibly reported regular and appropriate intake of the levothyroxine. Of note, the patient did not present any symptoms of malabsorption. At that time, the patient intermittently took proton pump inhibitors but took no other medication known to interfere with thyroid hormone absorption or metabolism.
+Although he then took the levothyroxine under supervision during a week, the thyroid function tests did not improve: fT4 was 8.2 pmol/L, fT3 1.1 pmol/L, total T4 46 nmol/L (reference range 66–181 nmol/L), and total T3 0.5 nmol/L (reference range 1.3–3.1 nmol/L). Suspecting that the patient might have consumptive hypothyroidism, rT3 was ordered and immunohistochemistry of the tumor for D3 expression was planned. The rT3 level drawn 9 days prior to his passing but only available about a month later was found to be elevated at 0.79 nmol/L (reference range 0.14–0.54 nmol/L). Of note, the estimated increase of his tumor burden based on cross-sectional imaging studies was about 57% between June 2018 and March 2019 (557.01 cm3 to 878.73 cm3 based on RECIST (Response Evaluation Criteria in Solid Tumors) criteria).
+The patient and his family opted for palliative care and he left the hospital; he passed away shortly thereafter at home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1630_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1630_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ac681a5eb06e8c83e84575ccfaaaeca783924a4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1630_en.txt
@@ -0,0 +1,2 @@
+An 11-year-old girl was referred to our hospital with the chief complaint of a swollen left-sided neck mass. Two days prior, hoarseness began in the morning, followed by fever and sore throat in the afternoon. On the next day, neck discomfort with tenderness occurred. On admission, she had a fever of 38.2 °C, hoarseness, and an elastic soft mass with mild tenderness on the left anterior neck . Pharyngeal redness or swollen tonsils were not observed. Laboratory data indicated mild inflammation and thyrotoxicosis; increased white blood cell of 17,500/mm3 (neutrophils, 86.6% and lymphocytes, 8.6%) and C-reactive protein level of 3.4 mg/dL; increased free T4 of 1.98 ng/dL [reference 1.02~1.52 ng/dL], decreased free T3 and thyroid-stimulating hormone (TSH) level of 2.71 pg/mL [reference 2.78~4.90 pg/mL] and 0.009 μIU/mL [reference 0.62~3.36 μIU/mL] respectively; and an elevated thyroglobulin level of 308 ng/mL [reference 0~33.7 ng/mL]. Contrast-enhanced computed tomography (CT) of the cervical region revealed an abscess partially infiltrating the thyroid gland and an air pocket near the piriform sinus . Pharyngoscopy revealed swelling of the arytenoid region, with purulent retention . From the purulent discharge, Klebsiella oxytoca was isolated. The left vocal cord was swollen but not paralyzed. No evidence of airway narrowing was identified. Suspecting PSF infection, parenteral treatment with cefotaxime at 100 mg/kg/day and dexamethasone (DEX) at 0.16 mg/kg/day was initiated . On the day after admission, the hoarseness disappeared, and the fever resolved. On the third day of admission, pharyngoscopy revealed that the swelling had disappeared . DEX was tapered off within 5 days. On the seventh day of admission, a subsequent contrast-enhanced CT of the cervical region revealed a prominent reduction in the abscess. The patient was discharged on the eighth day of admission, and the antibiotic was switched to oral cefdinir 10 mg/kg/day.
+Three weeks after discharge, a barium esophagogram revealed residual contrast in the left pyriform sinus, and PSF was diagnosed . However, abscess was not detected by ultrasonography. At that time, thyroid function returned to the normal range (FT3, 4.19 pg/ml; FT4, 1.19 ng/dl; TSH level, 2.63 μIU/mL; and thyroglobulin level, 16.4 ng/mL). Chemocauterization was proposed to the patient’s family because this was the first episode of a neck abscess. However, the family did not opt for this method, and the patient is currently under observation without recurrence for a year.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_164_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_164_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5c64d709ba1ec1a3b08b8695973af2e82e360ce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_164_en.txt
@@ -0,0 +1,19 @@
+An Italian 7-year-old girl with a TMAU-like phenotype has come to our attention after her mother reported the production of strong body odor. The child’s history revealed that she is the third child of healthy, unrelated parents. Her two brothers aged 16 and 10 years were both apparently healthy.
+All her hematological parameters and her biochemical indices for renal, thyroid and liver function were within the normal range.
+TMAU was suspected and it was suggested that the child’s DNA be examined for mutations in the FMO3 gene. The study was approved by our local ethics committee. Written informed consent was obtained from the patient’s parents.
+Molecular analysis of FMO3 gene in the index patient and family members was performed. Genomic DNA was extracted from heparinized peripheral blood of all family members using the salting out method . Upstream sequence, the non-coding exon 1 and each of the coding exons (exons 2 to 9) of the FMO3 gene were amplified from genomic DNA by polymerase chain reaction using the primer pairs shown in Table .
+PCR products were sequenced with the BigDye® Terminator sequencing kit version 1.1 on the 377 ABI PRISM® Sequencer Analyzer (Applied Biosystems).
+We also analyzed urine samples from the proband and all family members for the presence of TMA and TMAO. A first urine sample was collected for 24 hours under normal dietary conditions (a diet not containing TMA-rich foods) and a second was collected for 6 to 8 hours after a 300g marine fish meal.
+Urine samples were acidified to pH 3.0 with formic acid and stored at -20°C. Creatinine was measured by the Jaffe reaction on an autoanalyzer.
+Derivatization of TMA was carried out according to the method by Johnson using ethyl bromoacetate as a derivative reagent [,]. Each sample was analyzed in duplicate.
+Mutations analysis of nine exons of the FMO3 gene was performed on all family members.
+The proband was found heterozygous for the previously reported polymorphism c.472 G>A p. E158K (rs 2266782) in exon 4, and a G-to-A transition at codon 158 (GAG to AAG) resulting in a glutamic acid to lysine substitution (Glu158 to Lys158).
+E158K polymorphism reduces FMO3 catalytic activity that appears to vary depending on the substrate [-]. Previous in vitro expression studies showed that the K158 form of the protein is a poorer TMA N-oxygenator than the E158 form.
+In some populations, this variant was found in a high degree of linkage disequilibrium with the E308G variant. When present on the same allele, the E158K and E308G exhibit an even more pronounced effect on FMO3 function , even leading to mild or transient forms of TMAU .
+The proband was heterozygous also for two polymorphisms in intronic regions: c.627+10 C>G (IVS5+10G>C) (rs 2066534) and c.485-21 G>A (IVS4-22G>A) (rs 1920149).
+The first, a variant of uncertain functional relevance, was found in cis with E158K polymorphism while the second was an intronic A-to-G substitution at the -21 position from the acceptor splice site of exon [,]. The parents and the eldest of two brothers were heterozygous for the same variants while the younger brother did not show any variation.
+Since the latter was wild-type it is possible to deduce that he has inherited the wild-type allele from each parent and that c.472 G>A, c.485-21 G>A and c.627+10C>G polymorphisms occurred in cis configuration on one of the two FMO3 alleles of the father and mother.On the basis of this it is possible to infer that the proband and the elder of the two brothers, as well as the parents, were compound heterozygotes for the three polymorphisms . However, among them, only the proband showed a TMAU-like phenotype.
+Therefore, we wanted to analyze the upstream region of FMO3 gene in order to identify polymorphic variants that could affect the enzymatic activity. No variants were identified in any family members. Analysis of the urine samples collected for 24 hours from both parents and two brothers under normal dietary conditions (a diet not containing TMA-rich foods such as fish or eggs) showed the presence of relatively small amounts of TMA excreted. The N-oxidation metabolic ratio (TMA/TMAO ratio) for the four subjects ranged from 0.02 to 0.04.
+For the proband the TMA excretion accounted for only 29.0% of total TMA excretion. The N-oxidation metabolic ratio for the proband was 2.4, two orders of magnitude greater than those observed for the parents and two brothers (affected ratio TMA/TMAO >0.2).
+After oral TMA challenge, the amount of urinary TMA excreted as TMAO, in the parents and two brothers remained high and it was very similar to the values under normal dietary conditions. N-oxidation metabolic ratio ranged from 0.02 to 0.04.
+After oral TMA challenge, in the proband, TMAO excretion accounted for 19.4% of total TMA excreted .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1655_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1655_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5509feb819a031251fdf11b9c305cbc39d3bb37
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1655_en.txt
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+A 35-year-old Caucasian male presented to the Maxillofacial Surgery service of Campo Limpo Hospital, in São Paulo, Brazil, with the main complaint of an intraoral swelling that had been growing for the last 8 years. The lesion was asymptomatic, and even though the patient had been aware of its constant growth, he decided to look for professional help only when its proportion began to cause him speaking impairment.
+The physical examination revealed a firm mushroom-like mass, with bony consistency covered by smooth regular mucosa spanning almost the entire right alveolar border of the mandible. The area was edentulous and, according to the patient’s report, had initiated its growth shortly after the extraction of a molar, which the patient could not specify. As it developed, the remaining teeth had been extruded until complete avulsion (teeth 28 through 32, in universal numbering system). No extraoral abnormalities were observed. The patient was in good health, with no history of previous diseases, smoking, or substance abuse. The diagnosis of Gardner syndrome was discarded due to the lack of any other symptoms, such as gastrointestinal implications or supernumerary teeth .
+Computed tomography revealed a well-defined pedunculated mass attached to the right body of the mandible with radiographic characteristics resembling the original bone, consisting of a central area of moderated radiopacity similar to medullary bone, surrounded by a denser, more radiopaque thin area, comparable to cortical bone. According to Rodriguez (2011), these particular growth characteristics make it easy to diagnose a peripheral osteoma clinically and radiographically .
+Since the tumor presented both clinical and radiographic features of a benign lesion, the patient underwent an excisional biopsy, with complete removal of the mass and an osteoplasty of the mandible. The access was intraoral, with an incision directly over the lesion, and divulsion of the mucoperiosteal tissues, preserving their integrity for suture later . After the complete exposure of the lesion, surgical drills were used to mark the limits of excision, and the mass was removed in two pieces, with the use of a chisel and hammer. An oval drill was used to perform an osteoplasty of the jaw, recovering its original shape and thickness . After surgical resection, the mucosa flaps had their wedges trimmed, to obtain straight margins that were sutured with 3–0 resorbable thread. The surgical piece was a white, oval, bony fragment, with a regular surface of approximately 4.2 × 4.8 × 2.5 cm . The postoperative course was uneventful, except for discrete dehiscence of the suture 5 days after the procedure, which was spontaneously healed with chlorhexidine mouthwash on clinical follow-up for the next 7 days . The radiographic aspect of the jaw, 14 days after surgery showing regular shape and dimensions .
+Histopathological analysis revealed mature adipose tissue, permeated by viable compact bone lamellae, consisting of medullary tissue, delimited by a thin and well-vascularized lamellar cortical bone. Thin and congested blood vessels were noted throughout the whole sample.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1658_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1658_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a4195ceae6ef35fa8f1de86b45a1301c2ff7d7c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1658_en.txt
@@ -0,0 +1,12 @@
+A 54-year-old male presented with numbness and edema in bilateral lower limbs in 2018 and then underwent positron emission tomography-computed tomography (PET-CT) at a hospital, indicating intense metabolic activity in multiple bones throughout the body. However, a definitive diagnosis wasn’t made. Subsequently, he experienced progressive numbness and edema as well as developed weakness in bilateral lower limbs for which he intermittently received Chinese medicine. Unfortunately, symptoms didn’t improve. In Sep 2022, he underwent a chest CT at another hospital, showing bilateral mild pleural effusion. For further diagnosis and treatment, he was admitted to the Rheumatology and Immunology Department of our hospital in Oct 2022. Since the disease’s onset, he has been frustrated and lethargic and has a normal diet and sleep, regular voiding, and no significant weight changes. Meanwhile, he denied a history of chronic diseases, tobacco and alcohol use, food and drug allergies, and genetic disorders.
+The patient’s vital signs were stable. He had no signs of jaundice, anemia, or cyanosis. His bilateral breasts were significantly protruded . Besides, fresh red hemangiomas were scattered throughout the anterior portion of his chest and back, with a maximum size of about 0.40 cm×0.50 cm . There were no apparent abnormalities in the cardiopulmonary and abdominal examination. However, pitting edema was noted in bilateral lower limbs . Neurological examination revealed normal cranial nerves and no cerebellar signs. However, there was diminished power in the bilateral lower limbs (4/5) by the Manual Muscle Test (MMT). Physiological reflexes were present and pathological reflexes were negative. Deep and shallow sensations were weakened below the bilateral ankle joints. The upper limb examination was unremarkable.
+His complete blood count, clotting test, and blood glucose were generally normal. IgA, IgG, IgM, and IgE were also within the normal range. His serum/urine PEP and IFE showed negative M-protein. The levels of serum-free light chains κ and λ were increased, while the ratio of κ/λ in serum was normal . The levels of serum VEGF were elevated. FT3 and FT4 were decreased, and TSH was increased. Sex hormone measurement revealed increased prolactin (PRL), follicular estrogen (FSH), estradiol (E2), and progestational hormone (P) but normal testosterone (T). ACTH was increased and cortisol (COR) at 8:00 AM was decreased. Rheumatism-related indicators, hepatitis B and C, syphilis, and AIDS serology tests were all negative. The detailed results are shown in Table .
+The thyroid ultrasound showed two small hypoechoic nodes in the lower pole of the right lobe of the thyroid gland, the larger being 0.47 cm×0.29 cm. Echocardiography revealed bilateral atrial enlargement and pericardial effusion (small amount). Abdominal ultrasound displayed splenomegaly with an intercostal thickness of about 5.70 cm and a length of 16.30 cm. Chest and abdominal CT revealed enlarged lymph nodes in the bilateral axilla and mediastinum (the largest with a diameter of approximately 1.10 cm), as well as small amounts of pleural effusion and pericardial effusion. Bone scintigraphy with [99mTc]-methylene-diphosphonate (MDP) single-photon emission computed tomography/computed tomography (SPECT/CT) exhibited a symmetrical bilateral skeleton and mixed sclerotic and lytic bone lesions in bilateral ilium, vertebral bodies, and ribs. .
+BM smears revealed that the proportion and morphology of red blood cells, granulocytes, and megakaryocytes were generally normal, and mature PCs constituted 2% of cells. Flow cytometry of BM specimens showed no significant evidence of monoclonal PCs and other abnormal cells (immunophenotypic abnormalities). Besides, the karyotype revealed normal male chromosomes. BM biopsy of the posterior superior iliac spine displayed no increase in the abundance of immature cells, lymphocytes, and PCs .
+He experienced a CT-guided coarse needle puncture of the posterior superior iliac spine. Pathological assessments indicated no increase in the number of PCs and lymphocytes. The results of immunohistochemistry indicated CK (-), LCA (+), langerin (-), CD68 (+), CD163 (+), CD1α (-), S100 (-), Ki-67 (80% +), CD138 (-), and CD56 (-) .
+The classic symptoms of MM are elevated calcium level, renal insufficiency, anemia, and lytic bone lesions, which were not found in our case. MM doesn’t generally present with peripheral neuropathy, organ enlargement, multiple endocrine gland abnormalities, skin-specific changes, sclerotic bone lesions, and increased VEGF levels, which all were present in our patient. In addition, the proportion of monoclonal PCs in the BM of MM should be at least 10%, while monoclonal PCs in the BM of our patient were not present.
+The CD is clinically divided into focal and multicenter types. The former is more common in young people. Multicentric Castleman disease (MCD) also presents with lymphadenopathy, hepatomegaly, splenomegaly, rash, and cavity effusion. However, it is usually not accompanied by peripheral neuropathy, sclerotic bone lesions, endocrinopathy, and increased VEGF levels, which were present in our patient. Patients with MCD are prone to infection and lymphoma. MCD usually has an aggressive course and poor overall survival (OS). However, the onset of this patient is insidious, and the course is chronic and stable, just like POEMS syndrome.
+Both GBS and POEMS syndrome can lead to motor neuron paralysis, but GBS is not accompanied by visceral enlargement, endocrinopathy, skin changes, bone lesions, and increased VEGF, which all were present in our patient.
+POEMS syndrome and CIDP affect the motor and sensory nerves, slowing nerve conduction. However, CIDP doesn’t present with organ enlargement, endocrinopathy, M-protein deposition, skin changes, bone lesions, or increased VEGF levels, most of which were present in our patient.
+Although the M-protein of the patient was undetectable, he had peripheral neuropathies in bilateral lower limbs. Additionally, he showed signs of male breast development and characteristic hemangiomas in the anterior chest and back. Hormonal tests revealed hypothyroidism, hyperprolactinemia, hypoadrenalism, and feminization. More importantly, he had an increased VEGF level, and SPECT/CT revealed sclerotic bone lesions. Ultrasound and CT showed enlargement of lymph nodes, splenomegaly, and extravascular volume overload. After excluding the disorders that are easily confused with POEMS syndrome, we proposed the diagnosis of POEMS syndrome with undetectable M-protein.
+Then the patient was treated with the RD regimen (25 mg/d of lenalidomide capsules on days 1–21, 20 mg/d of dexamethasone tablets on days 1–4 and 8–11, each cycle is 28 days). At the same time, he received levothyroxine sodium tablets (25 µg/d) to improve hypothyroidism and aspirin to prevent coagulation. Nearly 6 months after receiving the treatment, the numbness and edema of bilateral lower limbs significantly improved, and the color of skin hemangiomas altered from fresh red to dark red. Elevate serum VEGF and free light chains have returned to normal. All indicators were within the normal range on the thyroid, adrenal gland, and sex hormone tests. Imaging examinations exhibited normal volume of lymph nodes, normal size and morphology of the liver and spleen, and no signs of extravascular volume overload. Bone X-rays still indicated high-density shadows in multiple bone areas throughout the body. Thus, we will continue the follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1674_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1674_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..872c1f7f432379307239e7b9b2af96d8c0aeec40
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1674_en.txt
@@ -0,0 +1,6 @@
+An 18-year-old male with no past medical history presented as an outside hospital transfer for acute respiratory failure. Approximately 2 months before, he began to have a cough associated with intermittent hemoptysis. He was evaluated at an urgent care clinic and received antibiotics without resolution of his symptoms. At that time, his renal function and urinalysis were within the normal limits. He denied history of joint pain or subjective joint swelling. Dyspnea progressed, and he was taken to his local hospital. On transfer, patient was intubated and on mechanical ventilation.
+On physical examination, he was intubated and sedated. Lungs were with coarse breath sound bilaterally. There was bilateral swelling of his knees.
+Laboratory studies showed hemoglobin of 8.4 g/dL, WBC count of 5.6/L with a lymphopenia, platelet count of 126/L, creatinine of 1.6 mg/dL, INR of 1, and PTT of 26.6 seconds. Urinalysis was with 41 red blood cells, and protein to creatinine ratio was 0.94. Anti-nuclear antibody (ANA) was greater than 12, anti-dsDNA was 507 IU/mL, C3 was 63 mg/dL, C4 was 8 mg/dL, and anti-cardiolipin IgM was 15.8 mpl.
+His anti-smith,anti-MPO,anti-PR3,anti-cardiolipin IgG, anti-beta 2 glycoproteins IgG/IgM, anti-GBM, lupus anticoagulant, and cryoglobulins were negative.
+Blood and sputum cultures were negative. Chest X-ray showed bibasilar airspace disease . Bronchoalveolar lavage showed progressively hemorrhagic aliquots .
+He was treated with pulse dose methylprednisolone for three days, one dose of intravenous cyclophosphamide, and five days of plasmapheresis. Shortly after, he was extubated and weaned to room air. His hemoptysis resolved with stabilization of his hemoglobin. He was discharged in the stable condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1675_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1675_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..420915f0f2e20384113d586a7a929606af53dc07
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1675_en.txt
@@ -0,0 +1 @@
+A 29 year-old female, non-smoker, who was diagnosed with Polycystic Ovarian Disease (PCOD) presented with a history of cough and fever for 25 days. She had delivered a baby 4 months back after hormonal treatment. On examination she was obese with significant hirsuitism, and had bilateral corneal congestion. Ophthalmologic evaluation did not reveal uveitis. The lab tests including complete blood picture, renal and liver functions and autoimmune profile were within normal limits. The chest X-ray and HRCT showed bilateral nodular infiltrates, for which she underwent CT-guided biopsy. Histopathology of the lung showed non-caseating granuloma . The serum ACE level was 110 U/L. She was started on steroids with remarkable clinical and radiological improvement on subsequent clinic visits.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1679_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1679_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c3a30f2b7a2c0264a6650630f8c611432c3a3808
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1679_en.txt
@@ -0,0 +1,3 @@
+A 12-year-old Turkish girl, born at 38 weeks of gestational age to unrelated healthy parents, was well until 1 year of age, when she developed pustular cutaneous lesions that responded to corticosteroid and antibiotic treatment with healing and scar formation. Various treatments of these lesions had required four hospitalizations during the previous 11 years. No other family member had similar skin conditions. She was hospitalized at the age of 12 years for arthralgia of her knees, elbows, and ankles and arthritis of her left knee, with concomitant pustular cutaneous lesions. She developed septicemia and was admitted to the intensive care unit of a public hospital with respiratory insufficiency during her follow-up. After recovery, she was referred to our pediatric immunology department for further evaluation.
+A hyperpigmented scar lesion on the right side of the face; bilateral inguinal, paraumbilical hyperpigmented scar lesions; and paronychia of the thumbs were noted on admission . Additionally, the patient had contracture of the left knee limiting her motion, episcleritis, and failure to thrive [25kg (below third percentile), 132cm (below third percentile)]. The results of her laboratory studies revealed iron deficiency anemia, hypergammaglobulinemia, and elevated acute-phase reactants (red blood cell count 4.2 million/mm3, hemoglobin 9.1g/dl, hematocrit 27.8%, mean corpuscular volume 81fl, thrombocytes 254,000/mm3, immunoglobulin G (IgG) 1760mg/dl, IgM 186mg/dl, IgA 195mg/dl, C-reactive protein 6.5mg/dl, erythrocyte sedimentation rate 100mm/hr, and serum amyloid A 123mg/L). Total IgE level, eosinophil count, lymphocyte subset levels, and the oxidative burst activity of granulocytes were normal. Autoantibodies (anti-nuclear antibody, anti-neutrophilic cytoplasmic antibody, and rheumatic factor) were negative. She was evaluated for tuberculosis and was found to have two bacillus Calmette-Guérin scars, a 12mm tuberculin response, and a negative QuantiFERON® assay result (QIAGEN, Chadstone, Australia). Serologic investigations yielded negative results for cytomegalovirus, Epstein-Barr virus, hepatitis B and C viruses, syphilis, and HIV. Her blood and urine cultures were negative for bacteria. Splenomegaly was detected by abdominal ultrasonography. Skin biopsy of hyperpigmented lesions demonstrated neutrophil infiltration in epidermis and subepidermal pustular dermatosis. The results of chest radiography and skeletal surveys were normal.
+DIRA was clinically suspected on the basis of clinical similarities between our patient and other patients with DIRA described in the literature to date. The resequencing of the entire coding sequence of IL1RN and the flanking splice sites revealed a homozygous mutation (p.R26X) confirming DIRA. Treatment with canakinumab 150mg subcutaneously once every 6 weeks was initiated, and a full response was achieved. She did not experience any cutaneous lesions or arthritis during 12 months of treatment and follow-up. Her inflammatory markers regressed to normal values . She was able to walk independently, and gradual weight gain was observed. Treatment-related adverse events were not detected.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_169_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_169_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3fb708ac310c22a142348e7900875a2beaab6707
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_169_en.txt
@@ -0,0 +1,2 @@
+A 47-year old male patient presented to the emergency department of our center with a 4-day history of moderate abdominal pain increasing gradually in severity over the duration of illness. The pain started as generalized all over the abdomen, and then mobilized to the right iliac fossa. The pain was associated with frequented vomiting which started as greenish juice then became food particles. It was also associated with increased an abdominal girth and obstipation. Physical assessment showed a distressed patient with a respiratory rate of 22 and heart rate of 120 bpm. His Blood pressure was 90/60 and Temp 37.8° C orally. O2 Saturation was 90 at room air. Abdominal examination revealed marked abdominal distention, with localized guarding in right iliac fossa. On Digital rectal examination there was no masses or blood and no stool. On presentation, laboratory findings included elevated Creatinine (1.5 mg/dl), BUN (27.0), Na (143) and normal WBC count (5900 cell/mm3), hemoglobin (10.4 g/dl), platelets (136 × 103/μl), INR 1.7. Plain abdominal radiographs showed dilated small and large bowel loops .
+The abdomen CT scans with contrast enhancement was advised after resuscitating the patient and stabilizing his condition, and showed dilated small and large bowel with sigmoid volvulus plus large amount of preihepatic and pelvic free fluid. Swirl sign at the mesentery of cecum suspected strangulated bowels due to transmesentric defect . Intraoperative findings: 2 × 4 cm defect in the mesentery of cecum, Gangrenous sigmoid volvulus and part of the terminal ileum entrapped through the mesenteric gate, and much free fluid . Surgical treatment started with deflating the sigmoid colon, and reducing it through the defect. We also reduced the small bowel. After that, resection of all nonviable segments was performed. End-to-end anastomosis of small bowel, colostomy on the left side, and closure of defect was done. Immediately after recovery from surgery, the patient was transferred to ICU and stayed for three days, during which he developed atelectasis and systemic inflammatory response with acute kidney injury and blood hemolysis but these rapidly reverted to normal. Following that, the patient was transferred to surgical ward in which he spent seven days with a complication of superficial wound infection and ileus. The infection was treated with IV antibiotics according to antimicrobial susceptibility testing and dressing was applied. Ileus was treated conservatively. On the tenth postoperative day, the patient was discharged with functioning stoma and excellent general condition. We are planning to restore GI continuity after 3 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1740_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1740_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e3160e3c2086fcae72bd3b588267e4ddc53ef028
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1740_en.txt
@@ -0,0 +1,5 @@
+A 17-year-old girl self-reported nocturia that progressed for half a year. Before being hospitalized, she had noticed foamy urine for 3 weeks. She was admitted following 5 days of nausea and vomiting. Blood tests revealed increased serum creatinine of 18.02 mg/dl, high urea nitrogen, low hemoglobin of 75 g/L, low serum albumin of 28.2 g/L, and severely increased parathyroid hormone (PTH) of 606.0 pg/ml. A lipid panel blood test revealed that the levels of triglyceride (TG), total cholesterol (TC), high-density lipoprotein cholesterol (HDL-C), and low-density lipoprotein cholesterol (LDL-C) were normal, and the level of very-low-density lipoprotein (VLDL) was decreased a bit. A urine analysis showed an increased level of proteinuria of 10.85/L/day, a positive result of a hematuria blood test, and a high level of pro-B-type natriuretic peptide (>9,000 pg/ml). In the meantime, there was no significant change in her weight. She did not has mental development delay. Ultrasonography revealed the reduced size of bilateral kidneys with hyperechoic reflections inside the renal parenchyma. A kidney biopsy was offered, but it was refused by her parents. Echocardiography indicated small accumulations of pericardial fluid, the mildly regurgitant tricuspid valve, and a slightly enlarged left ventricle. The primary diagnoses were NS, CKD5, renal anemia, and secondary hyperparathyroidism. After admission, the hemodialysis was initiated in 48 h and continued for 4 months. Then, the patient received an allogeneic kidney transplant from her father.
+The patient was the third child of phenotypically normal Chinese parents. The other two siblings were healthy and proteinuria was not found . Her parents did not have consanguineous relation and family history was not remarkable. She was naturally conceived with an uneventful perinatal period. She was born at term at 40 weeks of gestational age. Based on the fact that disease-causing gene variants have been identified in adolescents with idiopathic NS, genetic screening in the patient’s family for inherited diseases was recommended.
+The patient and her parents signed informed consent for genetic analysis. Our legal ethics committee approved this genetic study. Genomic DNA was extracted from the peripheral blood of the patient and phenotypically normal parents for WES. Sanger sequencing was used for further verification. We identified a de novo heterozygous missense variant c.494C > T in the ACTN4 gene (NM_004924.6). This variant has not been registered in population databases (1,000 Genomes Project, gnomAD, and dbSNP) or reported in disease databases (ClinVar, Human Gene Mutation Database, OMIM).
+A cosegregation analysis was performed among family members. This variant was de novo and verified by Sanger sequencing . Silico predictive algorithms (SIFT, PolyPhen-2, REVEL, MutPred, MutationTaster, PROVEAN, and MVP) of pathogenicity all showed damage. The analysis of conserved sequences suggested this variant was located in highly conserved sequences across several mammalian species . The variant c.494C > T (p.A165V) was located in a critical and well-established functional domain (the calponin-homology domain of ACTN4 protein) without benign variants . Summing up the above, according to the guidelines of the American College of Medical Genetics and Genomics (ACMG) for interpreting sequence variants, the novel missense variant was pathogenic (PS2 + PM1 + PM2 + PP3 + PP4).
+DynaMut (a web server) is a well-established normal mode approach. We used it to visualize and assess the stability and interatomic interactions of mutant proteins. We put information into DynaMut as follows: wild-type structure (PDB accession code: ), mutation detail (A165V and chain A). The prediction outcome of stability was ΔΔG: −0.087 kcal/mol (destabilizing). In comparison with p.A165V, we put p.G195D into DynaMut. The prediction outcome of stability of p.G195D was ΔΔG: −1.349 kcal/mol (destabilizing). The residues 165 and 195 in the wild-type were observed to form residue interactions (colored in light green) with their surrounding residues, whereas some interactions were seen to be increased in mutant sites (p.A165V and p.G195D) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1748_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1748_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3421ff1eee0ebd7dc23847dcccc0d325ee6984a7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1748_en.txt
@@ -0,0 +1,8 @@
+A 22-year-old Persian man was referred to our outpatient SLE clinic for regular follow-up on 27 December 2018. He complained of severe and progressive generalized bone pain that he had begun experiencing 2 weeks before his admission. He did not report any clinical symptoms in favor of SLE flare-up. His physical examination revealed generalized bone tenderness over the sternum, vertebra, and pelvis. His joints were normal without any sign of arthritis. He weighed 69 kg and was 170 cm tall (body mass index, 23.87 kg/m2). The results of the rest of his examinations were unremarkable. The patient’s vital signs were within the normal range, and the results of examinations of his mucocutaneous, cardiopulmonary, and neurologic systems were normal.
+However, the laboratory examinations showed an exceedingly elevated level of serum alkaline phosphatase (ALP) of 3609 U/L (reference range, 40–130). The rest of the tests consisted of a complete blood count, erythrocyte sedimentation rate, C-reactive protein, liver function, glucose and lipid profiles, serum creatinine, urinalysis, and anti-double-stranded deoxyribonucleic acid (DNA); all of these were within the normal ranges. The last laboratory examination was performed on 15 November 2018 and indicated a normal serum ALP level of 141 U/L.
+The patient’s medical history was significant for an antecedent of SLE from 2 years earlier, which was diagnosed with the primary manifestations of oral ulcers, polyarthritis, hematuria, and proteinuria, along with positive antinuclear antibody and diminished complement level. A renal biopsy was performed at the time of diagnosis; this biopsy was compatible with mesangial proliferative lupus nephritis (class II). At this time, hydroxychloroquine (400 mg/day), prednisolone (15 mg/day), azathioprine (2.5 mg/kg/day), and calcium vitamin D supplementation began being administered. According to the patient’s gastrointestinal side effects and persistent dysmorphic hematuria, azathioprine was replaced with mycophenolate mofetil (2 g/day), and prednisolone was tapered to 5 mg/day from 1 year prior.
+The patient’s bone mineral densitometry (BMD) was assessed at the time of the diagnosis and again one year later using the same instrument (Hologic, Marlborough, MA, USA) . At the time of diagnosis, the patient had osteopenia (lumbar spine Z-score, − 2.2), which was unjustifiable on the basis of his age. The results of laboratory examinations, including serum electrolytes and endocrine panel evaluations, were normal . However, the patient’s serum ALP level was lower than normal at 175 U/L (normal range, 245–768). Supplemental calcium vitamin D was administered, and the patient was referred to a sports medicine specialist.
+A detailed investigation of the patient’s past medical history revealed instances of idiopathic kyphoscoliosis, mitral valve prolapse, and a bilateral congenital inguinal hernia that was operated on in the infantile period. The patient’s physical examination was compatible with hypermobility of the joints (Beighton score, 4). There was no evidence to suggest delayed or absent puberty. The results of the rest of the investigations, including a complete endocrine panel and ocular evaluation, were normal. It was speculated that the patient had an occult connective tissue disease such as Ehlers-Danlos syndrome. However, due to the unavailability of genetic studies and the lack of full-blown manifestations of inherited collagen disease, this diagnosis remained unidentified.
+According to the very low bone mass of the patient and diminished bone density at the hip and the lumbar spine , subcutaneous injection of teriparatide (Forteo® 20 μg/day; Eli Lilly, Indianapolis, IN, USA) was started on 2 May 2018. Additionally, he was receiving hydroxychloroquine 200 mg/day, prednisolone 5 mg/day, mycophenolate mofetil 500 mg/day, and calcium vitamin D supplementation. He denied any use of other medications, even over-the-counter medicines and herbal remedies. He tolerated the teriparatide well without any adverse drug reactions and was strictly adherent to his medications and physical activities. His family history was remarkable for SLE in his mother. His history was negative for cigarette smoking and any drug abuse.
+The workup began for this patient according to his generalized bone pain and tenderness and extremely elevated level of serum ALP. The results of laboratory examinations done on 31 December 2018 are shown in Table . The serum and urinary bone turnover marker measurement kits were unavailable at that moment, and the patient did not consent to undergo bone biopsy. His whole-body bone scan showed a superscan pattern with diffusely increased osseous uptake in the calvarium, supraorbital crests, and mandible (Lincoln sign), as well as all the costochondral joints, both sacroiliac joints (butterfly sign), and the pubic symphysis . Most of the epiphyseal plates also showed a significant diffuse and symmetric uptake. The pattern of the scan was compatible with metabolic bone disease (MBD) associated with a diffuse bone formation state without any evidence for fracture, bone metastasis, or Paget disease. Abdominopelvic ultrasonography and skull and pelvic x-ray results were entirely normal .
+Briefly, we had a patient complaining of recent-onset generalized bone pain and tenderness in addition to a newly raised serum ALP level. The patient’s γ-glutamyltransferase level, liver function test, and biliary system ultrasonography were normal. His whole-body bone scan was in favor of MBD without any evidence of bone tumors. Neither the patient’s clinical manifestations nor his laboratory test results were compatible with SLE flare-up. Taken together, all of these manifestations were probably related to teriparatide use, and the medication was discontinued on 31 December 2018. The patient’s serum ALP level began to decline with the level of 6423 U/L (normal range, 80–306) on 10 January 2019, to 3492 U/L (80–306) on 18 January 2019, 598 U/L (40–130) on 24 January 2019, 151 U/L (40–130) on 10 February 2019, 40 U/L (40–130) on 18 June 2019, and 42 U/L (40–130) on 2 March 2020. The calcium supplement dosage was augmented to prevent probable hungry bone syndrome. However, the serum calcium and phosphorus levels were strictly normal during this period. Most of the laboratory examinations were performed in a single laboratory, whereas the abnormal findings were also rechecked in another medical center. This could justify the enormously different ALP levels in a short time interval. The clinical manifestations completely resolved, and the patient did not experience any SLE relapse. The third BMD was performed on 8 April 2019 with a similar machine, revealing a significant increase of bone density . After 7 months of treatment with teriparatide, the bone density of the lumbar spine, femoral neck, total hip, and one-third distal radius was increased 4.5%, 4.8%, 23%, and 6.1%, respectively. To the best of our knowledge, this is the highest rate of increased bone density in such a short period of time reported in the literature.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1776_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1776_en.txt
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index 0000000000000000000000000000000000000000..d3d82a19421bef1f69a7ee90aa4d310d42e89c30
--- /dev/null
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+In June 2017, a 49-year-old Chinese woman was admitted to the emergency department of the Northern Jiangsu People’s Hospital owing to chest tightness and breathing difficulty that persisted for 3 days. She was previously in good health and was a non-smoker. In addition, she had fever, chills, and a maximum body temperature of 38 °C. She did not have urinary or fecal incontinence, chest pain, general fatigue, cough, or hemoptysis during the course of her disease. Following admission, results of complete blood test revealed that white blood cell count was 12.21 × 109 cells/L and the percentage of large white blood cells was 85.5%. Blood gas analysis results showed 7.480 PH, 100 mmHg PaO2, 31 mmHg PaCO2, and 23.1 mmol/L HCO3−. D-dimer assay indicated a value of 5.28 mg/L. A computed tomography pulmonary angiography (CTPA) revealed filling defects in the main pulmonary artery, upper and lower pulmonary artery branch . There were no distinct signs of embolism in color ultrasonography examination of the upper and lower limbs. The patient was diagnosed with PE, and was treated with anticoagulation, antiplatelet aggregation, and anti-infection medications. During the 18 h after admission, the patient experienced worsening shortness of breath and anoxia and was subsequently transferred to the Emergency Intensive Care Unit (EICU) for non-invasive ventilator assisted ventilation. Additionally, the patient was intravenously administered alteplase once every 12 h for 3 consecutive days and 5000 units subcutaneous unfractionated heparin. Warfarin (5 mg) was orally administered once a day. On noting that the prothrombin time (PT) and international normalized ratio (INR) were 2–2.5 times their respective normal levels, warfarin therapy was singly administered along with anti-infective, supportive, and oxygen therapies. Once her condition had considerably improved and the anoxia was reduced, she was discharged from the hospital.
+After 10 days, dyspnea and chest tightness recurred. In addition, she experienced persistent right chest pain, which aggravated when she lied on her right side and was not relieved by rest. Minor vaginal bleeding was also observed. She presented to the Department of Respiratory and Critical Care Medicine of our hospital for a CTPA, which revealed filling defects in the left and right branches of pulmonary artery as well as bilateral pleural effusion . A routine coagulation test revealed 37 s PT and 3.33 INR, and a D-dimer assay showed a value of 8.75 mg/L. No abnormalities were observed in limb color ultrasonography, tumor antigen testing, or surrogate markers of autoimmune diseases (anti-nuclear antibody, anti-RNP antibody, anti-CCP antibody, c-ANCA, p-ANCA, anti-SS-A antibody, and anti-SS-B antibody). Based on the monitoring of PT and INR, we decided to discontinue warfarin to prevent an overdose situation. Relevant contraindications were excluded and the patient underwent interventional inferior vena cava filter implantation combined with thrombolysis implantation therapy, along with low-dose urokinase. Following surgery, she continued to receive anticoagulant treatment. On considerably improvement in her condition, she was discharged.
+One month later, she was referred to our hospital again due to swelling in her right lower limb. She received interventional inferior right iliac vein dilation and stent placement. In October 2018, she presented again with a week-long history of right-sided chest pain, cough, difficulty in breathing, and weight loss. A CTPA revealed no evident improvement of the thrombosis in the right and left main pulmonary artery, progression of pneumonia, and a reduced right pleural effusion, compared with the previous CTPA. Once again, the tumor associated antigen test was performed. Tumor antigen testing revealed an elevated Ca125 level of 69.16 U/ml (normal value < 35 U/ml) and Ca199 level of 30.22 U/ml (normal value < 27 U/ml). She was treated with anticoagulation, anti-infection, supportive, and oxygen therapies. We recommended her to undergo a positron emission tomography-computed tomography (PET-CT) test, but she refused and was discharged from the hospital.
+She subsequently underwent a PET-CT examination in another hospital. The PET-CT revealed diffuse heterogeneous thickening of the right pleura, substantially increased glucose metabolism, fluorodeoxyglucose (FDG) uptake on L5 vertebral body, striated soft tissue lesions along the right iliac vein, and increased FDG uptake. In November 2018, she was once again admitted to our hospital. Results of enhanced chest CT scan revealed a bilateral PE, bilateral pulmonary infection, right pleural thickening, and pleural effusion . She completed the CT-guided pleural biopsy and postoperative histopathology revealed the tumor consisting of squamous cells were arranged in the nest bulk with invasive growth . Immunohistochemical (IHC) staining was performed for pleural lesion was positive for P63 , P40 , CK5/6 , epithelial membrane antigen (EMA) and negative for CD5 , CD117 and Calretinin . Combining with the IHC analysis, the pathological diagnosis was squamous cell carcinoma. Based on her medical history and results of histopathological examination and imaging, the patient was finally diagnosed with PPSCC.
+Between 1977 and 2019, we identified 9 previous reports of squamous cell carcinoma arising from the pleura in patients. As described in Table , patients ranged in age between 49 and 75. These cases underwent chest pain, cough, dyspnoea, and other clinical symptoms. Most lesions of these patients were observed in the right pleura. Most of the cases had been in long standing chronic empyema, bronchopleural fistula or pneumothorax before a diagnosis of squamous cell carcinoma. But in our case, the patient was previously healthy without chronic empyema or bronchopleural fistula. After being diagnosed with pulmonary embolism, our patient experienced recurrent chest wall pain and pulmonary embolism.
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index 0000000000000000000000000000000000000000..71bb7fbecfc1e6b10427ac510795508043b92840
--- /dev/null
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+A 63-year-old female presented with 2-months of the low back pain (LBP) and the left lower extremity sciatica. The thoracolumbar spine MRI showed an irregular L5 osteolytic epidural lesion that was hypointense on T1-weighted studies, hyperintense on the STIR sequences, and inhomogeneously enhanced with contrast [-]. Hypointense lesions also involved the L2, L3, and L4 vertebrae. The patient underwent a L4-L5 laminectomy for tumor removal (piecemeal resection), a L4-S1 transpedicular screw/rod fusion plus L2-L3 radiofrequency ablation.
+The histological examination confirmed primary spinal Burkitt’s lymphoma (i.e. CD20, BCL6, and PAX5 positivity, negativity for CD10, BCL2, CD23, cyclin D1, PANCK, and CK20) and a high proliferation rate (many mitotic figures and lymphoid cells with a typical starry-sky pattern).
+Postoperatively, the patient’s whole-body CT scan showed pleural and splenic metastatic lesions plus pathologically enlarged right hilar lymph nodes.
+Within 1 month postoperatively, the patient’s sciatica fully recovered. She subsequently had radiotherapy, chemoradiotherapy, and 6-months later, showed >50% disease remission (i.e. on whole body CT studies).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1783_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1783_en.txt
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index 0000000000000000000000000000000000000000..b2736975e0cc6536870793a4319f32d121aea129
--- /dev/null
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+A 72-year-old man presented with a mass in the right parotid area that had become rapidly enlarged for 2 months. His medical history included a subtotal gastrectomy for a gastric ulcer 20 years earlier and low anterior resection for moderately differentiated adenocarcinoma of the rectum (Stage T1N0) 1 year earlier. Preoperative computed tomography (CT) showed a relatively well-defined heterogeneous enhancing solid lesion with calcification in the superficial lobe of the right parotid gland, with no indications of metastasis to the regional lymph nodes .
+Fine-needle aspiration specimen showed that the tumor contained many clusters of malignant epithelial cells and scattered atypical spindle cells on a necrotic background. Under suspicion of a malignant tumor, the patient underwent total parotidectomy. Gross examination of the specimen revealed a multifocal, ill-defined, grayish-white, and heterogeneous solid tumor, accompanied by calcification and measuring 3 × 2.5 cm. Microscopically, the tumor was composed of two malignant components, carcinoma and sarcoma , with multifocal invasion (> 1.5 mm) of the capsule and adjacent tissues on a background of pre-existing pleomorphic adenoma and the osteosarcoma component was diffusely positive for vimentin . Both components showed some degree of nuclear immunoreactivity for p53 .
+Following surgery, the patient received postoperative radiation therapy. Six months later, he complained of abdominal pain. Abdominal CT showed a distension of small bowel with luminal narrowing and localized high density material in the abdominal cavity . The lesion was regarded as mechanical obstruction with postoperative adhesion because the patient had undergone previous abdominal surgery for rectal adenocarcinoma. After conservative management for several days, he experienced severe abdominal pain and an increased heart rate, and an emergency laparotomy was performed. Multiple hard calcified masses were observed in the abdominal walls, omentum, and mesentery, and mass excision with small bowel resection was done. On gross examination, bulky, gritty, and hemorrhagic mass adhered to the mesentery was identified . Microscopically, the tumors were identified as osteogenic sarcomas, with histologic features identical to those of the osteosarcomatous component of the carcinosarcoma of the parotid gland . The tumor cells were positive for vimentin on immunohistochemical staining . Because of its rapid development over 6 months and no history of osteosarcoma at any sites, we concluded that the abdominal osteosarcoma was metastatic from the carcinosarcoma of the parotid gland. The patient was postoperatively admitted to the intensive care unit and died of acute respiratory distress syndrome (ARDS) caused by aspiration pneumonia.
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index 0000000000000000000000000000000000000000..c7d5c1d1847272649a17eedd4ad03473069721f4
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+A 50-year-old female patient presented to the emergency department (ED) in significant respiratory distress. She had a known past medical history of tobacco dependence, chronic obstructive pulmonary disease (COPD), gastroesophageal reflux disease, and hypertension. On arrival, the patient was noted to be apneic and was actively being ventilated with a bag-valve-mask ventilation. She rapidly progressed from an irregularly irregular cardiac rhythm to sinus bradycardia, and then into a pulseless electrical activity (PEA) arrest within minutes of arrival. She underwent approximately 30 minutes of cardiopulmonary resuscitation, with endotracheal intubation performed via video laryngoscopy. She was noted to have significant resistance to bagging after intubation, and after return of spontaneous circulation, was noted to have high peak pressures on the ventilator and was persistently hypotensive.
+On examination, the patient was noted to have distant, rhonchorous, and wheezy breath sounds bilaterally, and she was treated for her bronchospasm with nebulized albuterol-ipratropium solution, continuous nebulized albuterol, magnesium sulfate, methylprednisolone, subcutaneous terbutaline, and titratable epinephrine (to also assist with her hypotension). She was noted to have continuously high peak pressures; so, an intravenous push of vecuronium was given without improvement in ventilation and with continuously high peak airway pressures noted on the ventilator. She had an electrocardiogram concerning for new-onset atrial fibrillation with rapid ventricular response, left axis deviation, a new right bundle branch block, and a left anterior fascicular block with signs of right heart strain. Given her difficulty with ventilation with high peak pressures and hypotension, she was taken for a computed tomography (CT) with pulmonary embolism protocol as there was concern that the etiology of her arrest may have been a massive pulmonary embolism.
+This revealed no evidence of pulmonary embolism; however, it did show evidence of alveolar rupture with pneumomediastinum consistent with the Macklin effect and a small left-sided pneumothorax with associated medial left hemi diaphragmatic rupture with pneumoretroperitoneum tracking along the left upper abdomen and left perinephric space with left-sided nondisplaced rib fractures of the fifth and sixth ribs . A CT of the abdomen and pelvis was then performed, which showed a small amount of free air consistent with pneumoretroperitoneum adjacent to the gastric cardia, left kidney, and left adrenal gland, but with no definitively identified intra-abdominal traumatic injury.
+Further history from the family, who arrived several hours after the patient’s initial presentation, revealed she had been complaining of difficulty breathing earlier in the day, and she subsequently suffered a witnessed fall down a flight of stairs with head trauma and apparent loss of consciousness. The patient’s physical examination revealed no external signs of trauma on initial arrival.
+The patient was admitted to the medical intensive care unit in the setting of cardiac arrest with prolonged down time, with improvement in her pneumomediastinum and pneumoretroperitoneum with lung-protective ventilation strategies and paralytics. The patient’s treatment for her COPD exacerbation was extensive and included continuous albuterol nebulization of 40 milligrams (mg) over four hours, intermittent scheduled three-milliliter ipratroprium-albuterol nebulizers every six hours, 0.25 mg of budesonide twice daily, 0.5 mg of ipratroprium four times daily, isolated two mg of magnesium sulfate administration daily if worsening wheeze on examination, 80 mg of methylprednisolone daily, a one-time dose of 0.25 mg of subcutaneous terbutaline, and a one-time dose of one microgram (μg) of epinephrine. Sedation was maintained with both ketamine at 1.5 mg per kilogram (kg) per hour and propofol at 20 μg/kg per minute. For the patient’s hypotension, she was treated with epinephrine as the first-line vasopressor choice given its underlying beta adrenergic effects in the setting of her profound bronchospasm.
+However, the patient’s cardiac arrest resulted in severe hypoxic brain injury, leading to subsequent diffuse cerebral edema with effacement of the basal cisterns and tonsillar herniation seen on CT of her head. She became increasingly hypertensive and was weaned off vasopressors and started on titratable nicardipine at a maximum of 12.5 mg per hour and was given a hypertonic saline bolus. The patient lost all evidence of brainstem reflexes five days after suffering cardiac arrest but continued to trigger some spontaneous breaths on the ventilator. Multiple family meetings were held regarding patient prognosis, and ultimately the patient was palliatively extubated with subsequent demise 26 days after arrival.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_182_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_182_en.txt
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index 0000000000000000000000000000000000000000..e2e98c442736c6a1081607337c2e0bb7fa99a404
--- /dev/null
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+A 72-year-old man was admitted with shortness of breath for more than 1 year after the activity and then had hemoptysis for 1 week. The patient has a history of dermatophytosis for 4 years and never-treated, smoking more than 20 years cigarettes 3 per day and quitting smoking for 6 months, drinking for more than 10 years. On physical examination, her bilateral zygomatic and lips had cyanosis, hepatic jugular venous reflux sign was positive. Mild systolic murmur of grade 2/6 could be heard in the auscultation area of pulmonary valve and peripheral oxygen saturation was 97% while breathing ambient air. Two-dimensional transthoracic echocardiography showed a solid mass was detected at the pulmonary valve orifice, showing moderate-to-strong echo. Its outline was clear, and the internal echo was uniform, with the size of about 57mm × 36mm. It was attached to the pulmonary valve orifice, part of which was located in the right ventricular outflow tract, and part in the main pulmonary artery. There was no obvious motion, causing obvious stenosis of the pulmonary valve orifice . The right atrium and right ventricle were enlarged, and the interventricular septum shifted to the left ventricle, showing “D” sign . Color Doppler flow imaging showed moderate regurgitation in tricuspid valve with regurgitation area of 8.8cm2 , regurgitation velocity of 420 cm/s and PG of 70 mmHg . Computed tomography angiography (CTA) findings of superior vena cava: right ventricular and the root of pulmonary artery has low-density imaging, considering that it is thrombosis, neoplastic lesions are not excluded . The patient underwent surgery, which showed pulmonary valve has solid occupying lesions, pale yellow, soft, nonenveloped, wrapping of the pulmonary valve leaflet, adhesion of the posterior wall of pulmonary valve, clipping the mass along the posterior wall of the pulmonary valve, the size of the mass is about 6.0cm × 4.5 cm . Cardiac surgeons explored that the posterior wall is very thin, fresh autologous pericardium to reconstruct the pulmonary valve. Continuous observation intraoperative by transoesophageal echocardiography. Postoperative transoesophageal echocardiography demonstrated no obvious abnormalities in the pulmonary arteries. Doppler examination showed a maximum flow velocity of 110 cm/s; color Doppler flow imaging (CDFI) displayed there was no stenosis in the pulmonary arteries. The final pathological diagnosis is Pulmonary artery endometrial sarcoma . The lesions presented three regions under the microscope: including necrotic regions, sparse region and intensive areas. Tumor cells grow in solid neoplasm, invade from pulmonary artery intima to adventitia, most of the tumor cells are spindle cells, it is very obvious in heteromorphism. Collagen presents predominantly in the interstitial matrix, also bone matrix visible, nuclear compartmentalization and necroptosis is frequent. An immunohistochemical analysis showed that CD vimentin-positive and α-smooth muscle actin-positive, desmin-negative, CD34-negative, CD31-negative, F8-negative, Stat6-negative, Ki67(+ 10%), S100-negative, SOX10-negative, TLE1-negative, CK-negative, EMA-negative. A further treatment for this patient after cardiac surgery was carried on in the cardiac intensive care. Persistent hypoxemia could not correct after giving various intravenous drugs. The patient died in the fifth day after cardiac surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1877_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1877_en.txt
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index 0000000000000000000000000000000000000000..f8775aa809f3e1490973842056c52f71f3546ca1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1877_en.txt
@@ -0,0 +1,7 @@
+A 55-year-old female experiencing a progressive headache and vomiting for one month was admitted to our hospital.
+55-year-old female experiencing a progressive headache and vomiting for one month was admitted to our hospital. She was diagnosed with lung adenocarcinoma with osseous metastasis 10 mo prior to admittance. EGFR mutation was detected upon genomic examination, so she was first treated with gefitinib for 10 mo before acquiring resistance. A previous enhanced cerebral magnetic resonance imaging (MRI) and PET-CT one month prior showed that there was no obvious abnormality in the CNS. Lumbar puncture showed an increased intracranial pressure (+ACY-gt+ADs-330 mmH2O) without positive cytology and biochemical examination findings in the CSF. However, further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation. After the patient was admitted, a second enhanced MRI was performed and showed comprehensive linear leptomeningeal enhancement in the cerebral sulcus . A second cytology and biochemical examination of the CSF remained negative.
+The patient had no special history of past illness other than a hysterectomy procedure for fibroids 10 years prior.
+The patient had no special history of past illness other than a hysterectomy procedure for fibroids 10 years prior.
+Neurological and pulmonary examination of the patient showed no obvious abnormalities.
+Lumbar puncture showed an increased intracranial pressure (> 330 mmH2O) without positive cytology and biochemical examination findings in CSF. However, further CSF ctDNA detection by next-generation sequencing showed an EGFR-Thr790Met mutation, and the variation frequency was 11.7%.
+(1) Chest CT image at admission shows a lesion in the lingual segment of the upper lobe of the left lung (arrows); and (2) A follow-up cerebral contrast-enhanced MRI shows diffuse and linear enhancement along the surface of the cerebrum (arrows).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1878_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1878_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..792184e8c32688edb545d3cf21bdc6f800401db6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1878_en.txt
@@ -0,0 +1,3 @@
+A 35-year-old female gravida eight para two with a recent left tubal pregnancy and a left salpingectomy 11 days prior, presented to the emergency department (ED) with two days of left lower and upper quadrant abdominal pain radiating to the epigastric region. The patient’s last menstrual period had been several months prior. She had a family history of ectopic pregnancies and a history of a prior sexually transmitted infection but no documented history of pelvic inflammatory disease. The physical examination revealed left lower quadrant abdominal tenderness, rebound, guarding, and left adnexal tenderness. Her vital signs were unremarkable, with an initial blood pressure of 132/82 millimeters of mercury, pulse of 75 beats per minute, temperature of 98°F, and oxygen saturation of 99% on room air.
+Her laboratory studies were notable for a hemoglobin of 11.9 grams per deciliter (g/dL) (reference range: 11.6–15 g/dL) and a normal white blood cell count of 8.4 thousand per cubic milliliter (k/μL) (reference range: 5–10 k/μL). Her lipase and liver function tests were within normal limits. Her human chorionic gonadotropin (hCG) had tripled from 6,253 milli-international units per milliliter (mIU/mL) (reference range: ≤2 mIU/mL) from her prior presentation to 18,038 mIU/mL. Transvaginal ultrasound showed a possible ectopic pregnancy adjacent to the right ovary and no intrauterine pregnancy .
+The patient declined medical abortion and was taken to the operating room for a right salpingectomy. On her initial presentation 11 days prior, the patient’s preoperative ultrasound had shown a complex focus of the left ovary with a hyperechoic thick rim suggestive of ectopic pregnancy and probable right-sided corpus luteal and anechoic cysts (, ). No evidence of right ectopic pregnancy was documented intraoperatively during the patient’s initial salpingectomy. Pathology findings from the initial left- and subsequent right-sided procedures showed immature chorionic villi, congestion, and hemorrhage consistent with a tubal pregnancy. The patient had an uneventful recovery after her second surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1900_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1900_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dc1addefb9cdccfdefbfb7eae619855c5cadf0ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1900_en.txt
@@ -0,0 +1,3 @@
+A 69-year-old Japanese man underwent treatment for liver dysfunction 3 years after aortic valve replacement. Later, rapid elevation in his serum alkaline phosphatase (ALP) level was recorded and he was readmitted to determine the etiology. His body temperature was 36 °C, blood pressure 164/65 mmHg, and pulse rate was 66/minute. Laboratory data revealed mild anemia and liver-renal injury: white blood cells (WBC) 4600/uL, hemoglobin 9.7 g/dL, platelet 18.9 × 104/dL, C-reactive protein (CRP) 0.29 mg/dL, ALP 1138 U/L, aspartate aminotransferase (AST) 40 U/L, alanine aminotransferase (ALT) 37 U/L, and γ glutamyl transpeptidase (γ-GTP) 298 U/L. His blood urea nitrogen (BUN) was 22.4 mg/dL, creatinine 1.14 mg/dL, activated partial thromboplastin time (APTT) 45.6 seconds, and prothrombin time-international normalized ratio (PT-INR) 2.67. He also had a past history of duodenal ulcer perforation and was currently being treated with warfarin, angiotensin receptor blocker, and proton pump inhibitor. In addition, he was taking orally administered ursodeoxycholic acid for unknown liver function disorder. He had no alcohol consumption or tobacco smoking history and no relevant family history.
+A plain radiograph showed no significant findings, but computed tomography (CT) revealed an enhanced tumor within the hilar bile duct and dilatation of the left hepatic duct , which are typical findings for hilar cholangiocarcinoma. In addition, endoscopic retrograde cholangiopancreatography (ERCP) revealed tumor shadow in his bile duct, and the cytology confirmed malignant cells in the bile . As no lymph node and distant metastases were detected, we inserted endoscopic nasobiliary drainage (ENBD) to reduce jaundice as preparation for surgery. We performed extended left hepatectomy with resection of his bile duct; his postoperative course was good without severe complications. After 3 months postoperatively, he was readmitted for subacute cholangitis and obstructive jaundice. Immediately, percutaneous transhepatic cholangiography drainage (PTCD) was performed, followed by cholangiography that exhibited the intrabiliary tumor growth in the remnant liver.
+Simultaneously, histological examination of resected specimens revealed tumor growth in the hilar duct across the left hepatic duct . Microscopic findings at the same site revealed a dilated bile duct filled with well-differentiated tubular adenocarcinoma . On immunohistochemical examination, tumor cells were positive for cytokeratin (CK) 20 but negative for CK7 . Furthermore, CK18 as control and CDX2 were stained. Although these findings were not typical of intrahepatic cholangiocarcinoma, hepatic metastasis from another primary lesion was strongly suspected [, ]. Furthermore, CT revealed an enhanced tumor-like lesion at the descending colon, followed by diagnosis of type 2 cancer in total colonography. Then, left hemicolectomy was performed; the immunohistochemical-identified feature matched with an intrabiliary tumor. Meanwhile, the PTCD fluid turned bloody, which was considered to indicate bleeding from a residual bile duct tumor . Accordingly, we planned chemotherapy with orally administered capecitabine but our patient experienced a spike fever because of refractory cholangitis. Thus, we abandoned chemotherapy and initiated radiotherapy to stop the tumor bleeding around the hilar bile duct. After completing radiotherapy (total 50 Gy) for approximately 1 month, we observed an improvement in his liver function because of tumor shrinkage. Unfortunately, the effects were short-lived, intrabiliary growth and cholangitis rebooted after 1 month leading to his death due to septic liver failure . Autopsy revealed a remnant tumor in the bile duct , but no noticeable nodular metastasis was observed, except for a single small metastasis in the lower lobe of his left lung.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1913_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1913_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..71b5244b07ca99e1ca278e8d529eaed29703c84d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1913_en.txt
@@ -0,0 +1,11 @@
+The donor was a 35-year-old male, Maastricht category III, who died after cardiac arrest (DCD) due to intracranial haemorrhage secondary to trauma. The right kidney was sent to another centre first and declined due to vascular damage. It then went through the fast-track scheme and was accepted by our team at Guy's Hospital. Once we had the kidney, the initial evaluation showed a right kidney, with three veins in a single cava patch, three renal arteries, the main artery with aorta patch that is 8 cm long, a small lower pole artery, which was sectioned during retrieval surgery at approximately 1 cm from its origin, and a third small mid-lower pole artery. The ureter had bifid renal pelvis.
+During bench surgery the kidney was well perfused well with Soltran solution. From the three veins in the single cava patch, it was decided to ligate the posterior branch in order to allow the single patch to be more mobile. The small mid-lower pole artery was already damaged and was deemed unreconstructable and was therefore tied off. The main artery was left with a 1 cm aortic patch. The lower pole damaged artery was reconstructed using tubularised aorta patch to a total length of 5 cm. No additional donor vessels had been sent.
+Although the inferior epigastric artery is sometimes preferred for this kind of reconstruction, in this case, it would probably have been too small for the reconstruction; also, the availability of a long and healthy aortic patch and the fact that during benching we did not know the status of the recipient vessels made us decide to take this approach.
+The reconstruction was carried out with an aorta patch that is 5 cm in length that was part of the main artery patch of the organ. Using an 8 ch Nelaton bladder catheter as a mold a 5 cm long aorta segment was tubularised using 3 7-0 Prolene interrupted stiches in the distal area to avoid stenosis and Prolene 7-0 continuous suture in the rest of the patch to minimize bleeding risk. After construction of the tubulised aorta, E-E anastomosis to the damaged polar artery was done with interrupted 7-0 Prolene .
+The recipient was 68-year-old male, with past medical history of ESRD secondary to IgA nephropathy on peritoneal dialysis and no other medical issues nor surgical procedures. After a detailed discussion with the patient, regarding the benefits and the risks due to the surgery and donors/organ characteristics, the patient was happy to proceed and signed the consent.
+Transplant surgery was performed in the right iliac fossa with an extraperitoneal approach to the iliac vessels. The common cava patch was anastomosed to the recipient's external iliac vein. The main artery was anastomosed to the common iliac artery. Finally the reconstructed artery with the tubulised patch anastomosed the external iliac artery. After completion of all three vascular anastomoses the kidney was reperfused . The ureter was anastomosed to the bladder over a double J stent. A Robinson drain was left and wound was closed. The cold ischemic time was 27 hours and 15 minutes and warm ischemic time was 75 min.
+There were no immediate postoperative complications. The first ultrasound was performed two hours after finishing the surgery in the recovery ward, showing good perfusion of the kidney.
+After 48 hours a second ultrasound was performed. The presence of a superficial haematoma within the subcutaneous tissues and slightly reduced perfusion within the interpolar region was reported; otherwise appearance of the transplant kidney was satisfactory.
+Haemoglobin fell from 11.2 (preoperatively) to 6.4 gr/dl. A decision to transfuse two units of blood cells and a relook surgery was reached. There was subcutaneous and perigraft haematoma and no active bleeding. The three vascular anastomoses were identified, both arteries, main and reconstructed, had good thrill, and the vein was soft and had good outflow. A new drain was left at the surgical site and wound closure was performed.
+Three days later, the ultrasound was repeated showing that the right iliac fossa transplant kidney had normal cortical thickness and appearance. There was no pelvicalyceal dilatation. The previously demonstrated superficial collection was no longer present. There was satisfactory global vascularity. The sampled interlobular and arcuate vessels demonstrate normal flow with resistive indices between 0.65 and 0.8. The two renal arteries and veins had normal spectral waveforms, with a final impression of normal appearances of right iliac fossa transplant kidney.
+Ureteric stent was removed at week 4 after transplant. Three months after transplantation the patient was stable and had no dialysis requirements with creatinine of 187.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1916_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1916_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6084ab48cca00c8a2c9b8e0a2deac9b7c3a177ac
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1916_en.txt
@@ -0,0 +1,3 @@
+A 71-year-old woman presented to our emergency room with a complaint of increasing right-sided neck pain at the thyroid cartilage level after she accidentally tripped and hit her neck against a pole 3 h back. At the time of admission, her vital signs were stable without evidence of respiratory distress, and there was no swelling or subcutaneous emphysema . Laryngeal endoscopy revealed normal vocal fold mobility and mild edema of the arytenoids.
+Contrast-enhanced computed tomography (CT) revealed rupture of the right lobe of the thyroid gland accompanied by a large hematoma extending from the thyroid to the mediastinum . There were no cysts or goiter in either thyroid lobe and no fracture of the laryngeal framework, cartilages, and trachea. In view of the patient’s condition and the presence of the large hematoma, neck exploration under general anesthesia was undertaken. During surgery, the dorsal side of the right lobe of the thyroid gland was found to be ruptured with lacerations . The ruptured right lobe was resected and the hematoma, which extended to the upper mediastinum, was evacuated. Pathological examination of the resected lobe revealed otherwise normal anatomy, with no evidence of goiter or cyst.
+The patient required postoperative intubation for 24 h because of laryngeal edema, but she subsequently made a full and uneventful recovery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1918_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1918_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a68abdf5640a996157430b7b8157095225076088
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1918_en.txt
@@ -0,0 +1,8 @@
+The patient, a 47-year-old male piano tuner, complained of weakness in his left hand, with no apparent traumatic causes of flexion or extension of the distal phalanges of his left thumb for two months.
+Over the past 2 mo, his condition has progressively deteriorated with weakness in his left hand, as well as ancient flexion weakness in the distal left thumb and significant restriction of movement.
+The patient has no family history of alcohol or tobacco addiction and was in good overall mental condition.
+No significant medical history.
+Left thumb long flexor tendon strength grade 4, left index finger deep flexor tendon strength grade 0, left thumb short flexor strength grade 5, left index finger short flexor strength grade 5, no significant abnormalities of superficial skin sensation in the left hand and left forearm. The palmar aspect of the left wrist is flatter than that of the right wrist (anterior rotator muscle), and there are no significant abnormalities in finger movement or blood flow in the remaining fingers.
+None.
+Digital radiography examination: The left ulnar radius is regular in shape with continuous bone cortex and clear bone trabeculae, with no obvious signs of bone destruction. The distal ulnar flexor and flexor carpal joint gaps were moderate and there were no obvious abnormalities in the surrounding soft tissues .
+Colour ultrasonic Doppler examination: Widening of the median nerve cross-section over the left elbow, left side wide (0.48 cm × 0.29 cm), hypoechoic, star grid-like changes, the left side of the median nerve at the elbow is about 0.54 cm × 0.29 cm wide (right side is about 0.52 cm × 0.27 cm wide) locally hypoechoic, local nerve bundle thickness varies, one obvious narrowing is visible, local nerve bundle width is about 0.08 cm, proximal segment is 0.17 cm, the distal segment is 0.14 cm. The body surface was marked and the median nerve at the wrist was approximately 0.62 cm × 0.23 cm wide on the left (0.76 cm × 0.38 cm wide on the right).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_193_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_193_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..daaf6afad047cf133aba6e956b6ee970d81a9ec8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_193_en.txt
@@ -0,0 +1 @@
+A 62-year-old woman was admitted to the emergency department suffering from weakness and acute chest pain during the preceding two hours. There were no records in the patient’s history of any chronic diseases, including renal failure or hypo/hyperthyroidism. In fact, she had no remarkable medical history, except for being put on lithium 400 mg/day and duloxetine 20 mg/day, a week earlier, due to bipolar disorder. Physical examination disclosed tremor in both hands and bilateral nystagmus. The patient’s arterial blood pressure was 90/60 mmHg, with a heart rate of 78 bpm, a respiratory rate of 22 bpm, and a transcutaneous SaO2 of 97%. Surface electrocardiography revealed ST elevation in leads DI, aVL and V5-6, with a ventricular rate of 80 bpm . Blood chemistry, including renal function tests and complete blood count were within normal limits. The patient’s blood lithium level was measured as 2.3 mmol/L (therapeutic range 0.5 to 0.8 mmol/L), and her troponin I level was 0.892 ng/mL (N: 0–0.01 ng/mL). Echocardiographic findings, including myocardial wall motions, pulmonary arterial pressure and ejection fractions were normal. The patient was admitted to the coronary intensive care unit. A subsequent coronary angiography performed within one hour of admission provided normal results . This was concurrent with a resolution of electrocardiographic abnormalities accompanied by elimination of lithium, which suggested that the observed ECG changes were linked to LI. The patient’s lithium level, measured on the seventh day, was found to be within normal limits (0.6 mmol/L). The clinical course in the intensive care unit was uneventful, with the patient being provided medical treatment and then discharged.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_194_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_194_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d66574d12e50922f90df0e0872f651ca51a9ebe6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_194_en.txt
@@ -0,0 +1,3 @@
+A 31-year-old female was referred to the ED with spontaneous onset pain in the right upper quadrant and flank region accompanied by nausea and flatulence. Initial vitals were apyretic, respiratory rate 28/min, heart rate 118 beats/min, blood pressure 85/50 mmHg, with normal oxygen saturation. On physical examination, the patient had significant pain in the epigastric and right flank region with involuntary guarding, but signs of peritoneal irritation or a palpable intra-abdominal mass were absent. There was no evidence of acute cholecystitis, appendicitis, or peritonitis. The patient had no history of surgery, trauma, calculus, and drug abuse. Her family and social histories were unremarkable.
+Laboratory investigation showed a white blood cell count of 11.3 K/cmm, hemoglobin of 48g/dL, hematocrit of 30.7%, and serum creatinine of 2.4 mg/dL. Tumor markers, including alpha-fetoprotein, carcinoembryonic antigen, and carbohydrate antigen (CA 199 and CA 125), were within normal limits. Also, no abnormal data in the blood hormonal sampling, including adrenocorticotropic hormone, cortisol, aldosterone, and epinephrine, were observed. Bedside ultrasound of the abdomen revealed an irregular and heterogeneous mass in the retroperitoneal space with an obvious fluid collection in the right subhepatic space. Hemoglobin on repeat cell count was 39 g/dL. After a rapid intravenous infusion of 500 ml of Ringer’s lactate solution and 500 ml of 10% hydroxyethyl starch, urgent non-contrast-enhanced computed tomography (CT) of the abdomen showed a 7×8 cm well-contained, right-sided retroperitoneal hemorrhage between the liver and right kidney .
+An urgent laparotomy was performed, revealing a massive right-sided retroperitoneal hematoma with a small amount of intraperitoneal blood. The ascending colon was mobilized to give a more complete view of this large mass and hematoma situated between the liver and right kidney. The right adrenal gland was closely adherent and was excised along with the mass. The cut surface of the mass showed some areas of necrosis. Histological examination confirmed the features of cavernous hemangioma. Microscopically, histology showed degenerative changes in vessel walls, some of which were obliterated. The blood-filled lacunae were lined by benign endothelial cells. The periphery represented a normal adjacent adrenal gland . There were no signs of malignancy. The patient did well postoperatively and was discharged after 7 days. Surgical resection was curative, with no recurrence at the 1-year follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1958_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1958_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..215a76cde1ca668eca114c27e51b656c5b58f632
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1958_en.txt
@@ -0,0 +1,3 @@
+A 39-year-old black male with known sickle cell trait presented to the emergency department with lower extremity swelling with blisters and odynophagia. He developed petechial lesions on both feet that progressed to ulcers on the bilateral lower extremities. The odynophagia started 2 weeks prior to presentation and was associated with a tongue ulcer. He had been evaluated by an infectious disease team during a previous visit and had an unrevealing workup. He was not on any treatment for lower extremity lesions. He denied fever, chills, nausea, vomiting, diarrhea, weight loss, night sweats, recent travel, and history of IV drug use.
+His initial vital signs were BP 156/86, HR 114, temperature 102.2 F, and O2 saturation at 98% on room air. Physical exam was remarkable for oral thrush with right tongue ulceration and healing ulcers on the dorsal surface of his feet bilaterally. His complete blood count (CBC) and basic metabolic profile (BMP) were within normal limits. Urinalysis was positive for blood and 2+ proteinuria. His urine toxicology was positive for oxycodone. He was initially treated for Systemic Inflammatory Response System (SIRS). Blood cultures were drawn and he was started empirically on vancomycin and piperacillin and tazobactam. Bilateral venous duplex was negative for deep vein thrombosis. Computed tomography (CT) of the chest showed multiple irregular nodules with suspected infectious versus inflammatory etiology and septic emboli could not be excluded . Transthoracic echocardiogram was negative for infective endocarditis. Bilateral foot ulcers drained serosanguinous fluid with cultures positive for Enterococcus faecalis and Serratia but four sets of blood cultures remained negative. Magnetic resonance imaging (MRI) of the left foot was normal and MRI of the right foot showed metatarsal stress reaction versus early osteomyelitis. Skin biopsy showed extensively necrotic fibroadipose tissue with acute inflammation. Right lateral oral tongue ulcerative lesion biopsy showed predominantly hyperplastic squamous mucosa showing an ulcer site and abscess with fragments of necrotic squamous epithelium associated with cytologic atypia and colonies of bacteria, and one fragment of necrotic squamous epithelium displayed vague papillary architecture. The patient later developed right eye conjunctivitis. Appropriate consultations with nephrology, pulmonology, and podiatry were obtained.
+Based on the constellation of oral and cutaneous ulcers, CT chest findings, bilateral foot ulcers, and conjunctivitis, a rheumatologic process was suspected. The antinuclear antibody (ANA) was negative, rheumatoid factor was with 1 : 640 titer, C-ANCA (antineutrophil cytoplasmic antibody) was positive with 1 : 1280 titer, and the diagnosis of Wegner's granulomatosis was made. He was started on rituximab 375 mg weekly and methylprednisolone 250 mg every 6 hours for 3 days. He later had a renal biopsy which showed granulomatosis with polyangiitis and mild interstitial fibrosis with tubular atrophy and a pauci immune crescentic glomerulonephritis . He underwent debridement of his bilateral foot ulcers and received an additional dose of rituximab. Following the second dose of rituximab, the oral ulcers improved. Toward the end of his hospitalization, his hemoglobin decreased and he was noted to have blood streaked sputum. Repeat CT chest was ordered and was consistent with diffuse alveolar hemorrhage . Unfortunately, he left prior to pulmonology evaluation. He was called and encouraged to come back to the hospital but declined and ultimately sought further medical attention at another hospital where he was ultimately admitted to the intensive care unit (ICU). Nephrology was consulted and began plasmapheresis for a total of 7 treatments. He was given a one-time dose of cyclophosphamide on initial presentation and then an additional dose of rituximab following plasmapheresis. He gradually improved and was discharged home 8 days after admission.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1962_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1962_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9db6a44fa600c4ea05aec68c004704292eda597e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1962_en.txt
@@ -0,0 +1,4 @@
+An 80-year-old woman was admitted to the emergency department of our hospital with dyspnea and without other respiratory symptoms or fever. She had back pain, which started 1 week before admission, radiating in the right knee. She had similar complaints a year before, due to a herniated disc. The patient’s past medical history included triple-negative, node-positive cancer of the right breast (cT3 cN1 cM0 G2, estrogen receptor- and progesterone receptor-negative, HER2-negative, PD-L1-negative, BRCA-negative) diagnosed 7 months earlier. After eleven cycles of chemotherapy with paclitaxel and carboplatin, a mastectomy was performed. Subsequently, she received adjuvant chemotherapy with capecitabine and percutaneous radiotherapy of the right breast inclusive of axillary, paraclavicular and parasternal lymphatic drainage. When radiotherapy was completed, she had shortness of breath on light exertion. At admission, tachypnea was present with a respiratory rate of 24 breaths per minute and an oxygenation saturation of 89% breathing ambient air. The heart rate was 78 beats per minute, and blood pressure 160/76 mm Hg. The hemoglobin level was 11.2 g/dL, and the platelet count was 68,000/mm3. The white blood cell count was 7,400/mm3, with 79.6% neutrophils. Serum C-reactive protein was elevated (80 mg/L), and the sodium level was decreased (125 mmol/L), diagnosed as syndrome of inadequate antidiuretic hormone secretion. A pronounced D-dimer elevation (55 μg/mL) was also detected. The patient’s characteristics are summarized in .
+A CT scan with pulmonary embolism detection program of the chest revealed smooth interlobular septal thickening with centrilobular consolidation and pleural effusions, as shown in . Angiography of the greater pulmonary arteries was negative for pulmonary embolism, and there were no signs of acute right heart failure, but signs of chronic pulmonary arterial hypertension were evident. Additionally, progressive mediastinal lymphadenopathy and right mammary soft tissue thickening, highly suspicious for a locoregional recurrence of the breast cancer, were detected. Further, the CT scan showed multiple metastases and suspect sclerotic lesions in the thoracic spine.
+Advanced tumor progression was suspected, but neither chemotherapy (due to the poor condition [ECOG 3] and low platelets) nor immunotherapy (due to low PD-L1 expression in a previous biopsy) nor an antibody-drug conjugate (due to hematotoxicity) was a causative treatment option. Symptomatic treatment for the respiratory distress consisted of oxygen, inhalation therapy with anticholinergic and beta-agonist bronchodilators, as well as oral corticosteroids. A follow-up CT scan of the chest 7 days later showed regressive pulmonary congestion. The platelets continued to decrease with a count of 22,000/mm3 7 days after admission. The patient’s condition massively deteriorated under the initiated therapy, and finally, end-of-life-care was initiated, given a situation with rapidly progressive carcinoma. The patient died 8 days after admission.
+An autopsy was then performed, revealing numerous tumor embolisms in the small- and medium-sized pulmonary vessels, partly with associated thrombi indicating PTTM . In addition, advanced metastatic disease with manifestations in the liver, non-regional lymph nodes, visceral pleura, all vertebral bodies, both suprarenal glands, and the mucosa of the stomach was found. The histomorphology was consistent with the pre-diagnosed triple-negative breast cancer.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1970_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1970_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..05e28924c08eb96ee2cdf8b92f6668a53c32d97f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1970_en.txt
@@ -0,0 +1,5 @@
+A 10-year-old Ethiopian boy presented to Tikur Anbessa Specialized Hospital, Addis Ababa, Ethiopia, with a sudden onset of weakness over his lower extremities. It had started 10 days earlier, accompanied by incontinence of urine and feces. He also had long-standing epigastric pain. He had no fever, diarrhea, cough, unconsciousness, abnormal body movements, or trauma. He had no close contact with a chronic cougher. He had received all scheduled vaccines during infancy, including four doses of oral polio vaccine, except hepatitis B vaccine, because he was born 1 year earlier than the incorporation of a routine three-dose series of hepatitis B vaccines into the national vaccination schedule. (He presented to our center in 2016.) Upon examination, he had an axillary temperature of 38.0 °C and tachycardia (115 beats per minute). He had a hard and tender hepatomegaly of 16-cm total span (10 cm below the right costal margin). Neurologic examination revealed a sensory level at T10, power of 0/5 of bilateral lower extremities, areflexia, and hypotonic anal tone.
+Investigations confirmed a normal complete blood count and erythrocyte sedimentation rate of 25 mm/hr. The patient’s liver enzymes were elevated: alanine aminotransferase 160 U/L and aspartate aminotransferase 136 U/L. Alkaline phosphatase was 761 U/L, and serum albumin was 3.4 mg/dl. His coagulation profile, renal function, serum electrolytes, blood and urine cultures, and human immunodeficiency virus and hepatitis C serologies were negative. His hepatitis B surface antigen was positive. Additional serologic testing to identify the state of his hepatitis B infection was not accessible.
+Thoracolumbar magnetic resonance imaging outlined a T9 vertebral body collapse with marrow signal change showing T1 isointensity and T2 heterogeneous hyperintensity. An epidural and paravertebral soft tissue swelling extending from T7 to T11 with postcontrast enhancement was seen to significantly compress the spinal cord. Differential diagnoses of tuberculosis spondylitis and metastases were considered.
+Workup for a primary malignancy showed elevated serum lactate dehydrogenase (599 U/L) but normal serum uric acid, chest x-ray, and abdominal ultrasound. Computed tomography of the abdomen revealed multiple well-defined, different-sized, solid hepatic masses with invasion and thrombosis of the right portal vein branch. The liver had a heterogeneous attenuation. The thoracic vertebral body had collapsed with an adjacent soft tissue mass extending into the spinal canal and prevertebral space.
+Serum α-fetoprotein (AFP) was greater than 40,000 IU/L, and an ultrasound-guided fine needle aspirate showed moderately pleomorphic polygonal cells with round nuclei and ample granular eosinophilic cytoplasm. Thus, a diagnosis of HCC with vertebral metastases was confirmed. The boy’s parents were counseled on the prognosis of the illness, following which they decided against further medical care and opted for home palliative care.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2003_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2003_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0d4db6942daa8c7996461fcf9d6eb611d53ccc81
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2003_en.txt
@@ -0,0 +1,3 @@
+A 74-year-old woman was admitted to our hospital department due to a right atrium mass. Three months earlier, she consulted a haematologist due to persistent fever and lymphadenopathy. A diagnosis of metastatic non-small cell lung carcinoma was made. Cardiovascular assessment before cancer treatment by transthoracic echocardiography (TTE) revealed the presence of a mass in the right atrium. A transoesophageal echocardiography (TEE) and a cardiac magnetic resonance were performed to further evaluate this mass, revealing a filamentous formation of 15 × 15 × 19 mm, originating from the inferior vena cava and extending to the interatrial septum, without gadolinium enhancement (; see ). This mass was interpreted as a Chiari’s network, and no specific treatment was proposed at the time. Immunotherapy with pembrolizumab was initiated. One month prior admission, she was hospitalized for fatigue. Physical examination revealed peripheral oedema and elevated jugular venous pressure. Laboratory investigation revealed cholestasis. Due to this right-sided acute heart failure, a computed tomography angiography of the chest was performed and showed a bilateral pulmonary embolism . The TTE showed the same previously known mass in the right atrium. Rivaroxaban, a non-vitamin K antagonist oral anticoagulant (NOAC), was started and patient was discharged. One day prior to admission, the follow-up TTE showed an increased size of the right atrium mass, as well as two new masses on the mitral valve . The patient was referred to our department.
+At presentation, she was still febrile with a body temperature of 38.1°C. She presented persistent dyspnoea for several weeks and reported amaurosis fugax as well as transient diplopia. Except for pulmonary cancer, the patient’s medical history was only relevant for arterial hypertension. Her usual treatment included perindopril. Her blood pressure was 120/60 mm Hg, heart rate was 90 beats/min, and oxygen saturation was 96% on room air. The physical examination was irrelevant, and there were no signs of heart failure or neurological deficit. Routine laboratory investigations showed a C-reactive protein at 195 mg/L (normal range < 10.0). Blood cultures were negative multiple times. Immunological assays for anti-phospholipid syndrome were negative. Coagulation factor VIII was 419% (normal range: 60–150%). TEE showed two masses on the mitral valve: the first one on the A2 portion of the anterior leaflet, and the second one on the posterior leaflet (; see , ). These two masses had the same echogenicity as the one in the right atrium. The valve had neither stenotic nor regurgitant complications. A cerebral magnetic resonance was performed and showed multiple bilateral lesions compatible with ischaemic embolism.
+A NBTE involving Chiari’s network and mitral valve in the setting of a procoagulant state related to the active cancer was suspected, and intravenous heparin was started. To achieve the target range of activated partial thromboplastin time and anti-Xa level, the patient required a high dose of heparin (50.000 units per day for a weight of 50 kg). TTE and TEE realized 2 weeks after heparin initiation, showed a favourable regression of the right atrium mass, as well as the two lesions on the mitral valve. After multidisciplinary discussion, 3 weeks of intravenous heparin was decided with bridging therapy to vitamin K antagonist (VKA) for life (international normalized ratio target range 2.0–3.0). Follow-up TTE and TEE at 6 weeks showed a persistent filamentous structure coming from the inferior vena cava, which is consistent with the Chiari’s network . The mitral valve was free from vegetations. On the oncologic level, the patient did not respond to immunotherapy and is undergoing chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2011_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2011_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dfb499d3fb3e2fa77b691728a2c7f973d74fd6b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2011_en.txt
@@ -0,0 +1,9 @@
+A 16-year-old woman treated with adjuvant Nivolumab presented with vomiting, nausea, and weight loss.
+The patient was diagnosed with stage IIIb malignant melanoma (T3bN1aM0). Both the primary melanoma and sentinel lymph node were radically removed. The patient was offered adjuvant treatment with Nivolumab (anti-PD-1), with 6 mg/kg administered every 4 wk. Initially, the patient tolerated the treatment well with only a small rise in plasma alanine transaminase compatible with a grade 1 hepatitis. An ultrasound examination of the liver was performed without any abnormalities observed.
+After the sixth series of Nivolumab, the patient presented with anorexia, vomiting, nausea, upper abdominal pain, and a weight loss of approximately 3 kg . The patient was admitted and received a short low-dose prednisone treatment for 4 d (40 mg methylprednisolone on the first day followed by 25 mg prednisone for 3 d) with a little initial symptomatic effect. The patient was discharged after 3 d, but readmitted 10 d later because of worsening of her symptoms with dehydration, vomiting, and stomach pain.
+The patient had no comorbidities. There was no history of prior gastroenterological symptoms.
+The patient did not smoke or consume alcohol. There was no noteworthy family medical history.
+Physical examination showed a pale and dehydrated patient with a weight loss of 3 kg. The abdomen was soft but revealed tenderness in the epigastrium.
+Blood tests showed a slight elevation in alanine transaminase (91 U/L; reference range 10-45 U/L) compatible with grade 1 hepatitis. Additional blood tests, including thyrotropin and cortisol, were in normal range.
+At first admission after the sixth Nivolumab dose, a cerebral magnetic resonance imaging was performed to rule out metastases to the brain. In the following week a positron emission tomography with computed tomography (PET-CT) was performed. Abnormal fluorodeoxyglucose uptake was demonstrated in the gastric wall, especially around the corpus antrum . Linitis plastica was suspected and an esophagogastroduodenoscopy (EGD) with supplementary endoscopic ultrasound (EUS) was performed. The EGD showed a vulnerable mucosa with a white fibrine-like membrane in the antrum, corpus, and fundus. EUS demonstrated increased thickening of the gastric wall to 13 mm. No focal malignant lesions were suspected, and the finding was interpreted as inflammation. Macroscopically, the mucosa was erythematous with severe fibrinous erosions .
+The initial endoscopical examination was compatible with chronic active pangastritis . Biopsies from fundus, corpus, and antrum ventriculi showed severe changes with ulceration, crustation, and only scattered glands. The glandular epithelium showed very reactive changes, apoptosis, neutrophilic inflammation, and crypt abscesses, as well as intraepithelial lymphocytosis (45 per 100 epithelial cells). The lamina propria showed a diffuse, full thickness lymphoplasmacytic inflammatory infiltrate. Epithelial granulomas, thickened subepithelial collagen layer, or prominent eosinophils, were not observed. There were no signs of malignancy, CMV infection, or Helicobacter pylori. Epstein Barr virus serology showed positive Epstein Barr virus nuclear antigen IgG corresponding with a previous infection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2025_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2025_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5909f5e413bc399ed41d62805ef112db6075364d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2025_en.txt
@@ -0,0 +1,4 @@
+An 83-year-old man noticed a left submandibular mass and visited our Department of Oral Surgery. He had no B symptoms. His family history was unremarkable, although he had a history of renal insufficiency. A physical examination revealed an elastic hard tumor (diameter: 4 cm) that was well-demarcated and had not adhered to the surrounding tissue. The covering skin was normal, and the patient reported not experiencing spontaneous pain or tenderness. Laboratory testing revealed slight anemia (red blood cell count: 385 × 104/μL, hemoglobin levels: 11.7 g/dL) and leukopenia (white blood cell count: 3,900/μL), although his serum lactate dehydrogenase levels were not elevated (207 IU/L). Levels of soluble interleukin-2 receptor were markedly elevated (2,730 IU/mL), although we did not detect elevated titers of antibodies to human T-cell leukemia virus-1 or human immunodeficiency virus (HIV). Computed tomography and diffusion-weighted magnetic resonance imaging revealed a left submandibular tumorous lesion and multiple swollen lymph nodes (the left cervical and inguinal nodes) . Magnetic resonance imaging also revealed multiple high-intensity areas in the vertebrae, bilateral ribs, and ilia, although there were no abnormalities in the mediastinum or abdomen. We obtained a biopsy specimen from the submandibular lesion, which supported our initial pathological diagnosis of anaplastic large cell lymphoma (ALCL), although a hematopathological consultant helped us make a final diagnosis of EBV-positive DLBCL. The patient underwent 2 courses of chemotherapy using the THP-COP regimen and achieved partial remission, although the tumor was ultimately resistant to the following therapies: molecular-targeted therapy using brentuximab vedotin, THP-COP (4’-O-tetrahydropyranyl adriamycin, cyclophosphamide, Oncovin®, prednisolone), and EPOCH (etoposide, prednisolone, Oncovin®, cyclophosphamide, hydroxydaunorubicin). The patient was alive with progressive disease at the 9-month follow-up.
+Hematoxylin-eosin (HE) staining revealed that the lymph node architecture was effaced and diffusely occupied by infiltrative large lymphoid cells. Many foci of necrosis were visible, and the lesion was comprised of centroblast-like cells (a large vesicular nucleus and several conspicuous nucleoli), immunoblast-like cells (prominent central nucleoli), and plasmacytic cells . There were scattered large multinuclear cells with prominent nucleoli, including large cells that were similar to Hodgkin/Reed-Sternberg cells (HRS-like cells) .
+The initial IHC revealed that the tumor cells were positive for CD30 and MUM-1, but negative for CD3, CD4, CD5, CD8, CD10, CD19, CD20, CD23, CD38, CD45, CD45RO, CD56, CD79a, CD138, Pax-5, immunoglobulin light chains (κ and λ), epithelial membrane antigen (EMA), anaplastic lymphoma kinase (ALK), Bcl-2, and Bcl-6 . These results could not define cell lineage and histological type of the tumor. Additional IHC revealed that the tumor cells were positive for B-cell-specific transcription factors (Oct-2 and BOB.1), which confirmed B-cell derivation of the tumor cells . In situ hybridization revealed clear positive signals for EBV-encoded small RNAs in the nuclei of the tumor cells . The tumor cells were negative for LANA-1 (a product of human herpesvirus-8), and the Ki-67 labeling index was very high (approximately 80%).
+We performed gene rearrangement testing using the BIOMED-2 multiplex polymerase chain reaction-based method, which revealed clonal rearrangement of the immunoglobulin heavy chain and light chain genes. No clonal rearrangement was detected in the T-cell receptor genes.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2031_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2031_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a896343e396fdf6bb3800f812a65b29d0ee8c194
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2031_en.txt
@@ -0,0 +1,2 @@
+A 71-year-old woman with suspected AvWD was referred to our clinic for the first time in February, 2010 and treated from 2010 to 2022. Her past medical history included a normal pregnancy at 24 years of age, mastectomy, radiotherapy and chemotherapy for carcinoma of the left breast at 38 years, lacrimal duct agenesis surgery at 51 years, and meniscus tear surgery at 67 years of age. No complications or bleeding were associated with any of these treatments. The patient was in complete remission from the carcinoma. The patient was diagnosed with advanced arthrosis in the right knee and hip aged 60. Cardiovascular risk factors including dyslipidaemia, hypertension, hyperglycaemia and obesity were recorded. A family history of bleeding was noted.
+Significant history included the development of frequent epistaxis and bleeding following a dental extraction at the age of 60 years. The patient was treated at our clinic over a period of 12 years (2010–2022) for retinal haemorrhage; recurrent hemarthrosis; and advanced gonarthrosis. The patient had poorly controlled pain and required treatment with oxycodone hydrochloride, paracetamol, metamizole, and infiltrations with triamcinolone 40 mg and ropivacaine (0.1% at a total dose of 8 ml) every 6–8 months. This case report follows the guidance of SCARE (Surgical Case Report) criteria.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2032_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2032_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..47fcaa2fcfddb39aad9615505d5f9968afdaa4d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2032_en.txt
@@ -0,0 +1,5 @@
+A 11 year old female child from South-Asia of Indian origin, presented to the orthopaedics department with complaints of fever, non-traumatic pain and swelling in the right leg for about 3 days. There was no significant past history. She was septic and was noted to have a diffuse swelling over the upper third of right leg with skin erythema, warmth and tenderness. No discharging sinuses were noted. Blood investigations showed a raised white cell count and marginally increased erythrocyte sedimentation rate (ESR). Rest of the haematological and biochemical markers were within normal limits. Blood sample was sent for culture and sensitivity which showed no growth. Anteroposterior and lateral views of plain radiograph of the right leg showed normal tibia and fibula with subtle irregular altered soft tissue density in the lateral aspect of the mid third of the leg . Incision and drainage was performed the following day under general anaesthesia. Thick purulent discharge was drained and about 5 ml of the discharge was sent for culture and sensitivity. The wound was left open and dressed appropriately .
+Gram staining of the purulent material showed numerous pus cells and gram negative bacilli. Inoculation in blood agar showed dark yellow pigmented colonies with no hemolysis . On nutrient agar yellow pigmented colonies were seen and were noticed to turn to red when 10 % potassium hydroxide (KOH) was added on to the culture . It did not grow in Mac Conkey agar. The isolate was non-motile, catalase and oxidase positive, indole positive, methyl red negative and Voges–Proskauer’s negative. Urea was not hydrolysed and citrate was not utilized. On triple sugar iron agar, glucose was utilised with gas production. The organism was identified by both conventional method and VITEK-2 systems version: 07.01 as C. indologenes.
+Genus was presumptively identified as Chryseobacterium after 24 h and genus confirmation, species identification and sensitivity results were available in 48 h. The minimum inhibitory concentration (MIC) values by VITEK-2 system are in Table .
+Our isolate was susceptible to imipenem and resistant to meropenem and doripenem. Chryseobacterium species are intrinsically resistant to most beta lactams including carbapenems due to the production of chromosomally mediated metallobetalactamases (MBL). The isolate was a MBL producer which was confirmed by double disk diffusion method with ethylene diamine tetraacetic acid (EDTA).
+Patient was empirically started on parenteral cefotaxime, metronidazole and gentamicin, was changed over to intravenous ceftazidime 1 g twice daily and metronidazole infusion 500 mg thrice daily for 5 days based on the sensitivity report following which significant clinical improvement was noted. Subsequently secondary closure was done 10 days later. The wound healed well and the patient was discharged on oral antibiotics with follow up. Consent for publication was obtained from the patient’s parent.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2036_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2036_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc2e422927caeb8c25a37f2ecb2dafd0846ec029
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2036_en.txt
@@ -0,0 +1,3 @@
+Our patient was a 19-year-old woman who was the restrained driver in a roll-over accident at highway speed. Her Glasgow coma scale was 4 with extensor posturing. She was sedated, paralyzed, intubated, and transported to our hospital as a level 1 trauma. Her medical history was unremarkable.
+CT imaging of the head revealed multiple punctate hemorrhagic lesions, early effacement of the gray-white junction and diffuse traumatic subarachnoid hemorrhage .
+An intraparenchymal ICP monitor was placed with initial readings of 23–25 mmHg. Supportive care was instituted with midline placement of the head and elevation of the head to 30°, sedation with propofol and analgesia with fentanyl. She required bolus doses of 20% mannitol for ICP surges with physical stimulation. On hospital day 3 she developed refractory intracranial hypertension and fever which persisted through hospital day 12 despite aggressive medical management. She was very sensitive to any physical stimulation, particularly changes in position or tracheal suctioning which resulted in ICP spikes. Osmotic therapy including alternating boluses of 20% mannitol and 23% saline were used to treat ICP surges. Maintenance fluids were changed to 3% saline solution in order to induce mild hypernatremia and decrease the need for rescue osmotic therapy. We induced mild hypothermia (35°C) using the Arctic Sun device (Bard, Inc., Atlanta, GA, USA) as an adjuvant to osmotic therapy with pharmacological neuromuscular paralysis to control the shivering response. Several attempts at reducing the degree of metabolic suppression by slowly increasing the core body temperature and lightening the degree of neuromuscular paralysis and propofol requirement failed. She consistently required a temperature under 35°C and a dose of Propofol greater than 40 mcg/kg/min to maintain control of her ICP. A repeat CT scan on hospital day 11 did not show significant cerebral edema to explain the persistent and refractory intracranial hypertension. It was noted that despite adequate hydration and apparent intravascular euvolemia, she was consistently tachycardic with intermittent periods of hypertension. This raised the possibility of sympathetic hyperactivity for which she was started on propranolol with only marginal decrease in the heart rate. On hospital day 12 a bolus of 4 mg of morphine was administered following a rise in ICP to 30 mmHg in an effort to determine if the elevation in ICP was due to a sympathetic surge. Immediately following the administration of morphine the ICP rose steadily from a baseline of 30 mmHg up to 55 mmHg over 3 min without any appreciable change in heart rate or blood pressure. The transient but significant rise in ICP was easily managed with hyperventilation and administration of 1 g/kg of 20% mannitol. Following this unexpected surge in ICP after administration of morphine, the fentanyl infusion she had been receiving since hospital day 1 was discontinued with an ensuing decline in ICP over the next 24 h which reached single digits for the first time since monitoring was started. No new interventions were introduced during this period. Parallel with the normalization of ICP was a resolution of her persistent sinus tachycardia and intermittent arterial hypertension. Permitting transient increases of ICPs up to 30 mmHg after stimulation, we were able to rapidly resume normothermia (36.5°C), discontinue neuromuscular paralysis, and transition from propofol to a low dose of midazolam without the need for rescue doses of hyperosmolar therapy . Before discontinuation of the ICP monitoring, her ICPs had steadily settled below 15 mmHg.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_204_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_204_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6aad3992d42b4f6461c8708a1bb7f4a81f452af4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_204_en.txt
@@ -0,0 +1 @@
+A 67-year-old man with no medical history consulted a nearby doctor for the main complaints of fever and lower abdominal pain. Laboratory analysis revealed hemoglobin, 13.1 g/dL; white blood cell count, 13.76 × 103/μL; platelets, 12.7 × 104/μL; and C-reactive protein, 1.41 mg/dL. He was diagnosed with acute appendicitis, and oral antibiotic treatment was initiated. On the following day, he was referred to our hospital for suspected DIC, as laboratory analysis revealed hemoglobin, 13.3 g/dL; white blood cell count, 3.55 × 103/μL; platelets, 7.4 × 104/μL; and C-reactive protein, 12.2 mg/dL. At the time of hospital consultation, physical examination revealed stable cardiorespiratory dynamics and a fever of 38.3 °C, no abdominal distension, and only slight spontaneous abdominal pain without tenderness and peritoneal irritation. Laboratory analysis revealed hemoglobin, 14.0 g/dL; white blood cell count, 9.41 × 103/μL; platelets, 6.9 × 104/μL; serum total protein, 5.2 g/dL; serum albumin, 3.3 g/dL; total bilirubin, 1.6 mg/dL; aspartate aminotransferase, 218 IU/L; alanine aminotransferase, 198 IU/L; lactic acid dehydrogenase, 315 IU/L; blood urea nitrogen, 20 mg/dL; creatinine, 0.96 mg/dL; C-reactive protein, 13.47 mg/dL; prothrombin activation, 54%; international normalized ratio of prothrombin time, 1.36; fibrinogen/fibrin degradation products, 116.4 μg/mL; and antithrombin III activity, 70%. The sequential organ failure assessment score was 2 points. The Japanese Association for Acute Medicine DIC diagnostic criteria score was 7 points (platelet counts; 3 points, prothrombin time; 1 point, and fibrin/fibrinogen degradation products; 3 points). Contrast-enhanced computed tomography (CT) demonstrated an enlarged appendix (10 mm in diameter) without fecalith, ascites, intraperitoneal free air, and abscess . There was no evidence of perforating appendicitis. Laboratory analysis revealed septic DIC. The patient was diagnosed with non-perforating acute appendicitis with septic DIC. The patient was distressed regarding whether he should be treated conservatively with an antibiotics-first strategy or undergo an appendectomy, because he had few symptoms, no perforation, and no abscess. Ultimately, laparoscopic appendectomy was performed due to anxiety about exacerbation of septic DIC. The resected specimen revealed a necrotized appendiceal mucous membrane. There was no evidence of appendiceal wall perforation . Histopathological examination showed non-perforating gangrenous appendicitis. He required DIC therapy (thrombomodulin administration, antithrombin administration, and nafamostat mesilate) for 2 days postoperatively. Preoperative blood culture detected Bacteroides thetaiotaomicron. He was discharged on postoperative day 9, and remained in good health 1 month after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2050_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2050_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d5ca14be4eeaf5c0e40e8a9451c1e5864d94a0bc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2050_en.txt
@@ -0,0 +1,7 @@
+A 60-year-old male was referred to our clinic for a large AAA detected during ultrasound screening of the abdominal aorta during cardiovascular screening check-up.
+He had a history of heavy smoking (50 pack years). The patient had developed mild shortness of breath for the past 3 wk. Coronary angiography revealed chronic total occlusion of the mid right coronary artery with good collateral blood supply from the left coronary artery. Percutaneous coronary intervention was deferred as symptoms subsided after medical therapy. The patient was then referred to our clinic after the screening abdominal ultrasound revealed a CAAA.
+The patient had a history of hypertension and renal tuberculosis 5-years prior. His electrocorticography performance status was also dramatically decreased from 4 to 2 after his diagnosis of renal tuberculosis.
+The patient had not any personal or family history.
+A pulsating mass was palpable in the peri-umbilical area.
+The baseline creatinine level was 1.1 mg/dL. Other laboratory findings were all within normal limit.
+Computed tomographic aortography (CTA) was performed successfully. The diagnosis was made based on the serial axial images and its Three-dimensional reconstruction of the CTA. The patient had a Crawford type IV CAAA consisting of a proximal and distal aneurysmal sac separated by a 1 cm-healthy zone in the infrarenal level . The proximal AAA was a fusiform juxtarenal aneurysm (max diameter: 79 mm), starting directly below a sharp kink at the diaphragm level and ending at approximately 4 cm distal to the RA . The distal aneurysm (max diameter: 49 mm) was fusiform starting 5 cm distal to the RA and involving both the CIAs, where occlusion of the right internal iliac artery (IIA) was observed .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2098_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2098_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5f04cd9f4f05c4ed745fd3810d7bc9edc15a7707
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2098_en.txt
@@ -0,0 +1,3 @@
+In May 2018, a 43-year-old Chinese man was admitted to our hospital with lumbago and inguinal lymph node enlargement. Figure summarizes the important events of this patient according to the timeline. The blood routine examination showed an increase in lactate dehydrogenase (LDH; 887 U/L) and a decrease in hemoglobin (Hb; 105 g/L). PET/CT showed multiple lymph nodes enlargements, including a large abdominal mass which was 13.9 × 10.6 cm in size, together with multiple bone lesions. The biopsy of cervical lymph node demonstrated that the lymph node structure was destroyed completely, which was mainly composed of small to medium-sized lymphocytes with round or slightly irregular nucleus, deeply stained chromatin, inconspicuous nucleoli, scant pale cytoplasm and rare apoptosis . Also, significant hyperplasia of large cells with centroblastic and immunoblastic morphology was seen in the focal areas, with large and round nucleus, condensed chromatin, one or more small nucleoli . Immunohistochemical (IHC) staining demonstrated the cells were positive for CD20 , CD19, CD10, BCL6 , BCL2 and negative for TdT , C-MYC, Cyclin D1, SOX11, CD23, LEF1, CD21, CD43, CD3, CD5 and EBER. Ki-67 was 10% in small cell areas and 40% in large cell areas. Fluorescence in situ hybridization (FISH) showed the cells were positive for BCL2::IGH fusion , without translocation of MYC or BCL6 . Also, the biopsy of bone marrow was performed, and we observed the hyperplasia was extremely active with almost no adipose tissue, and the central mother large cells presented a diffuse growth pattern. The IHC result demonstrated that the cells were positive for CD19, CD20, CD79a, CD10, MUM1, Ki-67, BCL6, C-MYC and BCL2, while negative for CD3 and TdT. Thus, this patient was diagnosed with low grade FL (account for 80%) combined with DLBCL (20%) at a stage of IVB, and given R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vindesine, prednisone). After 1 cycle of R-CHOP treatment, lumbago was significantly relieved and the treatment regimen was changed to HD-MTX (high dose methotrexate) combined with 80% dose R-EPOCH (rituximab, cyclophosphamide, doxorubicin, vindesine) due to the high IPI (international prognostic index) score of 4. The abdominal mass reduced to 7.5 × 3.5 and this patient achieved partial remission (PR) following 1 cycle of HD-MTX/R-EPOCH treatment. In the following 5 cycles of HD-MTX/R-EPOCH treatment, the abdominal mass was treated with additional 30 Gy radiotherapy. However, multiple masses in the abdominal cavity, many nodules around both kidneys and the right adrenal gland, were found after 6 cycles of the treatment, together with the increased glucose metabolism. Thus, he achieved progression disease (PD).
+In Jan. 2019, a fine needle aspiration biopsy of the abdominal mass was taken. The biopsy demonstrated that the tumor cells presented with diffuse growth pattern, mainly composed of uniformly medium-sized blastoid cells with round or slightly irregular nuclei, dispersed chromatin, unclear nucleoli and scant bluish-grey cytoplasm . The cells were negative for CD20 , BCL6 and CD3 staining, while positive for TdT (Fg. I), PAX5, CD38, CD10, BCL2, C-MYC and MUM1 staining. Ki-67 was about 60%. FISH revealed fusions of BCL2::IGH and translocation of MYC , without BCL6 translocation . According to the 5th WHO classification, a diagnosis of TdT positive HGBL with MYC and BCL2 rearrangements (“double hit”) transformed from FL/DLBCL was made after 8 months of FL/DLBCL confirmation. Then, chidamide and pembrolizumab were given and the disease was mitigated, but he discontinued chemotherapy for 3 months due to the COVID-19 pandemic, and the disease progressed. The biopsy of the abdominal neoplasm was taken once again in Apr. 2020, and the diagnosis of TdT positive “double hit” HGBL remained valid. This patient died in Jul. 2021, with an OS time of 37.8 months.
+To further understand the pathogenesis of TdT positive “double hit” HGBL after the treatment of FL/DLBCL, the targeted sequencing of 571 lymphoma-related genes (Supplementary Table 1) were carried out on Nova-seq (Illumina, San Diego, CA, USA). Variants, including SNVs (single nucleotide variations) and Indels (Insertion and deletion) were screened by Shanghai Rightongene Biotechnology Co., Ltd. (Shanghai, China) based on the following filter conditions: (1) SNVs or Indels with a mutation allele frequency (MAF) ≥ 0.001 in databases of 1000 genomes project , 1000 genome East Asian, ExAC all or ExAC East Asian and gnomAD were removed; (2) SNVs or Indels with a variant allele frequency (VAF) ≥ 5% was retained; (3) SNVs or Indels including stopgain, stoploss, frameshift, non-frameshift and splicing sites were retained; and (4) Missense mutations with sift ≤ 0.05, Polyphen2_HVAR_pred ≥ 0.447 and CADD > 4 were retained. KMT2D, FOXO1, CREBBP, ATM, STAT6, BCL7A, DDX3X, MUC4, FGFR3, ARID5B, DDX11 and PRKCSH were the co-mutations detected in both the primary and transformed tissues, while mutations in CCND3, BIRC6, ROBO1 and CHEK2 genes emerged when transformed into HGBL .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_209_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_209_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c7eba0cbbc54eb2d3f77478b20e525753dc9cb3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_209_en.txt
@@ -0,0 +1,3 @@
+The Columbia University Medical Center IRB (AAAR0802) exempted this retrospective case report from review.
+A 36-day-old female was fussy for a day and then developed respiratory distress. She was born at term, and a New York State newborn screen was negative. In the Pediatric ER, she was tachycardic (260 beats/minute) and hypothermic (32.4 degrees C) with prolonged capillary refill and faint distal pulses. She was placed on continuous positive airway pressure via nasal prongs. Adenosine was given twice via an intraosseous line for supraventricular tachycardia with conversion to sinus rhythm. She was then intubated for worsening respiratory distress and placed on an FiO2 of 1.0. An echocardiogram was notable for decreased biventricular systolic function and left to right shunting through a patent foramen ovale. A dobutamine infusion was started. Arterial cannulation was unsuccessful; transcutaneous pulse SO2 was consistently 100% during rewarming. Results from the first blood gas (all blood gas results were reported uncorrected for temperature) drawn from a catheter placed in the IVC (by Seldinger technique; sutured in place after advancing to its full length overlying the L3 vertebral body; ) were pH 7.01, PCO2 33 mm Hg, PO2 101 mm Hg, SO2 94%, and lactate 18 mmol/L. Early during rewarming, the IVC SO2 remained above 90% and was as high as 99% ; declines in IVC SO2 and lactate during the first 3 hours of rewarming correlated (Spearman r: 0.94; p = 0.002). An arterial catheter was then placed, and the FiO2 weaned. B-type natriuretic peptide was increased (4578.5 pg/mL). Capillary refill and distal pulses improved, and dobutamine was discontinued at 8 hours; a repeat echocardiogram the next day showed improved (though still diminished) biventricular systolic function with continued left to right shunting through a patent foramen ovale. Hypothermia and hyperlactatemia resolved over 10 and 12 hours, and IVC SO2 was 80% on hospital day 2. The patient was diagnosed with supraventricular tachycardia secondary to Wolff-Parkinson-White syndrome. Prior to discharge a week later, serum acylcarnitine profile, lactate, pyruvate, thyroid stimulating hormone, and thyroxine were all normal.
+IVC PO2 values were corrected retrospectively for the patient's temperature .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_211_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_211_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8d0543bd39147d1f029cdb6a67c6df76c87390c1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_211_en.txt
@@ -0,0 +1 @@
+A 75-year-old man with acute cholecystitis was scheduled to undergo a laparoscopic cholecystectomy. He had a history of emphysema and spontaneous pneumothorax with no limitations in his daily activities. Preoperative respiratory function tests indicated mild obstructive disorder. Preoperative chest radiography indicated a giant bulla occupying the lower half of the right hemithorax . Computed tomography (CT) of the chest indicated that the giant bulla compressed the middle and lower lobes of the right lung, leading to atelectasis. Conversely, the upper lobe had good air content . To prevent rupture of the giant bulla and tension pneumothorax during laparoscopic cholecystectomy, we planned to manage the patient under general anesthesia with OLV. Anesthesia was induced with propofol 80 mg, fentanyl 100 mcg, rocuronium 60mg, and maintained with 4–5% desflurane and remifentanil 0.13–0.18 mcg/kg/min. After two to three times of manual ventilation via a facemask, the patient’s trachea was intubated with a 37-Fr left DLT. OLV was started immediately after intubation and continued throughout the surgery, with the right-sided lumen open to ambient air. The surgery was completed uneventfully in 125 min; peripheral oxygen saturation was 98–99% throughout the surgery. Chest radiography before extubation indicated a large lucency occupying the entire right hemithorax . Initially, we suspected a pneumothorax due to rupture of the giant bulla; however, chest tube insertion was withheld because his hemodynamics and respiratory status were stable. Instead, we continued the OLV and obtained a chest CT scan to determine whether any conditions other than pneumothorax were present. Chest CT indicated compression atelectasis of the entire right lung, including the upper lobe wrapped around the giant bulla. A small amount of pleural fluid did not form a liquid surface. Instead, it was compressed by a giant bulla to form a concave surface. These findings led us to diagnose hyperinflation of the giant bulla rather than a pneumothorax. Returning to the operating room, an attempt was made to relieve atelectasis using a recruitment maneuver with moderate pressure. However, follow-up radiography indicated that the right lung had not expanded. We decided to observe the hyperinflated giant bulla conservatively under spontaneous breathing and extubated the patient after emergence from general anesthesia. After extubation, the patient’s respiratory status was normal with no evident abnormalities. The hyperinflated giant bulla deflated and the right upper lobe gradually expanded under spontaneous breathing. The chest radiograph on postoperative day three was similar to the preoperative radiograph. The patient was discharged on postoperative day seven.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2125_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2125_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8eb95d03dcd41f42bced1d12f424fb662ea3b410
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2125_en.txt
@@ -0,0 +1,5 @@
+A 6-month-old female American Shorthair cat was presented for the investigation of vomiting and regurgitation following the ingestion of solid food. The cat had been experiencing this problem since it had been acquired as a kitten, and the issue had been dealt with by providing meals with water or wet food.
+Physical examination revealed poor growth (body weight 2.4 kg, body condition score 3/9), although the cat had a voracious appetite. Auscultation revealed normal heart and lung sounds. Thoracic radiography, including a positive contrast oesophagram (barium with wet food), was performed. The lateral view of the positive contrast oesophagram is shown in . Radiographic findings included marked dilation ofthe oesophagus cranial to the heart base, and a VRA was suspected. However, the site of constriction of the oesophagus was not clearly identifiable on the radiograph, and it was concluded that the oesophageal constriction was too far cranial with respect to the heart base to have been associated with a classic persistent right aortic arch VRA. Other examinations, including complete blood cell count, serum biochemical analysis, electrocardiography, echocardiography, abdominal ultrasonography and non-invasive blood pressure measurements, revealed normal findings.
+For the CT examination, the cat was induced by propofol (approximately 6 mg/kg, to effect, IV), maintained with 2% isoflurane mixed with 100% oxygen and mechanically ventilated. Electrocardiography-gated CTA (Iopamidol, 2 ml/kg, bolus tracking method) was performed with an 80-detector-row CT system (Aquilion Prime; Toshiba) in order to confirm and classify the suspected VRA, and to determine if surgical correction would be possible. Three-dimensional reconstruction images of CTA in the cat are shown in . The aortic arch and proximal descending aorta were located to the left of the midline, which is a normal finding. However, the following vascular anomalies were observed: (1) the right subclavian artery branched aberrantly from the proximal descending aorta (aberrant right subclavian artery); (2) the origin of the aberrant right subclavian artery from the aorta was markedly dilated (Kommerell’s diverticulum; this is considered to be present when the diameter of the subclavian artery near its origin from the aortic arch is at least 1.5 times the diameter at its more distal end); and (3) the left and right carotid artery directly branched from the aorta (bicarotid trunk). The site of constriction of the oesophagus was apparent at the level of the aberrant right subclavian artery with Kommerell’s diverticulum. Any other malformations that could cause oesophageal constriction were not detected.
+The cat was premedicated with midazolam (0.2 mg/kg IV) and morphine (0.3 mg/kg SC), induced by propofol (approximately 4 mg/kg, to effect, IV), maintained with 1–1.5% isoflurane mixed with 100% oxygen, and manually ventilated. A left lateral thoracotomy was performed at the level of the third intercostal space via standard procedures. The intraoperative view of the cat is shown in . The aberrant right subclavian artery with Kommerell’s diverticulum extended over the oesophagus from left to right, pressing it ventrally. Angiography (Iopamidol, 1 ml/kg) was performed with fluoroscopy to check the blood flow in the right subclavian artery peripheral to the right thoracic limb . The aberrant right subclavian artery was ligated using 3-0 non-absorbable polyester suture (Ethibond excel; Ethicon) and transected. Balloon dilation of the oesophagus was also performed. A gastrostomy tube was installed to ensure adequate nutrition postoperatively. Atropine sulphate (0.01 mg/kg, IV) was administered, as needed. Bupivacaine hydrochloride (1 mg/kg) was administered at the incision area and the surrounding intercostal muscles during the operation. After the operation, orbifloxacin (5 mg/kg q24h), famotidine (1 mg/kg q24h) and metoclopramide (0.2 mg/kg q12h) were administered for 7 days and postoperative pain was treated with meloxicam (0.1 mg/kg q24h) for 7 days after surgery. Wet food was gradually introduced, with the cat an upright posture, on the day after surgery. To maintain the minimum calorie intake (resting energy requirement calorie), residual wet food and fresh water were administered, as needed, using a gastrostomy tube.
+The cat recovered well after surgery and the gastrostomy tube was removed on day 14 postoperatively. Right thoracic limb function appeared normal. There was no evidence of reduced perfusion in the limb; the foot was warm and the pad colour appeared normal. At 3 months postoperatively, fluoroscopy with a positive contrast oesophagram (barium with wet food) was performed. Although mild dilation of the oesophagus was still observed, the constriction of the oesophagus had resolved and the passing time of barium was markedly shortened. More than 1 year after surgery, the general condition of the cat was stable (no regurgitation after ingestion of solid food) and the body weight was 2.8 kg (body condition score 5/9).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2140_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2140_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6f3f114eb25b71d65e4ff327aca9a481d840c98c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2140_en.txt
@@ -0,0 +1,4 @@
+A 74-year-old man working as a car washer visited our cardiology department for chest discomfort and hypoxaemia. He had no previous medical history and was not taking any medications. On arrival, his temperature was 36.8°C, his blood pressure was 94/76 mmHg, his pulse rate was 117 beats/minute (regular rhythm), his respiratory rate was 24 breaths/minute, and his oxygen saturation was 89% on room air. Despite the presence of hypoxaemia and tachypnoea, we could not detect any other abnormal findings from his physical examination suggesting any disease related to hypoxaemia. Electrocardiogram on admission suggested right ventricular strain pattern with complete right bundle branch block and S1Q3T3 pattern. Echocardiography on admission revealed that remarkably enlarged right ventricular suppressed left ventricular contraction . Hence a contrast CT scan was performed, revealing bilateral pulmonary embolisms to be the underlying cause of the symptom . Despite other examinations, such as ultrasonography of the inferior limb deep vein, the source of the thrombosis could not be found. Laboratory findings revealed congenital coagulation disorders, including protein C/S deficiency, anti-thrombin III deficiency, and anti-phospholipid antibody syndrome to be negative.
+After admission, the patient was initially administered systemic thrombolytic therapy with monteplase (1,200,000 unit) and heparin. Contrast CT scan performed 7 days after admission revealed complete disappearance of the thromboembolisms and symptoms were mitigated as well.
+Three months later, the patient was referred to our hospital because of recurring chest discomfort. Another contrast CT scan was performed, revealing a new pulmonary embolism despite continuous anticoagulation therapy with warfarin. PT-INR during treatment period was in the standard treatment range [PT-INR (1.6–2.6)] and PT-INR on second admission was 2.1. A giant thrombus (43 × 50 mm) located in the right axillary vein, which we could not find during previous hospitalization, was pointed out . Vein angiography was also performed, revealing a giant thrombus with no collateral vessels. Since ultrasound echography showed sufficient blood flow around the thrombus, swelling, and pain of his right arm were not observed before the operation.
+We were finally able to identify that the source of his recurrent pulmonary embolism was a giant thrombus located in the right dilated axillary vein. Eventually, the huge thrombus was removed surgically , and the symptoms were subsequently alleviated. Anticoagulation with warfarin was continuously prescribed and chest discomfort completely resolved. The patient retired his job due to this experience and his old age, and reported no post-operative complication during 2 years after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2143_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2143_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7f996431314b74238b5bb685354989dd8c9c750f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2143_en.txt
@@ -0,0 +1,3 @@
+A 15-year-old female presented with three months of lower back pain radiating into her bilateral posterior thighs and knees. She had no history of trauma, infection, connective tissue disease, or previous spine condition. She had no weakness in her upper and lower extremities, bowel or bladder incontinence, saddle anesthesia, or difficulty ambulating. Twice daily ibuprofen and physical therapy for two months did not improve or resolve her symptoms. Thoracic and lumbar spine magnetic resonance imaging (MRI) demonstrated a large dorsal extradural meningeal cyst at T11–L2 with associated neural foraminal extension and bony expansion . Imaging also showed ventral displacement and compression of the distal spinal cord and nerve roots of the cauda equina. On imaging, there is a flow void noted at L1 on the left side, thought to be the site of a dural defect leading to the cyst . The patient’s bilateral lower extremity symptoms were due to the extension of the large cyst into the bilateral neuroforamina from T11 to L2 and associated ventral compression and displacement of the distal spinal cord and cauda equina nerve roots.
+Instead of a traditional approach with multi-level laminectomy and given the identification of the likely site of the dural defect at L1, a minimally invasive approach in the form of L1–L2 laminectomy, fenestration of the arachnoid cyst, and L1 dural defect repair was selected to reduce the potential morbidity associated with a more extensive approach. Intraoperatively, the extradural cyst wall was located dorsally . A microdissection of the cyst was completed. A portion of the cyst wall was bipolared, cut and removed and sent to pathology for the permanent specimen. A dural defect at the L1 nerve root was confirmed . Primary repair was not possible as the dural edges were too far apart, and the dural opening was near the axilla of the nerve root. The secondary repair was completed by sealing the dural defect with a fibrin sealant, harvesting the fascial graft, and adding another layer of fibrin sealant. Valsalva demonstrated no evidence of a CSF leak, and the incision was closed in standard fashion. Histological findings of the spinal cyst wall showed benign fibrovascular tissue, consistent with a spinal arachnoid cyst.
+The patient had an uneventful postoperative period. Repeat imaging four months postoperatively demonstrated no residual extradural meningeal cyst . The patient’s lower back pain, bilateral thigh pain, and paresthesias completely resolved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2146_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2146_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cddbaecf6ece2dcc73789a9594ad2bc10ae89f50
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2146_en.txt
@@ -0,0 +1,4 @@
+A 34-year-old man with ccTGA collapsed and suffered cardiopulmonary arrest. He underwent bystander cardiopulmonary resuscitation and was transported to the hospital where ventricular fibrillation was confirmed . He was immediately converted to sinus rhythm by external defibrillation. A secondary prevention ICD implantation was indicated and the patient was transferred to our tertiary hospital. Physical examination revealed a systolic murmur (3/6 on the Levine grading scale), without any other clinical manifestations of heart failure. His blood pressure was 106/62 mmHg. Electrocardiography (ECG) revealed sinus bradycardia with a heart rate of 42 b.p.m. . Twenty-four-hour Holter ECG revealed an average heart rate of 48 b.p.m., maximum heart rate of 59 b.p.m., and minimum heart rate of 38 b.p.m. Echocardiogram showed that reduced systolic function of both ventricles (left ventricular ejection fraction was 36%, right ventricular ejection fraction was 42%, and tricuspid annular plane systolic excursion was 18 mm), but there was no significant valve regurgitation or haemodynamically significant valve vitia.
+He had undergone pulmonary artery banding operations twice as a child, and then underwent a double-switch operation with combined Senning and Jatene operations at the age of 14. He did not take any medications after cardiac surgery; echocardiograms were followed up about once a year until age 31 (last right ventricular ejection fraction was about 50% and relatively well preserved). Our contrast-enhanced computed tomography scan revealed that the superior vena cava and inferior vena cava were connected to the anatomical right ventricle via Senning pathway . Coronary artery angiography revealed no stenosis or anomaly of coronary arteries. We also conducted cardiac magnetic resonance imaging scan. The results revealed left ventricular ejection fraction around 30%, right ventricular ejection fraction difficult to assess, and no apparent scar. The adult congenital heart disease team decided to implant a dual-chamber ICD for ventricular fibrillation and sinus bradycardia. Implantation of the atrial lead was expected to be challenging, so it was decided to perform an electrophysiological study prior to the ICD implantation. This was also expected to reduce the implantation procedure time and thereby reduce the risk of procedure-related complications. We performed an electrophysiological study using a 3D mapping system (Ensite®) to determine the best placement site for the atrial lead.
+Right femoral vein was cannulated and two sheaths were inserted. Two quadripolar electrode catheters were positioned in the right atrium and right ventricular apex, respectively. A 3D substrate map was performed in sinus rhythm. Then, we evaluated the function of sinus node and atrioventricular node by atrial pacing. The paced cycle length of atrioventricular nodal Wenckebach-type block was 620 ms. Pacing from the right atrium at a basic cycle length of 500 ms for 30-s showed that the maximum sinus node recovery time was 1728 ms. Finally, we checked electrical potential and the threshold of the right atrium. The electrical potential of the right atrium was relatively good, but the threshold was high overall [about 3 volts (V)]. The roof of the right atrium was mostly with low voltage, with the exception of a scattered limited region where the threshold was 1 V and the sensed electrical potential was normal (, black arrow). Three weeks later, a dual-chamber ICD implantation was performed (Fortify Assura DR, St Jude medical; atrial lead, 2088TC-52; shock lead, 7120Q-58). We implanted a shock lead in the right ventricle and then introduced an atrial lead to the right atrium. The thresholds at the free wall side and bottom of the right atrium were high, so we placed the atrial lead at the roof of right atrium beyond cavoatrial junction using a J-shaped stylet as third attempt to implant atrial lead. The threshold there was 0.7 V. We did not perform defibrillation threshold testing. The device was programmed in DDD mode at 60–90 b.p.m. with two zones of therapy; ventricular tachycardia: ≥171 b.p.m., anti-tachycardia pacing + shock therapy [anti-tachycardia pacing × 6, 36 joule (J), 40J x2]; ventricular fibrillation: ≥200 b.p.m., shock therapy with anti-tachycardia pacing while charging (36J, 40J × 5). shows a chest X-ray 1 week after the ICD implantation. The slack did not reduce after then. We introduced bisoprolol 2.5 mg and continued after his discharge. The patient was discharged without no complications in his postoperative course.
+We checked the parameters of the pacemaker and leads 5 months after implantation. The amplitude of the sensed P wave was 5.0 mV or more and the pacing threshold was 0.5 V. The percentage of atrial pacing was 18% and that of ventricular pacing was 1%. Two years after implantation, the first appropriate therapy (anti-tachycardia pacing) was delivered for ventricular tachycardia. The patient was asymptomatic. A monomorphic ventricular tachycardia with a cycle length of 330 ms was terminated by a sequence of anti-tachycardia pacing (a burst of eight ventricular paced beats at 88% of the cycle length of ventricular tachycardia).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2149_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2149_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e198113526cc41967d41546c6c9ee9d0a0b93429
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2149_en.txt
@@ -0,0 +1 @@
+A 4-year- and 8-month-old boy was brought to our hospital with fatigue, polyuria, and excessive drinking for one month. There was no recent history of fever, hair loss, facial erythema, oral ulcers, vomiting or diarrhea. There was no consanguineal marriage history, no family history of kidney disease and other genetic diseases. He was born spontaneously at 39 weeks, weighed 2.8 kg at birth, was 50 cm long, and had no history of asphyxia (Apgar score unknown). The family thought that he was shorter than other children of the same age and gender, but he was not lagging behind in motor, language and intellectual development. At the age of 1, he was 72 cm tall (−2SD∼−1SD) and weighed 8.5 kg (−2SD∼−1SD); he was 103 cm tall and weighed 12 kg at the time of consultation, and his physical examination height and weight were less than 2 standard deviations of the standard value, his intellectual development was normal, and he could talk and express needs normally. Blood pressure was normal, and there was no edema throughout the body except a ∼3 cm × 3 cm area of cafe au lait spoton the skin of the left lower limb. No other abnormalities were found on physical examinations. Urinary examination showed alkaline urine (urine pH >5.5), glycosuria and highly positive proteinuria, but no hematuria was detected by high-power microscopy. Blood gas analysis and biochemical tests indicated metabolic acidosis and electrolyte disorders, mainly manifested as hyponatremia, hypokalemia, hypocalcemia, hypophosphatemia, and hyperchloremia. The complication of Fanconi syndrome was considered. Further, we carried out humoral immunity test which revealed a decrease in complement C3 (0.38 g/L; the levels of C3 with the normal range was 0.70–2.06 g/L), and the complement C4 was normal (the normal range of C4 level was 0.11–0.61 g/L). Autoantibody ANA was positive, with the highest titer >1:3,200. Thyroid function was normal. Recent laboratory results were shown in . Urinary ultrasound indicated enhanced renal parenchymal echoes with unclear corticomedullary boundary, hydronephrosis in both kidneys, and no renal calcification or stones. The bone age was relatively below the standard, equivalent to 3.6-year-old or 10–25 percentiles. The contrast-enhanced voiding urosonography (VUS), CT urography (CTU), axial enhanced MRI of the sella turcica, conventional MRI of the lower limbs, and electromyography examination revealed no abnormalities. The whole-exome sequencing of the child did not found any suspected pathogenic gene mutations. After excluding diseases such as tuberculosis, hepatitis B, diabetes, genetic diseases and tumors, the patients were treated with sufficient oral methylprednisolone, captopril, potassium citrate, sodium citrate, potassium dihydrogen phosphate, and sodium dihydrogen phosphate for 28 days, but there was no improvement in proteinuria. Then renal biopsy was performed, and hematoxylin-eosin and other specific staining revealed 1/4 glomerular glomerulosclerosis. The remaining glomeruli showed mesangial cell and stroma mild hyperplasia, with thickening of the basement membrane and a small amount of spike like structures. Subepithelial deposition of immune complexes was observed. The staining also revealed granular and vacuolar degeneration of renal tubular epithelial cells, occasional protein tubular type, focal renal tubular lumen dilation accompanied by segmental epithelial cell detachment, brush border detachment, a few renal tubular atrophy, renal interstitial edema, small focal lymphoid and monocyte infiltration. There was no obvious lesion on the small artery wall. Immunofluorescence showed that IgG was deposited (++) in fine particles along the capillary loop. The electromicroscopic examination of ultrastructures showed mild irregular thickening of the basement membrane with a thickness of about 300–700 nm, diffused fusion of the foot processes, deposition of a large amount of electronic dense materials in the subepithelial and basement membranes, vacuolization and degeneration of the epithelial cells of the renal tubules, and no special changes in the renal interstitium. The pathological diagnosis was stage II membranous nephropathy with acute tubulointerstitial lesions. Paraffin section fluorescence staining showed IgG1 subtype+, IgG4++, while negative in IgG2, IgG3, PLA2R, and THSD7A staining, consistent with stage II membranous nephropathy (–). Clinical diagnosis of lupus nephritis (nephrotic syndrome type, V-type) was made, with a SLE disease activity index (SLEDAI) score of 14. After receiving a sufficient oral dose of methylprednisolone (12 mg, bid) for 60 days with the subsequent dosage tapered, and sequential anti-inflammatory treatment with prednisone acetate (10 mg, qd), immune suppression with mycophenolate mofetil (0.166 g, bid), 5 times of plasma exchange, captopril, and dipyridamole, the patient was discharged. A follow-up after taking the above oral drugs for 11 months showed that the symptoms of fatigue, excessive drinking, and polyuria improved, the complement C3 returned to normal levels, but there were still persistent proteinuria (2 + to 3+) and glycosuria (2 + to 4+); no hematuria was detected under high-power microscopy; SLEDAI score was 12; autoantibody ANA was positive with a titer of 1:320; and eGFR was calculated to be >30 ml/min/1.73 m2 (The eGFR at initial presentation was 53.1 ml/min/1.73 m2). Then the treatment with belimumab monoclonal antibody was added. After 9 times of regular use of belimumab, the clinical symptoms of the patient achieved complete remission; blood electrolytes, complement C3 and C4 returned to normal levels; and ANA titer was maintained at a relatively low level (1:320); urinary protein fluctuated between+to ∼+; urinary glucose fluctuated between+to 3+, the UTP was 0.785 g/24 h (24 h urine output of 1,700 ml), and eGFR was calculated to be 32.8 ml/min/1.73 m2, recent laboratory results were shown in . The dose of prednisone was reduced to 7.5 mg, qd. The follow-up examination showed a body-weight increase to the 50th percentile of the same age and gender, a height of the 3th percentile, and a SLEDAI score decrease to 4.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2190_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2190_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..119bfc4f0ecdce009f1b45c000ab18638e6d1a3b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2190_en.txt
@@ -0,0 +1 @@
+A 19-year-old man presented to our hospital with complaints of fever (39.5 °C), headache, fatigue, night sweats, and lower abdominal pain, which had been present for about 1 month. For 20 days, he had used anti-flatulent medications before presenting to our hospital. He had no history of close contact with pets, he did not travel often, and similar complaints were not present in his social circle. According to the patient’s physical examination on admission, his general health status was good; body temperature, pulse, and blood pressure were 37.2 °C, 102 beats/min, and 106/70 mmHg, respectively. He was alert, oriented, and cooperative. Mobile, painful lymphadenopathies were observed on both sides of the cervical region, of which the largest was 2 × 1.6 cm in size. Bilateral cervical lymphadenopathy was present and involved a posterior group of cervical lymph nodes. Cardiac, respiratory, and neurological examination revealed no abnormality; vegetation was not detected by transthoracic echocardiography. Laboratory investigations showed leukopenia (total leucocyte count: 3200 cells/mm3). Cerebrospinal fluid (CSF) analyses were normal. No positive results that could explain the high body temperature were found during serological testing for Epstein Barr virus (EBV); cytomegalovirus (CMV); hepatitis A, B, and C; parvovirus; human herpesvirus; chlamydia trachomatis; mumps; human immunodeficiency virus; echo virus; coxsackie virus enterovirus; and measles spp. Results of tests for rheumatologic markers (ferritin, anti-nuclear antibody, anti-neutrophil cytoplasmic antibody, anti-cyclic citrullinated peptide antibodies, extractable nuclear antigen antibody panel, anti-double stranded DNA, and rheumatoid factor) were also negative. Results of tuberculosis polymerase chain reaction (PCR) and herpes simplex PCR were also negative in the CSF. Blood and CSF cultures showed no growth after incubation for 6 to 8 weeks. Brain T2-weighted and FLAIR MRI sequences showed a slightly hyperintense signal of about 4 mm in the left temporal lobe , and antibiotics and acyclovir treatment were begun because we could not rule out encephalitis. However, the patient’s body temperature could not be reduced by routine anti-inflammatory drugs and intravenous paracetamol. Thoracic and abdominal computed tomography (CT) and MRI scans revealed a testicular lesion having no contrast effect ; lymph nodes were predominantly located on the right side of the cervical region, with the largest measuring 2 cm in diameter. Thus, one of the lymph nodes located in the right cervical region was removed and sent to pathology for analysis. On the 4th day of hospitalization, an excision biopsy of the cervical lymph node was performed. Microscopic examination showed that the lymph nodes were expressed in paracortical and cortical areas of conspicuous apoptotic necrosis with an abundance of enlarged lymphocytes, which had prominent nucleoli in the absence of neutrophils and a proliferation of macrophages . Results of tests using in situ hybridization to detect EBV with marked paracortical expansion due to a proliferation of immunoblasts were negative. On the 20th day of hospitalization, the patient’s general status suddenly and temporarily worsened. The signal intensity on brain MRI had changed and showed an asymmetrical hyperintense signal in the wider larger left temporal lobe and both basal nuclei with slight Gd-enhancement. CSF protein levels and pleocytosis were increased (protein: 50 mg/dL; pleocytosis: 24 cells/μL), but CSF cultures were negative, and cytology showed no malignant findings. Anti-NMDA, CO, Tr, GAD65, Zic4, Titin, SOX1, Rec, Hu, Yo, Ri, Ma-2/Ta, Cv2, and Amp antibodies associated with auto-immune-mediated encephalomyelitis were all absent. Oligoclonal bands were also not detected in the CSF sample. Since acute disseminated encephalomyelitis (ADEM) was suspected, the patient was managed with intravenous prednisolone pulse treatment (1 g/day) for 3 days and intravenous immunoglobulin treatment for 5 days, and these therapies were repeated 3 times every 3 weeks. Electroencephalography showed no waves characteristic of epilepsy, but levetiracetam 1000 mg/day was begun. On the 34th day of hospitalization, MRI investigation of the brain revealed that the previous abnormalities were present and had not changed. Since the cervical lymph node biopsy before steroid therapy did not reveal lymphoma, a brain biopsy of the temporal lobe was performed. Steroids can obscure diffuse large B-cell lymphoma or intravascular lymphomatosis; however, no recurrence was experienced. The pathological results revealed many CD68+ macrophages and histiocytes, as in the cervical lymph node, suggestive of KFD . The cervical lymphadenopathies disappeared after 2 months of hospitalization, and the previous abnormalities on MRI became smaller during follow-up. The testicular mass that showed a contrast effect on MRI and CT similarly was smaller ; therefore, we suspected that the testitis had been caused by KFD. His complaints of fever, headache, and fatigue gradually improved; he was discharged on the 90th day of hospitalization. He was followed for more than 3 months in our clinic and did not show any recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2199_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2199_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a03861c4868e4d204f061aea0f1bab3b4df4d059
--- /dev/null
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@@ -0,0 +1,2 @@
+A 41-year-old woman was diagnosed with asthma and allergic rhinitis five years ago. She received medium-dose inhaled corticosteroids, long-acting β2-agonists, and leukotriene receptor antagonists. Her asthma gradually deteriorated. During the last month before her admission in the hospital, she experienced exertional dyspnea, continuous nasal congestion, and loss of smell. During the last seven days before her admission in the hospital, she experienced dyspnea at rest and paresthesia as well as pain in the bilateral lower legs and arthralgia in both knees. She was admitted to our hospital with complaints of severe dyspnea. During admission, a wheeze could be confirmed in the bilateral lung field and the patient experienced progressive paresthesia and pain in the bilateral lower legs and arthralgia in both knees. These neurologic symptoms occurred simultaneously, while no other symptoms were observed. Neurological examination revealed normal cranial nerve and manual muscle testing results were normal. The patient never experienced any neuropathic or residual neuropathic symptoms. Her blood pressure was 94/62 mmHg, pulse rate was 109 beats/minute, respiratory rate was 20 breaths/minute, oxygen saturation was 95% on room air, and body temperature was 36.7 °C. Laboratory findings revealed a white blood cell count of 22,200/μL with 66.7% eosinophils, hemoglobin 10.8 g/dL, C-reactive protein 8.48 mg/dL, and IgE 722 IU/mL. Myeloperoxidase ANCA and proteinase-3 (PR3)-ANCA were within normal ranges. Arterial blood examination at room air showed a pH of 7.434, partial pressure of carbon dioxide (PaCO2) of 38.8 mmHg, partial pressure of oxygen (PaO2) of 73.5 mmHg, and bicarbonate (HCO3−) of 25.9 mEq/L. A chest X-ray revealed reticular shadows in the bilateral lungs , which improved after the initial prednisolone treatment . Computed tomography revealed ground glass opacity and consolidation in the bilateral lung fields and paranasal sinusitis , which improved after prednisolone treatment . Bronchoalveolar lavage fluid (BALF) contained a high percentage of eosinophils (90.0%). Transbranchial lung biopsy specimens showed eosinophilic infiltration ; the same was also observed on nasal polyp biopsy . Electrocardiogram and echocardiography were normal. Magnetic resonance imaging revealed no dural thickening related to hypertrophic pachymeningitis. The patient was diagnosed with EGPA as her condition matched the characteristic clinical course described by the American College of Rheumatology classification criteria with symptoms due to vasculitis following asthma and elevated eosinophils in the peripheral blood.
+Figure A shows the patient’s clinical course. Pain scores on Numerical Rating Scale (NRS) were assessed . Quality of life was assessed using the Euro quality of life 5-dimension (EQ-5D) -3L scale . The Japanese version of EQ-5D has been validated previously . On admission, NRS score was 5 and EQ-5D score was 0.607. After admission, NRS peaked to 7 and EQ-5D was minimal 0.501. The patient was initially administered with 50 mg/day of prednisolone that resulted in the improvement of symptoms. However, considerable bilateral paresthesia remained (NRS: 3, EQ-5D: 0.769), and the patient was advised for a follow-up. After prednisolone was tapered, the patient was discharged. When prednisolone was tapered to 7 mg (10 months from treatment initiation), she again experienced increased eosinophil count in the peripheral blood and recurrence of symptoms (NRS: 5, EQ-5D: 0.667) such as paresthesia and pain in the bilateral lower legs and arthralgia in both knees. She then initiated treatment with mepolizumab (300 mg every four weeks). After administration of mepolizumab, her paresthesia, pain, and arthralgia gradually improved (NRS: 1, EQ-5D: 1.000). A nerve conduction test performed 3 months after prednisolone treatment showed motor and sensory nerve conduction amplitudes were decreased to 12.7 mV, 9.2 mV, and 12.6 μV in the right tibial ankle, right tibial popliteal, and right sural nerves, respectively . The test was repeated after 4 months of mepolizumab treatment, at which time these conduction amplitudes increased to 18.8 mV, 13.8 mV, and 28.3 μV, respectively .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2200_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2200_en.txt
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index 0000000000000000000000000000000000000000..1de8407fb59c80a249d04dbbff22f440dff29e9e
--- /dev/null
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+A 55-year-old Chinese female was admitted to our hospital complaining of exertional dyspnea for more than 10 years. She had been developing truncal obesity and facial rounding over the past 2 years, without evidence of acne, hirsutism or wide purple striae. The patient had a family history of hypertension and was diagnosed with hypertension 10 years prior to admission, and she had been using irbesartan, metoprolol and nifedipine XR since then. She was also diagnosed with hyperlipidemia and prescribed with statins for 5 years. The patient reported no history of alcohol or drug abuse, in particular, no history of steroid use.
+Physical examination on admission showed elevated blood pressure (164/104 mmHg) and normal heart rate (74 beats per minute). The patient’s height, body weight and waist circumference were 156 cm, 51 kg and 88 cm, respectively, with a body mass index (BMI) of 20.96 kg/m2. She had a plethoric moon-shaped face, centripetal obesity, buffalo hump, accompanied by ecchymosis and slight edema at both lower limbs. Neurological examination was unremarkable except for slight muscle weakness of the lower-extremities.
+Routine laboratory examinations showed normal complete blood cell count and hepatorenal parameters, whereas the level of serum triglyceride was slightly elevated. The fasting plasma glucose level was 7.33 mmol/L, and glycosylated hemoglobin (HbA1c) was 6.6% . Endocrinological examinations showed that circadian rhythm of cortisol disappeared, and the level of ACTH was less than 1.00 ng/L . Twenty-four-hour urine free cortisol (24 h UFC) elevated to 634.8μg/24 h (reference range: 20.26-127.55μg/24 h). The next morning (8 a.m.) serum cortisol level after an overnight 1 mg dexamethasone suppression test (DMST) was 787.5 nmol/L, indicated lack of normal suppression . The diagnosis of ACTH-independent Cushing’s syndrome was therefore established.
+For differential diagnosis, aldosterone-to-renin ratio (ARR) was measured after discontinuation of irbesartan and nifedipine XR for at least 2 weeks as they might lead to false-negative result. Plasma and urinary catecholamine concentrations were detected as well. The diagnosis of primary aldosteronism (PA) was excluded since both plasma renin activity (PRA) and aldosterone concentration (PAC) were within normal limits along with an ARR value of 2.59 ng/dL: ng/mL.h. Pheochromocytoma was also ruled out based on laboratory findings .
+Three adrenal nodules were found with adrenal contrast-enhanced CT. One on the right side was 2.5 cm in diameter, and the other two on the left side with diameters of 2.3 cm and 0.6 cm, respectively . Magnetic resonance imaging (MRI) of sellar region revealed normal findings. Bone mineral density measured by dual-energy X-ray absorptiometry scans showed that the T score of lumbar spine, femoral neck and the total hip was − 3.0, − 3.2 and − 3.3, respectively, which indicated osteoporosis. In order to locate the functional lesions in this patient, AVS was performed and the concentrations of plasma aldosterone and cortisol were measured from both adrenal veins (AV) and inferior vena cava (IVC). Adrenal venous catheterization was successful, and the hormone levels were shown in Table . The adrenal vein to inferior vena cava cortisol (AV: IVC) gradient was 13.57 on the right side and 13.88 on the left side. The left and right AV to IVC gradient of aldosterone were 5.58 and 6.79 respectively. Moreover, the cortisol/aldosterone ratio (CAR) in adrenal veins was 292.52 on the right and 359.29 on the left, along with a left-to-right odds ratio of 1.23 . In combination with the results of AVS, which indicated non-lateralization, this patient was diagnosed with CS induced by bilateral adrenal excessive cortisol secretion.
+The patient was treated with metoprolol succinate, rosuvastatin, insulin, calcium and vitamin D supplements during the investigation. Considering her poor cardiac function, a two-step operation was planned. Laparoscopic right adrenalectomy was performed, followed by left adrenalectomy after a two-month interval. Pathological findings of the removed right adrenal mass indicated a yellow adenoma with 2.5 cm in diameter, surrounded by atrophic adrenal tissue .
+Overnight 1 mg DMST was repeated 2 weeks after surgery, which demonstrated no inhibition on the serum cortisol at 8 a.m. on the following day, despite significantly decreased cortisol level post-operation . Therefore, it can be inferred that the autonomous cortisol secretion from left adrenal masses was persistent. The left adrenal gland was then removed and two adenomas were confirmed by pathological examination . The 8 a.m. plasma cortisol after 3 days of bilateral adrenalectomy was 37.30 nmol/L. Hydrocortisone replacement therapy (from 20 mg t.i.d to 20 mg q.d.) was administered after surgery. At 1 year after the operations, the patient lost 4 kg of body weight and the waist circumference reduced to 71 cm. Changes of other laboratory examinations at the last follow-up compared with the first admission were shown in Table .
+An electronic literature search in PubMed was performed to screen the case reports relating to ACTH-independent Cushing’s syndrome caused by bilateral cortisol-secreting adenomas. Searching words included “Cushing’s syndrome” and “bilateral adrenocortical adenoma”. All reference lists from the main reports and relevant reviews were screened manually for additional eligible studies. The results were limited to full-text articles published in English. Extracted data included the first author’s name, year of publication, country, preoperative diagnostic technique, patient characteristics (gender, age at onset and at diagnosis), lesions size, operative method and tumor cut surface.
+A total of 231 papers were identified, of which, 15 available reports were included in the review . The clinical features in these patients were summarized as following: 1) this disorder seemed predominated in females (male: female ratio 1: 14), with an adult onset (the mean age was 39.6 ± 8.6 years; ranged from 24 to 53 years); 2) the size of bilateral adrenal adenomas ranged from 1.0 to 5.0 cm in diameter, the majority of which were solitary in both sides (12 out of 15, 80%); 3) most of the bilateral adrenal lesions were found to occur synchronously, except that three cases occurred at different periods [, ]; 4) the surrounded adrenal cortex of resected adenomas was atrophic in most cases; 5) although no recurrence was reported postoperatively, long-term outcomes remain unclear with the longest follow-up duration of 123 months .
+All preoperative diagnoses were established based on endocrinological studies and imaging findings, while the methods used to determine the functional lesions were different. Nine patients underwent adrenocortical scintigraphy with different radio-imaging agents, all of which revealed bilateral adrenal uptake. AVS was performed in eight cases to evaluate the hypersecretion of cortisol, and only two of them applied cortisol gradient adjusted by plasma aldosterone [, ]. All patients underwent surgical resection of adenomas, including ten bilateral total adrenalectomy [, –], three unilateral partial adrenalectomy with contralateral total adrenalectomy [, , ], one bilateral partial adrenalectomy and one bilateral subtotal adrenalectomy . All patients received glucocorticoid replacement therapy postoperatively. It is noteworthy that glucocorticoid therapy was reported to be withdrawn during follow-up in patients who underwent bilateral subtotal adrenalectomy or partial adrenalectomy [–].
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2217_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2217_en.txt
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index 0000000000000000000000000000000000000000..7c79441d1cf8254f52e9815a71a4e1cb204e53de
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2217_en.txt
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+This was a 2.5 year-old girl admitted to the hospital with a 5 day history of high grade and persistent fever. The patient received amoxicillin (50mg/kg/day) for 3 days and acetaminophen (15mg/kg/dose every 4-6 h), but she no improvement was noted. After 3 days fever she developed generalized erythematous macular rash. On admission she was febrile (39.5°C) and restless. She had red lips, strawberry tongue, bilateral non suppurative conjunctival injection, and edema of extremities. No rash was noticed.
+Laboratory findings: white blood cell (WBC) 14×103/µl, hemoglobin 10.9 gr/dl, platelets 126×103/µl, C-reactive protein 192 mg/dl, erythrocyte sedimentation rate 80 mm/hr, albumin 2.8 gr/dl, Serum glutamic pyruvic transaminase (SGPT) 24 U/L, Serum glutamic oxaloacetic transaminase (SGOT) 25 U/L, alkaline phosphatase 451 U/L, Lactate dehydrogenase (LDH) 430 U/L, Creatine phosphokinase (CPK) 124 and total billirubin 8 mg/dl. Blood, throat, stool, and urine cultures were negative. Electrocardiogram and chest x-ray were normal. Echocardiography showed dilatation of right coronary artery. KD was diagnosed based on the presence of clinical criteria, and lesion of coronary artery. She was treated with aspirin (100mg/kg/day), and intravenous gamma globulin (2 gr/kg). On day 2 from admission she developed abdominal pain.
+Ultrasound examination of abdomen revealed presence of multiple lymph nodes in paraaortic area distributed from below the pancreas to the bifurcation of the aorta; the largest was 6 mm ×12mm . After 36 hour from receiving of intravenous gamma globulin, the fever was not subsided, so another dose (2gr/kg) was given. One day later the fever stopped. Four days thereafter we reduced aspirin dose (4mg/kg/day) and discharged the patient in good condition.
+One week later blood tests revealed platelet count 480×103/µl, WBC count 6.7×103/µl and plasma albumin 3/5 gr/dl. Ultrasonography was normal without signs of lymphadenopathy. CT scan of abdomen was also normal. A second echocardiography showed ectasia of the right coronary artery. On follow up 8 weeks later, erythrocyte sedimentation rate decreased to 13mm/hr and echocardiography showed disappearance of ectasia of the coronary artery, so aspirin was discontinued. The patient was followed by cardiologist for 1 year and the last echocardiography has been normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_222_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_222_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2beb7d268b2e632dd9ee10cd6accba95483c3da9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_222_en.txt
@@ -0,0 +1,24 @@
+A pregnant female, 34 years old, fourth gestation primiparity with current pregnancy estimated at 25 weeks of amenorrhea (WA) + 5 days, diabetic for 1 year, initially on oral antidiabetic drugs and then insulin therapy, hypertensive for 2 years on alpha methyldopa with a history of 3 miscarriages secondary to hypertensive peaks.
+During the 4th pregnancy, the patient was hospitalized at 20 WA in the endocrinology department for an etiological assessment of a hypertensive crisis at 180/110 mmHg associated with headaches, palpitations and hot flashes, without proteinuria or edema.
+In front of these symptoms the diagnosis of a secretory neuroendocrine tumor is suspected, and a biological assessment including urinary and plasma catecholamines (metanephrine and normetanephrine) came back positive after eliminating other causes of secondary hypertension (nephropathy, renal artery stenosis or hyperaldosteronism), by renal evaluation, renal artery Doppler ultrasound and renin-angiotensin-aldosterone system exploration.
+Urinary dosages showed Metanephrines at 0.87 μmol/24 h (normal: 0.20–1), high Normetanephrine 24.14 μmol/24 h (normal: 0.4–2.10), While plasma dosages showed a Metanephrine level of 0.10 nmol/l (normal: < 0.33 nmol/l), a high level of Normetanephrine of 14.02 nmol (normal: <1.07 nmol/l). A thyroid workup was performed to rule out multiple endocrine neoplasia (MEN) returning normal: TSH 1.821 (normal: 0.340–5.330), anti-thyroperoxidase Ac < 0.8 IU/ml (normal <0.8).
+Abdominal-pelvic magnetic resonance imaging (MRI) showing an abdominal latero-aortic mass measuring 36 * 33 mm, corresponding to paraganglioma without any other obvious location .
+For evaluation of maternal and fetal impact of the tumor:
+Clinical examination including cardiovascular examination was normal. With an ECG that did not show rhythm or repolarization disorders or left ventricular hypertrophy.
+A standard biological workup (blood cell count, platelet count, hemostasis, blood ionogram, blood sugar-HBA1c, renal and hepatic function) was unremarkable.
+On the obstetrical level, the clinical examination and the obstetrical ultrasound showed a monofetal pregnancy with no uterine or fetal abnormalities.
+After placing the patient on medical treatment and scheduling her for surgery, she was declared discharged with an ambulatory follow-up. At 25 weeks of amenorrhea; the patient was admitted to the operating room for laparoscopic removal of her paraganglioma.
+In the operating room, considering the risk of perioperative morbidity related to severe per and postoperative hemodynamic instability (hypertensive crisis with sometimes rhythm disorder, coronary ischemia, left ventricular failure and hypotension secondary to a sudden release of catecholamines: to stress, painful stimulation due to intubation and incision, insufflation and manipulation of the tumor, abrupt and profound hypotension by sudden decrease of catecholamines at the fall of the part and venous clamping) and in front of the obligation to maintain a uterine perfusion and a good oxygenation of the fetus while avoiding maternal hypoxemia, the anesthetic management was as follows:Monitoring:
+Hemodynamic: heart rate (HR), blood pressure (BP)
+Respiratory: respiratory rate, pulse oxygenometry (SpO2), capnography.
+ECG and ST segment monitoring.
+Cardiac output monitoring by pulse wave contour analysis.Left jugular venous line (for central venous pressure monitoring and vasoactive drugs perfusion) A right femoral arterial line with invasive arterial pressure monitoring Heating of the patient to prevent hypothermia
+After installation of the patient in left lateral decubitus proclive 30°, a pre-oxygenation was started, and an anesthetic induction was done by: 150mg Propofol 150μg Fentanyl, 50 mg Atracurium 50mg; intubation by tube No. 6.5 cm; maintenance of anesthesia was provided by: Propofol IVOC system with concentration of: 2ug/ml.
+Maintenance of etCO2 32–35 mmHG with insufflation pressures not exceeding 12 mmHG (8–10 mmHG) and close monitoring of blood glucose due to the risk of blood glucose imbalance.
+During tumor manipulation 3 episodes of arterial hypertension peaks were observed) (180/110–195/120-200/130 mmHg controlled by reinforcement of analgesia by reinjections of fentanyl 50 μg, deepening of anesthesia (Propofol concentrations 3.5 μg/ml), and administration of Nicardipine at 1–3 mg/h. Glycemia: varied between (0.98–1.21 g/l)
+The tumor removal was followed by episodes of arterial hypotension (75 -45 mmHg), the conduct was to lighten the anesthesia, a volemic expansion with administration of norepinephrine at 2mg/h.
+For paraganglioma extraction, the procedure lasted 2 hours [, ]., with an intraoperative diuresis of 500 ml and bleeding estimated at 80 cc.Norepinephrine infusion was gradually decreased and stopped just before extubation.
+The patient was subsequently extubated with the following parameters BP: 140/75 mm hg HR: 90bpm, SaO2 100% and then sent to the intensive care unit for clinical and biological monitoring. Postoperative analgesia was started with paracetamol, nefopam and morphine. The antihypertensive treatment was resumed in front of the reappearance of hypertensive peaks.
+An obstetrical evaluation with a foeto-placental ultrasound immediately and 6 hours after the operation returned normal with the presence of fetal heart activity .
+2 days after the postoperative hospitalization in the intensive care unit, the patient was weaned from all drugs with good evolution and was transferred to the visceral surgery department for further management.
+This cases report follows SCARE guidelines 2020 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2235_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2235_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28447c03a99081c23df04db4864f4c510e31cd3d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2235_en.txt
@@ -0,0 +1,6 @@
+We presented the case of a 55-year-old man with left peripheral facial nerve palsy. The symptoms appeared one week earlier, along with viral upper respiratory infection.
+Otalgia started after two days accompanied by hearing loss and tinnitus on the left side; on the third day, vesiculoerosive lesions manifested itself in the left auricle , followed by the incidence of left side FNP .
+The patient also suffered from true vertigo. On the same day of FNP incidence, the case developed hoarseness and fluid aspiration that became worse in the following days. The case had a surgery on the other ear (right side) 20 years earlier and 20 pack-year history of smoking. There were no diplopia, ptosis, headache, and the weakness of limbs or loss of consciousness. In addition, the patient had no history of diabetes or tuberculosis.
+The physical examination revealed a left peripheral FNP grade VI based on House-Brackmann (HB) grading. In the right ear, he had previous surgical scar, along with central perforation with otorrhea. In the left ear, herpetic vesicles, as well as papules and pustules, associated with erythema and edema were observed in the ear canal and the conchal bowl . The laryngoscopic examination confirmed left vocal cord paralysis that was fixed in the paramedian position. The audiological evaluation verified left side profound hearing loss .
+The patient was managed with RHS diagnosis associated with the paralysis of cranial nerves VIII and X, and the treatment started with acyclovir and prednisone 1mg⁄kg.
+The FNP recovered after 2 weeks and the synkinesis totally improved following 4 weeks. Although fluid aspiration remarkably improved, left recurrent laryngeal nerve paralysis persisted on indirect laryngoscopy, with the compensation from opposite vocal cord. The case’s vertigo improved after 4 days of treatment; however, occasional non-pulsatile tinnitus still lingered on. The vesicles changed into scabs within 5 days and the inflammation and erythema disappeared after 2 to 3 weeks. The left side sensorineural hearing loss and also recurrent laryngeal nerve paralysis sustained for a year of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2241_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2241_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e66ca36152f09f396de2d35e42ce74d631afd1ac
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2241_en.txt
@@ -0,0 +1,6 @@
+A 59-year-old male with a past medical history of hypertension presented to the ED for evaluation of a right-sided headache with an episode of palpitations and near syncope that developed while receiving an IANB for a tooth extraction at a dentist’s office. While his dentist was performing a dental block with lidocaine and epinephrine, he developed acute onset of severe right-sided headache accompanied by palpitations and near syncope with “trouble keeping his eyes open.” The dental extraction procedure was aborted and he was brought to the ED. By the time the patient had arrived to the ED, his palpitations and near syncopal episode had subsided, but his right-sided headache was persistent. The patient denied any other symptoms.
+Vital signs at initial presentation included blood pressure of 190/80 millimeters of mercury; heart rate of 73 beats per minute; respiratory rate of 20 breaths per minute; pulse oximetry 96% on room air; and temperature of 98.4° Fahrenheit. Physical exam revealed a middle-aged man in moderate discomfort from pain. His head was normocephalic and atraumatic; no ecchymosis, erythema, or crepitus was noted on his jaw or neck. His pupils were 5 millimeters, equal, round, and reactive to light bilaterally, and without objective ptosis. Cranial nerves II-XII were intact and symmetrical bilaterally. He had 5/5 muscle strength in both the upper and lower extremities bilaterally and 2+ bilateral patella and Achilles deep tendon reflexes. The patient had no ataxia or pronator drift and had a normal finger to nose.
+Initial laboratory studies included a basic metabolic panel, complete blood count, coagulation panel, thyroid stimulating hormone level, and troponin. None of these labs demonstrated any significant abnormalities. Twelve-lead electrocardiogram was noted to be normal sinus rhythm with a rate of 63 beats per minute with left axis deviation with high lateral T wave inversion, nonspecific ST changes in anterior leads with no change from previous. A chest radiograph was obtained and was without infiltrates or evidence of cardiomegaly.
+Computed tomography (CT) of the head without intravenous (IV) contrast revealed multiple small foci of air predominantly in the expected region of the intracranial venous drainage system ( and ). Multiple small foci of air were also noted in the right temporalis muscle. Given the patient’s history of dental procedure the possibility of intravascular introduction of air and local anesthetic was raised . There was no evidence of hemorrhage or acute territorial infarction or mass.
+Given the findings on the CT head, a dedicated CT neck with IV contrast was performed and showed residual punctate foci of gas in the left transverse sinus and posterior right cavernous sinus. Most of the previously seen bilateral cavernous sinus gas noted on CT of the head was not present on CT neck with IV contrast. The CT neck with IV contrast also reported that the patient was noted to have tortuosity of the extracranial internal carotid arteries with a short segment of the retropharyngeal course at the level of the hypopharynx.
+The patient was admitted to the intensive care unit for continued neurologic and cardiovascular monitoring after discovering the findings of intracranial venous air embolism and air near the carotid sheath on CT from suspected intravascular injection of local anesthetic. While hospitalized, the patient’s headache completely resolved. The patient had a repeat CT of his head and neck 24 hours later with near-total resolution of the previously noted gas in the cavernous sinus region and no acute intracranial infarct or hemorrhage. Neurology evaluated the patient and recommended no additional imaging as repeat CT demonstrated resolution of previously noted venous gas foci, and recommended symptomatic treatment of headache if symptoms recurred. The patient was discharged that next day with completely resolved symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2246_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2246_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..631e67183425f072cfd5d9b8ffc983f04df0280a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2246_en.txt
@@ -0,0 +1,11 @@
+A 57-year-old Japanese man was referred to our hospital because of increasing right lower abdominal pain. He had a history of appendectomy at the age of 17 years with no significant family or occupational history.
+On initial examination, an abdominal wall tumor (largest dimension, approximately 10 cm in diameter) was detected using transabdominal ultrasound . Laboratory data revealed elevated inflammatory markers (WBC = 14,400 × 109/L, CRP = 11.8 mg/L); major tumor markers (carcinoembryonic antigen, CA19-9, and soluble IL-2 receptor) were within normal limits. Helical computed tomography (CT) also revealed a solid mass (largest dimension, 10 cm in diameter) in the abdominal wall . Magnetic resonance imaging showed a mass that exhibited low intensity on T2-weighted images, slightly high intensity on diffusion-weighted images, and gradual reinforcement on dynamic study . Positron emission tomography–CT revealed fluorodeoxyglucose accumulation in the mass only (SUVmax, 41) . Because clinical and radiographic findings suggested malignant lymphoma, undifferentiated sarcoma, or liposarcoma, he underwent exploratory laparotomy and treatment.
+Intraoperative findings at laparotomy were an elastic, hard, milky-whitish mass with a rough surface and capillary growth in the right lower quadrant . On inspection and palpation, a malignant tumor was strongly suspected. No other tumor suspicious of a primary lesion was found in the intraabdominal organs, including the gastrointestinal tract. The mass was completely removed, and the surgical margin secured. The total weight of the mass was 120 g. No complications were observed during the perioperative period, and the patient was discharged on postoperative day 7.
+Pathologic examination revealed that these masses were foreign-body granulomas consisting of string-like crystals and a foreign-body giant cell . Immunohistological staining using anti-CD68 antibody (clone KP1) against the CD68 antigen, which is a known macrophage surface marker, was positive in cells surrounding phosphoglyceride crystals .
+The patient underwent regular follow-up abdominal ultrasound examination and CT postoperatively. As of 3 years after the procedure, no signs of recurrence have been detected.
+PGDD is a rare disease characterized by deposition of phosphoglyceride crystals, often simulating neoplasm in a scar of soft tissue or bone. It can sometimes form a large mass and be misdiagnosed as a malignant tumor.
+Little is known about its etiology and pathogenesis. This deposition disease is apparently triggered by injury and subsequent macrophage aggregation, with a histological picture of deposited crystal radiating from the cell membranes of epithelioid cells. The macrophages themselves may contribute to the formation of a nidus for the crystals. One hypothesis is that localized disturbance of phosphoglyceride metabolism within the macrophages may be initiated by local inflammation, leading to progressive amplification of macrophage infiltration and crystal deposition.
+To our knowledge, only 10 cases of PGDD have been reported previously, including our case. The available clinical information on these cases is summarized in Table [–]. The mean age of patients is 57 (range, 37–76) years. There appears to be no gender predilection. No congenital abnormalities or family history of metabolic disorders have been found. Deposition was characteristically noted at intramuscular injection sites or postoperative sites like the gluteal muscles and the deltoid, abdominal wall soft tissue, scapula, spine, myocardium, and pelvic soft tissue. The size of the tumors reported is highly variable, from 3.5 cm to the size of an infant’s head, but in general it is a relatively large tumor with a mean size of 8.9 cm. The time from the initial invasion to confirmation of the tumor was at least 20 years and was 45 years in the longest case. About half of the cases had multiple lesions. In most cases, excisional surgery was performed due to local tumor formation without apparent symptoms of inflammation. Tumors that occurred at postoperative sites were suspected to be true malignant neoplasms or recurrent tumors. In one case, intraoperative rapid pathological diagnosis revealed PGDD, so complete resection was not performed and the patient was observed clinically.
+No specific markers exist for PGDD, and differentiating this disease from malignant tumors without pathological examination is difficult. We considered needle biopsy in the present case but decided against it given the risk of needle tract seeding if malignant.
+In the present case, exploratory laparotomy, not laparoscopic surgery, was performed for a suspected huge malignant tumor of the abdominal wall, based on radiographic examination. Our patient had a history of appendectomy at the age of 17 years, and local inflammation at the operation site was suspected to have led to progressive amplification of macrophage infiltration and crystal deposition.
+Postoperative follow-up has not revealed any findings suspicious of recurrence in our case. However, there are reports in the literature of recurrence at 4 years after surgery . Few studies have reported on the process of crystallization and deposition of phosphoglycerides and so the mechanism remains unclear. Local injection of a bovine-derived medication has been suggested as causative, yet that alone does not explain PGDD, including the present case. In reviewing previous reports, a few cases suggest that during the process of phosphoglyceride metabolism, a locally invasive procedure increases macrophage activation and leads to phosphoglyceride deposition. Moreover, knowledge of the tendency of PGDD to form at sites of invasion may allow a clinician to clinically observe a similar mass found during routine follow-up, and debulking surgery may be considered as a therapeutic option for symptomatic cases.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2259_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2259_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0f049e30ac19b26498f654ade7cebfbf4247fd2d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2259_en.txt
@@ -0,0 +1,9 @@
+A 57-year-old Chinese man presented to the urology clinic with unable to self-urinate for two weeks.
+After two weeks of having the catheter in place and consistently taking tamsulosin, the patient remained unable to self-urinate.
+A 57-year-old male initially visited an outpatient clinic specialising in urological surgery due to urinary urgency and frequency. In October 2022, the patient was diagnosed with benign prostatic hyperplasia (BPH). Despite treatment with tamsulosin, an α-blocker, his symptoms rapidly worsened within two months. Subsequently, he was admitted to the emergency department for acute urinary retention and received an indwelling catheter. After two weeks of having the catheter in place and consistently taking tamsulosin, the patient remained unable to self-urinate. He revisited the urological surgery outpatient clinic in December 2022 and was admitted for BPH. Over the previous two months, the patient experienced no other symptoms, such as fever or weight loss.
+The patient denied any family history of malignant tumours.
+The patient's physical examination revealed no apparent abnormalities. Digital rectal examination indicated a Grade II prostate, characterised by a firm texture, smooth surface, lack of tenderness and an absent central groove.
+Blood routine examination and liver and kidney function test results were within normal limits. The serum total prostate-specific antigen measured 4.30 ng/mL (normal < 4 ng/mL), and the free prostate-specific antigen was 0.42 ng/mL. Routine urine analysis presented no significant abnormalities.
+Ultrasound examination of the urinary system demonstrated normal left and right kidneys. Computerised tomography (CT) estimated the prostate size to be approximately 57 mm × 36 mm × 34 mm, with a volume of around 36 mL. The bladder's residual urine volume was approximately 552 mL, as illustrated in Figure . The preoperative international prostate symptom score was 27, and the quality of life (QOL) score was 5. Urodynamic examination indicated a maximum urine flow rate of 6.4 mL/s and an average urine flow rate of 5.2 mL/s.
+Based on the aforementioned examinations and tests, the patient was preliminarily diagnosed with prostatic hyperplasia. Upon conducting a physical examination, laboratory tests and imaging, a HoLEP procedure was performed on the patient in December 2022.
+The surgeon observed that the patient's prostate tissue was notably swollen, with the left lobe of the prostate exhibiting significant oedema and protruding into the bladder. Additionally, extensive trabeculation was present within the bladder. The prostate tissue's texture was delicate, making it prone to bleeding upon contact. Once the bleeding from the prostate wound was controlled, the excised tissue was collected and submitted for examination. The patient experienced symptom regression following surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2272_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2272_en.txt
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index 0000000000000000000000000000000000000000..35864b278303b2adf7a0e231c597ab2af3ba7ba4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2272_en.txt
@@ -0,0 +1 @@
+A 69-year-old Tunisian female with no family history of auto-immune disease. She had a history of hypertension and was explored 4 years prior to admission for transient arthralgias and arthritis. At age 69, she experienced photosensitivity, malar rash and diffuse discoid lesions in her trunk and face for which she visited our hospital. She also reported weight loss of approximately 3 kg in the last three months. She had no history of drug abuse or significant alcohol consumption prior her admission. The physical examination showed synovitis of the wrists. Her general state of health was regular, eupneic. Cardiovascular and respiratory examinations were within the normal range. The patient had no previous laboratory tests. On admission, her initial laboratory tests were as follows: erythrocyte sedimentation rate at 45 mm/1st hour associated with hyper-γ-globulinemia 20 gr/l. Her leukogram showed lymphopenia 850/mm3, and platelets were normal. Creatinin and urinalysis are normal. The autoimmune profile confirmed a strong positivity of Antinuclear antibodies (ANA) with titre 1:400 and anti-double-stranded DNA (anti-dsDNA) at 115 UI/ml with normal serum complements. The patient was non-reactive for the following antibodies: anti-La; anti-cardiolipin; lupus anticoagulant; anti-SM; anti-RNP; anti-SCL-70; and anticentromere, rheumatoid factor and autoantibodies against citrullinated protein. Serology for VDRL was negative, hepatobiliary enzyme and lactate dehydrogenase levels were within normal range. Therefore, presence of 6 of 11 American College of Rheumatology criteria (photosensitivity + malar erythema + positive ANA and anti-dsDNA tests + hematologic abnormalities including lymphopenia + arthritis) allowed the diagnosis of SLE. The patient was treated with Chloroquine (200 mg/day). The patient showed improvement of her general state of health, and weight gain. No aggravation of SLE was observed. However one year later, she developed liver dysfunction. The patient was referred to gastroenterology unit. On physical exam, skin rash involving her face was observed. Abdominal examination revealed neither hepatosplenomegaly nor pruritus. Laboratory investigations revealed a normal complete blood count and urinalysis. His erythrocyte sedimentation rate was at 60 mm/1st hour while C-reactive protein was within normal range. Concentrations of both serum cholesterol and triglyceride are normal. Blood creatinine clearance 80 mL/min and there was no proteinuria. Aspartate aminotransferase 92 IU/L (normal range: 8–38); alanine aminotransferase 87 IU/L (normal range: 4–44 IU/L) (2 times above the normal limit), total bilirubin 0.9 mg/dl; alkaline phosphatase 107 IU/L, gammaglutamyl transpeptidase 42 IU/L and lactate dehydrogenase 230 IU/L are at normal range. Antimitochondrial antibodies (AMA) were positive (1:164), with positive anti-E2 fraction. The antinuclear antibody was positif as well as anti-dsDNA. Negative results were seen for anti-smooth muscle antibody and anti-centromere antibody. Serologic makers for hepatitis B and hepatitis C viruses were negative. Abdominal echo showed no fatty change of the liver and no abnormality of the bile ducts. Biochemical liver tests and AMA results are compatible to PBC. However, liver biopsy is required to give information on the stage of PBC. Microscopic examination reveals a focal florid duct lesion characterized by a portal lymphocytic infiltrate and epitheloid cells that are centred on interlobular ducts with evidence of destruction . These lesions are associated with a lymphocytic cholangitis and a portal inflammation containing conspicuous plasma cells and numerous lymphocytes . No granuloma was found in lobule. These findings led to a diagnosis of stage I PBC according to Scheuer’s classification. Based on the hematology and liver-tissue results, as well, she was diagnosed with asymptomatic PBC. Treatment with ursodeoxycholic acid (600 mg daily) was started. The transaminase levels normalized with one month. The patient has not complained liver dysfunction. She was followed up regularly with stable health.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2276_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2276_en.txt
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index 0000000000000000000000000000000000000000..fc05b61d61c7f91ec9e37002211877b40415b3b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2276_en.txt
@@ -0,0 +1,8 @@
+We present the case of a 50-year-old man who had been on dialysis for 6 years due to chronic kidney disease caused by glomerulonephritis. Abdominal enhanced computed tomography revealed a 22 mm left renal tumor, and a laparoscopic left renal nephrectomy was performed .
+Histopathology revealed clear cells with a tubular, cylindrical, and papillary shape .
+Immunohistochemistry revealed the tumor cells to be diffusely positive for CK7, negative for CD10 and AMACR, and immunoreactive with CA IX in a cup-like distribution .
+Following these findings, a pathological diagnosis of pT1aNxMx, CCPRCC, G2, Fuhrman grade 2, INFa, v0, ly0 was made. The tissue of the renal cortex exhibited a thyroid-like appearance and renal arteriosclerosis, consistent with the histology of ESRD.
+We studied the expression of miR-155 in the present case and compared it to that in nondialysis kidney tissue. Total RNA was extracted from frozen specimens of the tumor and renal cortex of the present case using a mirVanaTM miRNA isolation kit. Total RNA was also extracted from the frozen normal renal cortex samples of 96 patients with renal cell carcinoma who did not undergo dialysis. We generated cDNA from the RNA extracted from tumor and renal cortex samples using a TaqMan®microRNA RT kit (Thermo Fisher Scientific, Inc., Waltham, MA, USA). Relative quantitative analysis of miR-155 was carried out using a TaqMan miRNA Assay (Applied Biosystems, Foster City, CA, USA). We found miR-155 expression to be 2.4 times higher in tumor samples than in renal cortex samples of the present case . miR-155 expression in the renal cortex was 0.04 times lower in patients with ESRD compared with normal patients .
+mTOR is a highly conserved serine/threonine kinase that regulates cell growth and metabolism. It has been reported that miR-155 targets TSCs TSC1/TSC2 in the mTOR pathway in CCRCC.
+To compare CCPRCC in our patient and CCRCC for regulation of the mTOR pathway by miR-155, we investigated the expression of immunohistochemistry in mTOR pathway. As reported previously, we confirmed a decreased expression of TSC2 and increased expression of mTOR, S6, and 4EBP1 in CCRCC. Moreover, we confirmed the same expression pattern of CCPRCC in our patient .
+In addition, we investigated the quantitative analysis in our patient using a MantraTM Quantitative Pathology Workstation with inForm® image analysis software (ParkinElmer, Life Science, Waltham, MA, USA). The positive staining rates of TSC1/TSC2 in the carcinoma were lower than in the renal cortex. Conversely, the positive staining rates of mTOR and 4EBP1 in the carcinoma were higher than in the renal cortex .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2290_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2290_en.txt
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index 0000000000000000000000000000000000000000..1e9841c794d7c83a18988dccda41a6dd91d6b21d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2290_en.txt
@@ -0,0 +1,4 @@
+A male Chinese patient, aged 58 years, visited the cardiology clinic with recurring episodes of syncope for 20 days. He experienced episodes of transient loss of consciousness, each lasting approximately 30 seconds, accompanied by chest pain. The most recent episode of syncope occurred in the early morning and was characterized by dizziness and a temporary loss of consciousness. He had a history of hypertension.
+He smoked one pack of cigarettes daily for about 20 years with frequent alcohol intake. During the examination of the patient’s cardiac system, auscultation indicated normal heart sounds and no murmurs. Magnetic resonance imaging (MRI) and magnetic resonance angiography (MRA) of the brain, laboratory tests measuring cardiac enzymes, and electrocardiogram (ECG) were normal.
+A transthoracic echocardiogram provided confirmation of the left ventricle’s size and function being within normal parameters. Approximately 16 hours after admission, about at 5 a.m., during sleeping, the patient experienced a recurrence of sudden chest pain, diaphoresis, and subsequent syncope. Physical examination indicated a heart rate of 37 beats per minute (bpm), respiratory rate of 25 breaths per minute, and blood pressure of 62/38 mmHg. The ECG revealed dynamic ST-segment elevation of 0.1 mV in leads II, III, and augmented vector foot (aVF; Fig. ). Syndromes spontaneously improved within a few minutes, the ECG returned to baseline and blood pressure improved to normal later . Cardiac troponin I enzyme levels were negative. Coronary angiography (CAG) was not performed immediately due to the symptom relief. However, following the doctor’s advice, he had CAG examination 4 days later. Subsequent CAG confirmed diffuse coronary slow flow (thrombolysis in myocardial infarction flow grade 2), without any substantial flow-limiting lesions . The patient did not agree to undergo coronary vasospasm provocation testing due to possible adverse event risk, and refused further examination to further confirm the cause due to financial reasons. However, based on the patient’s symptoms, ECG findings, and coronary angiography, a diagnosis of CAS and presumptive CMD was established. The patient was prescribed diltiazem sustained-release capsules (30 mg, four times daily), nicorandil (5 mg, three times daily), and atorvastatin (20 mg/day).
+During the 3-month follow-up conducted on our outpatient basis, the patient successfully ceased smoking and effectively controlled his hypertension. Furthermore, he did not experience a recurrence of the previously reported chest discomfort, syncope, or any other symptoms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2294_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2294_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a967c801c210b3d5d4dfc154474bbb85bdaa5b9c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2294_en.txt
@@ -0,0 +1,4 @@
+A 52-year-old male weighing 70 kg who was a teetotaler and a biology researcher was admitted to hospital 3 h after intentional ingestion of 150 ml of 99.9% methanol. This is an analytical reference material stored in graduated glass laboratory apparatus, which was used for self-harm purposes by this patient. He was brought in by his wife, who had found him early in the morning vomiting, soon after the exposure. He was alert, cooperative, presenting nausea and vertigo, and reporting six episodes of vomiting, without other complaints. He said he had not co-ingested any ethanol. He had been taking bupropion, clonazepam and oxycarbazepine under irregular psychiatric treatment for depression, for the preceding four months.
+Physical examination showed no remarkable features. A blood sample for methanol and ethanol determination (gas chromatography) was obtained 4 h after ingestion, and the result came out 6 h later (10 h after ingestion), showing 70 mg/dl of methanol and no detectable ethanol. With this result, it was decided to institute a loading dose of 10% ethanol solution (7 ml/kg intravenously), followed by a maintenance dose of 0.9-1.0 ml/kg/h intravenously, for 42 h, and hemodialysis was also indicated. An eight-hour course of hemodialysis was then started 19 h after ingestion, during which 2.1 ml/kg/h of 10% ethanol was administered. Eight intravenous doses of folinic acid (50 mg in 5% dextrose, for 30-60 minutes every 6 h) were also given over a 48-hour period, starting 4 h after ingestion.
+summarizes the main laboratory results and treatment measures according to the time after ingestion. Blood glucose, complete blood counts, electrolytes, amylase, liver function tests, lactate dehydrogenase, creatinine, urea nitrogen and electrocardiographic analyses were within reference values.
+The patient was discharged on day 4, after undergoing ophthalmological evaluation and a cerebral computed tomography scan, which did not show any abnormalities. Follow-up did not show any sequelae, and the patient is currently under regular psychiatric treatment, with good compliance so far.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2296_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2296_en.txt
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index 0000000000000000000000000000000000000000..cecd87a28d404fea0588f28fd441557359b4f3aa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2296_en.txt
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+A 15-year-old previously healthy male presented with a 6 months history of severe right nasal congestion and rhinorrhea. Computed tomography (CT) and magnetic resonance imaging (MRI) demonstrated a large right nasopharyngeal-enhancing soft tissue mass obstructing the nasopharyngeal airway and extending into the right posterior nasal cavity, pterygopalatine fossa, nasopalatine fossa and inferior sphenoid sinus . Bilateral retropharyngeal and level II A/B adenopathy was present. Biopsy of the mass showed infiltrating mature lymphocytes and neoplastic cells strongly and diffusely positive for EBV-LMP and EBER; CPS PD-L1 was >20. The patient was diagnosed with T4N1 EBV-positive undifferentiated non-keratinizing NPC and started on 7 weeks of curative-intent radiation with concurrent chemotherapy. Radiation was given as 70 Gy in 35 fractions to the gross tumor and 56 Gy to the bilateral nodes. Intravenous (IV) cisplatin was given concurrently on days 1, 22 and 43 at 100 mg/m2. After completion, adjuvant chemotherapy with daily infusional fluorouracil 1000 mg/m2 for four days and IV cisplatin 80 mg/m2 was given for 3 cycles, with cisplatin omitted due to ototoxicity the last cycle.
+Post-treatment MRI scans suggested complete response . He was placed on thyroid hormone replacement for post-treatment hypothyroidism. At 6 months post-adjuvant chemotherapy, the patient developed right thigh pain. Radiographs showed periosteal reaction in the distal femoral diaphysis and, as the patient was a competitive ice hockey player, this was considered likely a stress fracture. A subsequent biopsy was negative for malignancy. The discomfort persisted and worsened, with two-years post-treatment MRI scan of the femur showing worsening of aggressive bony changes and the appearance of new lesions suggestive of osteomyelitis or metastatic cancer. A PET scan performed 29 months post-treatment showed multifocal bony lesions and multiple hypermetabolic lymph nodes in the chest, abdomen and retroperitoneum without evidence of disease recurrence in the primary nasopharyngeal site . Biopsy of the right femur confirmed EBV-positive metastatic carcinoma.
+The patient had moderately severe chronic right thigh pain, hemoglobin was 70 g/L, and serum EBV DNA titer was 678,000 IU/ml . Treatment was initiated with analgesics, packed red cell transfusion, palliative radiation 2000 Gy in 5 fractions to the femur, zoledronic acid 4 mg IV, and gemcitabine/cisplatin chemotherapy on a 21 day schedule. There was rapid improvement in the patient’s pain and a CT of the abdomen and pelvis following cycle 4 chemotherapy demonstrated complete resolution of the retroperitoneal and pelvic metastatic adenopathy . EBV titers nadired at 4000 IU/ml at chemotherapy cycle 5, and then began to slowly increase . Following cycle 7, the patient’s thigh pain recurred and he also developed progressive anemia which required transfusion. His energy level progressively deteriorated and he required wheelchair assistance. PET/CT after cycle 8 demonstrated cancer progression with new intrathoracic, retroperitoneal, and pelvic nodal lesions and left iliac bony lesion .
+Chemotherapy was discontinued, zoledronic acid was maintained, and the patient was switched to 200 mg pembrolizumab every 21 days. Improvement in hemoglobin level were seen and the patient reported decreased pain and increased energy level after cycle 1. A CT scan following cycle 5 showed size reduction of lymph nodes in the chest, abdomen, and pelvis and stable bony metastasis in the pelvis. By cycle 6, the patient was able to engage in full range of physical activities and by cycle 10, his EBV titer was undetectable . He appeared well with no signs, symptoms, or abnormal blood work suggesting disease progression, and did not experience any obvious immune-mediated toxicities. Subsequent CT results to date show only stable healed bony metastasis .
+Pembrolizumab was discontinued after 31 months (46 cycles). The patient is currently being surveilled quarterly with EBV serology and CT imaging, and receives maintenance zoledronic acid. Almost 2 years after discontinuing pembrolizumab, his physical examination, blood work, and CT are unremarkable, EBV levels are undetectable, and he has resumed playing competitive ice hockey. The patient’s treatment timeline and EBV titers are summarized in ; , respectively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2308_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2308_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0a053b41b772526eb3d2c0825a5911e02022ed32
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2308_en.txt
@@ -0,0 +1 @@
+A 74-year-old female presented to the emergency department for progressive left leg weakness that had resulted in multiple falls. An electrocardiogram (ECG) was obtained per . The ECG had a fixed frequency square wave artifact in all leads, not present on previous ECGs. The patient reported no implanted pacemaker and no neural stimulator, but he was wearing a BioTel event monitor (BioTelemetry, Inc, Malvern, PA), which had been placed in the prior month for syncope. The nurse turned off and removed the event monitor and replaced the ECG machine main cable. A repeat ECG was unchanged. The nurse then exchanged the room’s cardiac monitor leads. A repeat ECG showed complete resolution of the artifact, shown in . The initial set of cardiac monitor leads showed no visible damage but appeared to be the cause of this unique artifact.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2309_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2309_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1dc39e9199328ed4d024cc44be91836575e394fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2309_en.txt
@@ -0,0 +1 @@
+A 4-day-old male infant, who was born at 40 weeks’ gestational age and weighing 3660 g. He was delivered at term by episiotomy combined with forceps and admitted to the Department of Neonatology of The Second Hospital of Jilin University due to dyspnea in February 2022. No cutaneous lesions were observed. The patient underwent brain magnetic resonance imaging (MRI), the results of which showed a short T1 strip signal shadow (hemorrhage) under the cranial plate of the occipital region on both sides. He had no family history of diseases.The right eye appeared normal in the routine retinal screening performed with RetCam 3 (Clarity Medical Systems, Inc., Pleasanton, CA, USA). However, a color fundus photograph of the left eye revealed a solitary yellowish-white flat mass with an approximate size of 1.5-disc diameters located in the nasal retina . Diffuse hyperfluorescence with slight fluorescence leakage was observed by fluorescein angiography (FA) . On B-scan ultrasound, the mass was inapparent, with no distinct foci of calcification. No treatment was administered and follow-up reexaminations were recommended. Three months later, regression in the size of the retinal mass was observed . FA showed decreased vascularization of the lesion and slight mottled hyperfluorescence over its surface . Seven months later, the fundus examination indicated no lesion in the left eye . FA showed mild tortuous vessels without leakage . The right retina was normal, and thus the clinical course suggested that the isolated RAH may undergo spontaneous regression.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2326_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2326_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d84c7fca6c6ad5a15aef3d021ea818ea0d5a1e03
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2326_en.txt
@@ -0,0 +1,3 @@
+A 28-year-old male was referred to the emergency department coupled with fever and chills for 2 weeks and was diagnosed with infective endocarditis in another hospital. He reported that he had traveled for 2 weeks across deserts in the United States and accidentally tore the skin of his left ankle 2 weeks ago. There was no history of diabetes or hypertension and no family history. Then, he presented to a hospital in the US and was treated with ibuprofen for high fever (value unknown); however, his body temperature normalized for a few hours and then rose again, with decreased appetite. With a body temperature of 40.3 °C, he was admitted to a hospital in Beijing 10 days prior. Investigations revealed a white blood cell (WBC) count of 14.30*109/L, urine WBC count of 106.8/μl, urine red blood cell count 34.9/μl, and urine culture bacterium count of 203.2/μl, and repeated blood cultures showed Staphylococcus aureus. Chest CT (computed tomography) showed multiple inflammatory changes in both lungs, so the patient was started on anti-infective therapy with ceftriaxone and clarithromycin. During the treatment, fever occurred again, and his body temperature ranged from 38.6 to 40.3 °C, with cough and white phlegm. An echocardiogram revealed 2 masses (measuring 14*13 mm、11*16 mm in size), that were very mobile and appeared to be attached to the pulmonary valve. Then the patient was referred to our hospital with a WBC count of 16.4 × 109/L, and a CRP(C-reactive protein) level of 113.2 mg/L, and echocardiogram (just 1 day later than the previous one) showed a mass attached to the pulmonary valve, which is measured 43.8*19.9 mm in size. Chest radiology revealed that multiple patchy and large lesions with cavities in both lungs. Therefore, the patient was diagnosed with endocarditis, septicemia and pulmonary infection, and was admitted to our hospital.
+Given the patient’s age and short antibiotic treatment duration, valve replacement surgery was not the priority option and the patient wished to reconsider the surgery, so the treatment was mainly anti-infective and supportive therapy. Two days later, the patient reported chest tightness and dyspnea with increased DDi (D-dimer) (5.60 μg/mL) after using the toilet, and CTPA (computed tomographic pulmonary angiography) revealed filling defects of the right pulmonary artery and its branches as well as some branches of the left pulmonary artery, and a pulmonary embolism was considered. Therefore, the patient was transferred to the ICU (intensive care unit), and interventional pulmonary artery thrombectomy was immediately conducted. After 1 week of treatment in the ICU, the patient was transferred to the cardiac surgery department to prepare for valve replacement surgery, as the last echocardiogram showed multiple masses attached to the pulmonary valve with severe pulmonary insufficiency and the possibility of pulmonary cusp destruction . Nevertheless, repeated blood culture was negative. With the strike of both infection and pulmonary embolism, the patient’s hemachrome and albumin levels continued to decrease. Moreover, together with the recurrent fever and an increase in inflammatory indicators, the patient was too vulnerable to undergo surgery, so anti-infective therapy was conducted temporarily utill the patient was in a stable condition. The latest CTPA and chest CT results showed a right lower pulmonary embolism and right lower lobe pneumonia . Twenty days later, given the poor effect of the anti-infective treatment and the strong operation desire of the patient, pulmonary valve replacement, vegetation removal and right pulmonary thromboendarterectomy were performed. Destroyed pulmonary valve leaflets with friable vegetation measuring 2.5*1.0 cm in size and gray vegetation in the right pulmonary artery were revealed . Radical debridement with valve excision was performed, and then the St. Jude bioprosthetic valve (size 23 mm) was closed with interrupted sutures. Under direct vision through an incision into the right pulmonary artery, the thrombus was removed with a double-lumen catheter. During the operation, bronchoscopy showed that blood filled all levels of the bronchus on both sides, and active hemorrhage occurred in the distal right middle bronchus. After a brief multidisciplinary discussion, resection of the middle and lower lobes of the right lung was conducted.
+Histopathology revealed infectious destruction in the specimen from the pulmonary valve and extensive hemorrhage and infarction of lung tissue with inflammatory cell infiltration. The patient’s postoperative course was uneventful, and his laboratory parameters were all normalized before his discharge. He was discharged on the 30th postoperative day. The patient continued antibiotic therapy for 1 month after the operation. The mean peak systolic transvalvular gradients were 19 mmHg, 24 mmHg and 23 mmHg on postoperative days 8, 23 and 85, respectively, according to echocardiography.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_232_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_232_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1c8720a6882d5d181c977736f855000a3dc371cd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_232_en.txt
@@ -0,0 +1,6 @@
+On 15 March 2020, a 70 year-old man was admitted to a peripheral hospital in South Tyrol (Italy) because of fever (up to 39 °C) and a slightly dry cough. He presented with a history of arterial hypertension, a status post resection of a caecal tubular adenoma in 2018 and a nicotine abuse of 30 pack years until 2010. Nevertheless, the patient was in a good state of health, having run a half marathon two weeks prior to the admission. The performed SARS-CoV-2 test (RT-PCR) showed a positive result. On admission an empiric antimicrobial therapy was initiated with ceftriaxon 2g i.v. once daily and after two days escalated to levofloxacin 750 mg i.v. once daily and amoxicilline-clavulate 2.2 g i.v. tid. As an antiviral therapy the patient received hydroxychloroquine 200 mg p.o. for 8 days and darunavir 800 mg p.o. in combination with ritonavir 100 mg p.o. for 7 days. Remdesivir had been neither available nor recommended by the local treatment protocol at that time in Italy.
+The following week, the patient’s condition deteriorated rapidly, and on 23 March 2020, intubation and mechanical ventilation with the transfer to the intensive care unit (ICU) were inevitable. For gaining antimicrobial probes the antibiotic therapy was discontinued for 1 day and reinitiated with piperacillin-tazobactam 4.5 g i.v. tid, which was administrated for 11 days. Due to rapidly increasing inflammatory parameters the antibiotic therapy was switched to meropenem and linezolid. Despite, the patient developed an acute respiratory distress syndrome (ARDS) and ventilationtherapy required a FiO2 max of 1.0 for two days, a Pinsp between 20 and 30 mbar and a positive end-expiratory pressure level between 8 and 14 mbar. The patient underwent a total of 12 cycles of pronation with mostly a good response and an overall median increase of the pO2 of 50 mmHg. An extubation attempt two weeks later failed. Consecutively, due to the pronounced radiological findings and the expected prolonged weaning time, a tracheostomy was performed on 18 May 2020. Of note, because of the lack of experience and evidence no initial corticoid therapy had been started. In the further course the patient received twice a steroid cycle therapy, the first on 9 April 2020 after the failed extubation attempt in the 4th week of his hospitalisation, the second was started on 27 April 2020, in the 7th week . Firstly, due to a sepsis 200 mg hydrocortisone were administered which was then switched to methylprednisolone for tapering and secondly, 300 mg hydrocortisone was given for 3 days, with consecutive 240 mg methylprednisolone i.v. for 5 days as a rescue therapy because of the poor clinical improvement, which was again tapered for 4 days. Upon the methylprednisolone therapy the patient improved gradually. After approximately 6 weeks of intubation, the weaning phase was successfully concluded on 6 May 2020 and the patient was able to breath spontaneously without any mechanical support.
+Overall, the laboratory findings confirmed a status of hyper-inflammation with increased interleukin 6, ferritin, C-reactive protein and pro-calcitonin levels . The microbiological investigations revealed a moderate growth of Candida albicans in the bronchial aspirate without treatment indication from probes that were gained at a timepoint in April, at which the patient was in a stable clinical health status.
+Fatefully, in addition to COVID-19, an incidental pulmonary nodule of about 2.5 cm was detected in the right upper lobe in the former smoker. After the patient’s recovery and pulmonary rehabilitation, further clinical diagnostics of the pulmonary nodule revealed the diagnosis of a pulmonary adenocarcinoma. Astonishingly, six months post COVID-19, the 70 year-old man presented with normal spirometry findings, a VO2max of 26 ml/min/kg and a normal lung perfusion scintigraphy. Thus, a video-assisted thoracic surgery (VATS) lobectomy of the right upper lobe could be performed on 1 October 2020.
+The histopathological evaluation of the tumor-distant-lung parenchyma (craniolateral, Fig. F) revealed neither residual signs of late-stage diffuse alveolar damage, nor microvascular alterations, nor signs of interstitial lung disease.
+In particular, we were interested in a potential histological correlation to the residual ground-glass opacities and sub-pleural lines . In this context, some discrete sub-pleural septal thickening and peri-bronchiolar fibrosis were described histopathologically. Furthermore, electron microscopy confirmed sub-pleural braid-like islands of fibrosis, but otherwise no inter-alveolar septal fibrosis . According to the pathologists, peri-bronchiolar fibrosis was rather seen as a smoking-associated sequelae. In consideration of the patient’s good general condition, these changes did not appear to be linked to clinically significant functional impairment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2330_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2330_en.txt
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index 0000000000000000000000000000000000000000..2f00305766cbbea21a2c1c5e58d1aa0a68462dc3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2330_en.txt
@@ -0,0 +1,7 @@
+A 53-year-old male presented with a 4-day history of worsening chest pain. The pain was initially felt as episodic left sided non-radiating heaviness that resolved on rest, but in the last 24 h became constant and severe with associated sweating and shortness of breath. He had no known medical conditions but was a smoker.
+ECG showed inferior ST elevation with Q waves. A coronary angiogram confirmed occlusion of the mid right coronary artery; aspiration thrombectomy and coronary stenting with drug-eluting stent were undertaken as complete occlusion likely occurred 24 h before a presentation and was performed successfully. He was admitted to the coronary intensive care unit, with still intermittent chest pain, but no murmurs on auscultation and improving ST elevation on sequential ECGs.
+He remained persistently hypotensive post-procedure including an episode of cardiac tamponade with profound hypotension secondary to a haemorrhagic pericardial effusion that was emergently drained 10 h after coronary revascularization. Transthoracic echocardiogram (TTE) and cardiac computed tomography (CT) revealed a post-myocardial infarction inferior muscular VSD (14 × 16 mm and 12 × 17 mm diameter on TTE and CT, respectively, ). There was possibly an additional smaller VSD towards the base and an LV pseudoaneurysm due to inferior wall thinning or rupture that was felt to have been the cause of the haemorrhagic effusion.
+After extensive multidisciplinary discussion, percutaneous VSD closure under fluoroscopy and transoesophageal echocardiogram (TOE) guidance was undertaken in view of ongoing patient haemodynamic instability despite medical management. An intra-aortic balloon pump (IABP) was instituted after general anaesthesia for unresponsive systemic hypotension, along with inotropic support with noradrenaline and adrenaline. A Judkins right coronary catheter was used to cross from the femoral artery to the LV, through the larger VSD, and to the pulmonary artery. A double-length exchange terumo wire was snared in the pulmonary artery and externalized through the jugular vein, creating an arterial-venous loop. A 14Fr 65 cm Gore Dryseal long sheath was advanced from the venous side into the left ventricular outflow tract. A 37 mm GCA was chosen. To overcome the need to advance the device within the ventricle which would risk perforation, the distal extent of the device was advanced within the sheath before then unsheathing and deploying the left disc inside the LV (see , ). The LV disc was then brought back slowly onto the interventricular septum without tension and with TOE guidance. The waist and the right ventricular disc were then deployed (see , ). To keep tension off the device and to acknowledge that the apical extent of the device was only held by the free wall of the LV, the device was immediately locked. The locking loop was seen to engage the right islet.
+Hypotension and significant ST elevation occurred at this point, requiring a short period of chest compressions. Transoesophageal echocardiography confirmed complete VSD coverage and suggested device stability though no stability checks were performed as the device would likely pull through and enlarge the defect given the surrounding tissue fragility (, , ). The device was released by supporting the right disc islet with the long sheath to ensure no tension was placed on the device as the retrieval cord was removed.
+The post-procedural TTE showed complete occlusion of the defect covered by the GCA.
+The patient was successfully extubated the following day and subsequently weaned off IABP and inotropes over the next 3 days. He recovered well and was discharged home. The device remains well-positioned on subsequent echocardiograms.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2334_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2334_en.txt
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index 0000000000000000000000000000000000000000..520e30cdfbb37117cc92df38619598d82a4093e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2334_en.txt
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+A 71-year-old Iranian man developed severe right ear pain of three-week duration. He then developed a painful, vesicular eruption on the right side of his neck. With a presumptive diagnosis of herpes zoster reactivation, the patient was treated with oral acyclovir. However, he was re-admitted for an abrupt onset of facial weakness and mild vertigo. On examination, the patient had right-sided facial weakness . In addition, vesicular eruptions with adherent crusts and scabs (characteristic of VZV eruption) were noted within the right external auditory canal, over the mastoid, around the pinna, and C2-C3 cervical dermatomes (involvement of VII cranial nerve and C2-3 spinal nerves) . He had no associated immunocompromising condition including immunosuppressant drug use, leukemia, etc. A diagnosis of VZV reactivation from multiple ganglia was made based on the patient's characteristic presentation. The serum anti-VZV IgM antibody (ELISA) and VZV DNA (polymerase chain reaction) were negative. A computed tomography scan of the head was unremarkable. Further investigation revealed an increased white cell count (of 21600/μL) and a first hour erythrocyte sedimentation rate of 72 mm. The patient was placed on oral prednisone and oral acyclovir. A gradual improvement in facial weakness was noted. The herpetic vesicles on the head and neck were completely crusted. He was discharged with a favorable clinical condition.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2363_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2363_en.txt
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index 0000000000000000000000000000000000000000..f1bb1c73761db18b3da58d4ddada219b7b543feb
--- /dev/null
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+A 30-year-old female was presented with severe left flank pain for one year. Laboratory data was within normal limits. Her physical examination was unremarkable, with a body mass index of 19 Kg/m2.
+On April 8th, 2011, the computed tomographic angiography (CTA) and magnetic resonance angiography showed narrowing of the LRV in the aortomesenteric portion. On May 25th, 2011, a duplex ultrasound demonstrated the compressed LRV between the aorta and the SMA, varices of left gonadal vein arising from the LRV, and a peak velocity (PV) of 17 cm/s in the renal hilum and 106 cm/s in the aortomesenteric portion of the LRV (the PV ratio of 6.2) . On June 2th, 2011, left renal venography revealed obstruction of LRV outflow, perihilar varices, and an 8 mm Hg pressure gradient across the suspected narrowing in the LRV .
+After failed conservative approach, the left renal venography was performed under local anesthesia to confirm and manage the narrowing of the LRV. A 10 mm × 40 mm SmartControl stent (Cordis, Johnson & Johnson, USA ) was deployed. The left renal venography showed unobstructed blood outflow, and full stent expansion without obvious protrusion of the stent in the inferior vena cava . The patient had nearly immediate resolution of her symptom and was discharged on postoperative day 5.
+After one month of endovascular stenting, the patient began to experience recurrent left flank pain. On July 5th, 2011, the second CTA demonstrated an endovascular stent migration on the left of SMA . On July 15th, 2011, the third CTA demonstrated further migration of the endovascular stent on the left of SMA . Since there was a continuing migration of the stent on computed tomographic imaging within 10 days, the extravascular stent was proposed on July 26th, 2011. The endovascular stent was found migrated to the left of SMA and adhered to the vessel wall tightly, and the stent could not be moved. The varicose gonadal vein was seen arising from the LRV. Excessive fibrous tissue was found at the origin of the SMA, and excised for adequate decompression of the LRV . We estimated and cut the graft to an appropriate length to fit between the inferior vena cava and the gonadal vein or longer. After the left gonadal vein and adrenal central vein were ligated and transected , an externally reinforced polytetrafluoroethylene graft (REF F4008, Bard Peripheral Vascular, Inc. ) of 8 mm diameter was selected to form an extravascular stent around the LRV . The graft was wrapped around the LRV and fixed together at each ring . The graft was sewn to the adventitia of the abdominal aorta and the endovascular stent was sewn to the wall of the LRV to prevent from the further migration. The patient had nearly immediate resolution of her symptom and was discharged on postoperative day 7.
+At 36 months’ follow-up, the patient was asymptomatic. The fourth, fifth and sixth CTA demonstrated the extravascular stent was patent and well positioned, and the endovascular stent remained to be on the left of the superior mesenteric artery at the first week, third month, and ninth month after extravascular stent placement respectively .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2367_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2367_en.txt
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index 0000000000000000000000000000000000000000..1b066381e80145543d5a2733d545c3148531fc63
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2367_en.txt
@@ -0,0 +1 @@
+A 27-year-old Caucasian woman with hepatitis C (HCV), current IVDU, and TVR was transferred to our institution for IE due to surveillance blood cultures yielding Candida parapsilosis and Staphylococcus. Three months prior to this admission, she had completed a 6-week course of antibiotics, followed by TVR with a CorMatrix valve for endocarditis. Post-operative complications included pulmonary embolism (PE) treated with coumadin. Prior to arrival, levofloxacin, piperacillin-tazobactam, vancomycin, nafcillin, and amphotericin B were initiated. A computed tomography (CT) scan of her abdomen and pelvis revealed a pericardial effusion, mild hepatosplenomegaly, and anasarca. She was afebrile, with a blood pressure of 131/70 mmHg and heart rate of 90 b.p.m. Cardiovascular exam was remarkable for grade 2/6 holosystolic murmur at the left lower sternal border and jugular venous distention (JVD) to her ears. She had a distended abdomen and 3+ pitting oedema in bilateral lower extremities extending to her knees. Complete blood count showed normal white count, platelet count of 12 × 109/L (normal range 150 000–450 000 × 109/L), normocytic anaemia with haemoglobin of 9.7 g/dL (normal range 12–16 g/dL), and an international normalized ratio (INR) >10 (normal rage of 1.0–2.0) reversed with IV vitamin K and discontinuation of coumadin. Erythrocyte sedimentation rate (ESR) was 27 mm/h (normal range 0–23 mm/h), fibrinogen was 140 mg/dL (normal range 200–400 mg/dL). Aspartate transaminase (AST) was 55 U/L and ALT - alanine transaminase was 20 U/L (normal range are 10–31 U/L and 10–41 U/L, respectively). Peripheral blood smear revealed numerous schistocytes and rare large platelets. Transthoracic echocardiogram (TTE) showed a mobile mass involving the TV with a large pericardial effusion measuring 4.21 cm by 3.73 cm. There was also evidence of elevated intrapericardial pressure causing diastolic compression of the right ventricle (RV) . Removal of 600 mL of serous pericardial fluid returned negative for bacteria, fungi, and viruses. Analysis was consistent with an exudative effusion. There was no apparent abscess or paravalvular leak. Repeat TTE following pericardiocentesis showed reduced pericardial effusion with relief of RV compression. On Day 8, she developed cardiogenic shock with worsening metabolic acidosis despite vasopressors that were started the day before. TTE showed torrential tricuspid regurgitation (TR) with a filling defect in the right PA (, , ). Left ventricular function was normal but the RV was dilated and poorly functional. There was an attempt to perform CT chest, however, due to haemodynamic instability, she underwent emergent surgery. Several units of platelets, fresh frozen plasma, and packed red blood cells were required during surgery. The TV was replaced using a Biocor valve following retrieval of the CorMatrix valve from the PA. Pathology of the extracted valve showed acutely inflamed tissue with bacteria, fungal element and acid-fast bacilli. She was discharged home on a prolonged course of antibiotics with Linezolid, Amikacin and Micafungin. All her laboratory values improved. Upon discharge, the patient moved out of state, however, was re-admitted within 2 months for blood cultures positive for AFB. TEE revealed new TV vegetations. Due to recurrent IVDU, she was not a candidate for surgical intervention and was treated with 6 weeks of Linezolid and Imipenem. The patient has since been lost to follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2378_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2378_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4725a54499e20a5b2a3f66d052da885246d82760
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2378_en.txt
@@ -0,0 +1,2 @@
+A 78-year-old male with a history of PR3-ANCA vasculitis, chronic kidney disease and heart failure with reduced ejection fraction presented with a two-week history of confusion and non-productive cough. He was maintained on rituximab maintenance for ANCA vasculitis every six months without vitamin D supplementation. He was started on rituximab approximately 13 months prior to initial presentation, having received an induction dose over four weeks for a total of 2000 mg. This included a tapering regimen of prednisone 25 mg daily at time of induction and two maintenance doses of 500 mg of rituximab. During induction with prednisone, PJP prophylaxis was given but was subsequently discontinued with completion of steroids. Physical exam was unremarkable including cardiovascular, pulmonary, and neurologic exams. On presentation, laboratory values revealed an acute kidney injury with creatinine of 356umol/L (eGFR of 13; baseline of 250umol/L, reference range 50-120umol/L). CBC showed hemoglobin 110 g/L (baseline given CKD), platelets 231, leukocytes 7.1 109/L, eosinophils mildly elevated to 0.9 109/L (normalized two days later). Urinalysis showed trace protein and absence of blood. Ionized calcium was elevated at 1.76mmol/L (reference range 1.15-1.35mmol/L) with phosphate 1.84 mmol/L (reference range 0.70-1.50mmol/L). Parathyroid hormone level was low at 8.8ng/L (reference range 15-57ng/L), 1,25-Dihydroxyvitamin D3 (calcitriol) was elevated (299pmol/L, reference range 60-208pmol/L) while 25-hydroxyvitamin D3 (calcidiol) was normal (126nmol/L, reference range 50-200nmol/L). Repeat ANCA panel showed MPO level < 0.2 AI and PR3 2.2 AI (MPO < 0.2 with PR3 12.1 two months prior). Repeat HIV screen remained negative for mixed antigen/antibody detection. Serum and urine protein electrophoresis were negative for monoclonal proteins. Serum free light chains showed a normal kappa/lambda protein ratio of 1.12. Initial chest x-ray showed pleuro-parenchymal scarring that was stable compared to an x-ray six months earlier. Point of Care Ultrasound (POCUS) demonstrated B lines in lung zones 1, 2, 3, and 4 with some areas of pleural irregularity, as well as a shred sign, suggestive of consolidation, in zone 8 and therefore a high-resolution CT chest was performed which showed interval development of dense ground glass opacities.
+Given the atypical presentation, the decision was made to perform bronchoscopy. Cultures from bronchoalveolar lavage confirmed diagnosis of PJP. The patient was treated with trimethoprim-sulfamethoxazole (TMP-SMX) at 20 mg/kg three times per day along with prednisone 40 mg twice daily for 21 days. AKI resolved with serum creatinine improving to baseline level of 242 umol/L (eGFR of 21) prior to discharge. Ionized calcium normalized to 1.26 mmol/L prior to discharge. With treatment, hypercalcemia, confusion and respiratory symptoms resolved prior to discharge and has continued to remain stable.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_237_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_237_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ba6ee4d1b23695389065975b51db8bd8379bcd0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_237_en.txt
@@ -0,0 +1,2 @@
+A 72-year-old man, who had been suffering from right hip pain for 7 years when walking, was referred to our institute. Roentogenography of the right pelvic bone showed an expansion of the cortical contour and a soft-tissue mass with punctate calcification . Magnetic resonance imaging (MRI) showed a lobulated lesion expanding over the entire right pelvic bone with low-intensity on T1-weighted imaging and iso- to high-intensity on T2-weighted imaging, with the tumor protuberant to the pelvic cavity . Right hemipelvectomy was carried out. Histological sections showed a conventional chondrosarcoma having atypical chondrocytes with hyaline cartilage matrix or myxoid matrix . In a small section, dedifferentiated components were also identified, and these dedifferentiated components consisted of atypical spindle cells arranged in short fascicles or a storiform pattern showing MFH-like features, plus some pleomorphic cells with lace-like osteoid formation showing osteosarcoma-like features . Therefore, the final diagnosis was dedifferentiated chondrosarcoma because of the coexistence of conventional chondrosarcoma and dedifferentiated components.
+Preoperative laboratory data were not remarkable. After surgery, the laboratory data also showed leukocytosis predominantly in the neutrophils with an elevated level of C-reactive protein . The serum level of G-CSF was also elevated (330 pg/ml [normal, <8 pg/ml]). Magnetic resonance imaging (MRI) and computed tomography (CT) revealed evidence of local recurrence and metastatic lesions in the lungs. Flow-cytometry indicated no evidence of leukemia and serological studies showed no evidence of specific infections, such as candidiasis or tuberculosis. Despite the administration of several antibiotics, the leukocytosis did not disappear. Two months after the surgery, the patient died of multiple organ failure. An autopsy was carried out, and in addition to the lung metastasis, metastasis was also found in the liver, thyroid, diaphragm, adrenal gland, digestive tract and skin. The histology of the recurrent and metastatic lesions was not conventional chondrosarcoma but only dedifferentiated components. Immunoexpression of G-CSF (anti-G-CSF [Ab1], Calbiochem, San Diego CA, USA) was seen in the dedifferentiated components, but not in the conventional chondrosarcoma components .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2383_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2383_en.txt
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index 0000000000000000000000000000000000000000..cebfe37daccf0beafb3faee1abe6e17e569a648b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2383_en.txt
@@ -0,0 +1,2 @@
+A 71-year-old Japanese woman underwent a living-donor liver transplant for hepatocellular carcinoma 18 years prior to her inclusion in this case study. She was receiving TAC orally at 2 mg/day (twice daily), with a trough blood concentration of approximately 4 ng/mL and stable trough blood concentration/dose (C/D) ratio (ng/mL/mg) of approximately 2. The patient presented night sweats, anorexia, and swelling on the left side of the neck. Owing to the presence of atypical cells in her peripheral blood and a substantial decrease in her platelet count (20,000/µL), she was urgently referred to our hospital for admission, thorough examination, and treatment. The patient was diagnosed with post-transplant lymphoproliferative disease (histological type: Burkitt's lymphoma) after admission. She was managed in the intensive care unit with continuous hemodiafiltration (CHDF) and positive airway pressure (CPAP) for 2 weeks because of tumor collapse syndrome, left subdural hematoma, and acute kidney injury (AKI). Figure illustrates the course of this case. Upon admission, the patient presented with elevated lactate dehydrogenase (LDH; 11,232 U/L) and alanine aminotransferase (ALT; 164 U/L) levels, indicating potential liver dysfunction. Consequently, the TAC dose was reduced from 2 to 1 mg/day. Furthermore, owing to the presence of AKI, TAC administration was temporarily discontinued. As oxygenation improved and the patient's condition progressed, cyclophosphamide–prednisolone (CP) therapy was initiated. Following CP therapy, the LDH and ALT levels decreased. Subsequently, TAC administration was resumed at 2 mg/day. The patient received two cycles of R-HyperCVAD (rituximab, cyclophosphamide, doxorubicin, vincristine, and DEX) and R-MA (rituximab, methotrexate, cytarabine, and methylprednisolone) alternating therapy. DEX (33 mg/day) was administered intravenously on days 1–4 and days 11–14 of the R-HyperCVAD course. Additionally, aprepitant (APR) was administered on days 1–5 in both courses. The TAC dosage was adjusted to maintain a trough blood concentration of approximately 2 ng/mL. Fluconazole 200 mg/day was administered orally throughout the TAC-administration period.
+The C/D ratio of TAC during the first course of R-HyperCVAD was initially low (1.07) on day 11, but then increased, reaching 2.57 on day 25. Similarly, during the second course of R-HyperCVAD, the C/D ratio on day 3 (in Fig. , day 57) was 2.42, but subsequently decreased to 0.92 on day 11. However, it then exhibited an upward trend, reaching 1.8 on day 18 and 2.86 on day 32. The C/D ratio of TAC on day 4 (in Fig. , day 93) of the second course of R-MA was 4.4, but decreased to 1.25 on day 11. Notably, the C/D ratio started to increase during DEX administration on days 11–14 of R-HyperCVAD treatment and did not decrease after 2 weeks, whereas it exhibited a decreasing trend during R-MA treatment. Therefore, the decrease in the C/D ratio was primarily attributed to APR rather than to DEX.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2389_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2389_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..df50fe35ca793676006fcd2da909b51e17614a8d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2389_en.txt
@@ -0,0 +1,7 @@
+The patient was a 23-year-old woman who was 167.5 cm tall, weighed 62.9 kg, and had a body mass index of 22.4 kg/m2. The patient had no relevant medical history and had not been vaccinated against COVID-19. In early September 2021, she developed a fever with general malaise and tested positive for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection on polymerase chain reaction (PCR). At the time, the SARS-CoV-2 Delta (B.1.617.2) variant was prevalent in Japan.
+As the patient had signs of pneumonia, an intravenous infusion of 200 mg of remdesivir was administered on day 8 of COVID-19, followed by 100 mg of intravenous remdesivir once daily for the next 3 days. On day 9, the patient suddenly developed pain in the right hip, accompanied by general pain. On examination, she had tenderness in Scarpa’s triangle without redness, heat, or swelling around the hip. The range of hip motion was limited by pain on flexion (right 80°/left 120°).
+Blood tests on day 15 after COVID-19 onset showed an elevated C-reactive protein (CRP) level (14.63 mg/dL; reference: 0.00–0.23 mg/dL), and an elevated white blood cell (WBC) count (18.0 × 103 cells/μL; reference: 3.90 × 103–9.80×103 cells/μL) but were negative for rheumatoid factor, antinuclear antibodies, human leukocyte antigen-B27, hepatitis, and human immunodeficiency virus (HIV). Urine culture was negative; however, blood culture revealed β-lactamase-producing Staphylococcus aureus infection. An expanded low-density area was observed in the capsule of the right hip joint in the contrast-enhanced computed tomography (CT) on day 21 after the disease onset, and arthrocentesis was performed on the same day. The joint fluid was cloudy and yellowish-white in color . Culture of the joint fluid was negative. However, the possibility of pyogenic arthritis was considered because β lactamase-producing S. aureus had been detected on the blood culture. Therefore, cefazolin was administered intravenously on day 23 after COVID-19 onset.
+However, the patient’s right hip pain persisted without a change in the size of the low-density area of the right hip on CT. On day 36 after COVID-19 onset, after two negative SARS-CoV-2 PCR test results, contrast-enhanced magnetic resonance imaging (MRI) revealed restricted diffusion in the fluid reservoir of the right hip, suggesting abscess formation ( and ). Therefore, surgical treatment with curettage and irrigation was performed on day 53, 2 weeks after the negative PCR test, according to the hospital regulations .
+Intraoperative joint fluid culture and PCR test results for SARS-CoV-2 were negative. However, the cell count of the joint fluid was 20,800 cells/μL (neutrophil: 88%, lymphocyte: 2%, and monocyte: 10%) and the specific gravity was 1.040. Moreover, the protein and sugar levels were 8.0 g/dL and 52 mg/dL, respectively. The Synovasure a-Defensin Detection Kit (Zimmer Biomet, Warsaw, IA, USA) showed positive results, and histopathology of synovial tissue revealed numerous neutrophils with segmental lobe nuclei ( and ).
+After surgery, the patient was treated with intravenous cefazolin, and the affected hip joint was continuously irrigated with 100 mg of amikacin sulfate dissolved in 1 L of saline daily for 11 days. Cultures of the drainage fluid during continuous irrigation were repeatedly negative. Oral antibiotics (1600 mg sulfamethoxazole-trimethoprim 1600/320 mg/day and rifampicin 450 mg/day) were initiated the day after intravenous antibiotic administration and continuous irrigation was completed.
+The patient’s right hip pain improved, and she was discharged from the hospital on day 68 after COVID-19 onset. Rifampicin was discontinued 3 months postoperatively, whereas sulfamethoxazole-trimethoprim was discontinued 4 months postoperatively. Loxoprofen was administered from day 9 after COVID-19 onset until 1 month postoperatively, but no steroids were administered. Six months after surgery, the patient had no symptoms and a Harris hip score of 96. Radiography revealed no abnormalities , and MRI showed a marked reduction in the joint effusion of the right hip. Furthermore, no diffusion restriction was observed that would suggest an abscess ( and ). Blood tests revealed a normal CRP level and WBC count.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2395_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2395_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af59dd15c295cef21791b343ea82e09eda1e6466
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2395_en.txt
@@ -0,0 +1,3 @@
+A 43-year-old man, with blunt neck trauma after being hardly hit by a crane lifting hook , was referred to the Shahid Beheshti Hospital Emergency Department (affiliated to Yasuj University of Medical Sciences, Yasuj, Iran). At the initial visit, the cervical collar was fixed first. The patient was evaluated in the primary survey and findings were as below: A: The airway system was open without any tracheal deviation, and the respiratory rate was 18 breaths/min with the oxygen saturation value of 98% estimated by pulse oximetry, while oxygen was administered at a rate of 3 L/min. B: Breathing was spontaneous without decreased breathing sound in bilateral auscultation of the lungs (no pneumothorax), but there was stridor, and the chest had bilateral symmetrical expansion, and there was no or subcutaneous emphysema. C: His blood pressure and pulse rate were 100/70 mm Hg and 92 beats/min respectively. Carotid pulses were present bilaterally. There was no ecchymosis, bruising, hematoma, and external bleeding in the trauma site at the neck . D: The patient was alert with the Glasgow Coma Scale/Score (GCS) of 15/15, and there was no cervical spine pain and tenderness, while the cervical collar was fixed. E: The patient was exposed while kept warm, and there were no other findings in the physical examinations. There was no abnormality in the simple radiography of the cervical spine. Color Doppler sonography (CDS) of the carotid and vertebral arteries and jugular vein showed normal flow velocity and spectral waveforms in the common carotid artery (CCA), internal carotid artery (ICA), external carotid artery (ECA), and vertebral arteries, and there was normal flow in both internal jugular veins. While the patient’s hoarseness and dyspnea got worse with time, neck and chest CT scans were performed to rule out laryngeal and other chest trauma. The CT scans showed no pathology in the chest but comminuted fracture of the left anterior arch of the cricoid cartilage with left-sided mucosal thickening, inflammation, and edema which was extended to the glottis, causing a narrowing of the airway (transverse inner diameter of the cricoid = 3.7 mm) .
+The cervical spine had no fracture. Direct fiber-optic laryngoscopy revealed swelling and congestion in the epiglottis and swelling at the level of the left vocal cord. The arterial oxygen saturation value was sustained at > 98% by administration of oxygen at a rate of 3–5 L/min with the use of a mask. As the patient’s vital sign was stable, and the arterial oxygen saturation value through the pulse oximetry did not decrease with time, orotracheal intubation and tracheotomy were not performed. The patient tolerated the treatment and had good intervention adherence. There were no adverse and unanticipated events during the study.
+Dysphonia and dyspnea alleviated gradually, and on the 4th day after the admission, the patient was discharged. The patient visited again on the 7th day after the discharge, and there was no dyspnea but very mild and fading dysphonia (clinically improved). The patient was optimistic about his well-being and coming back to his work again in the future. One of the limitations of this study was that we could not follow the patient with the next-up laryngoscopy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2411_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2411_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbc012ec06c18e76c781ffb08165db057d539331
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2411_en.txt
@@ -0,0 +1,3 @@
+A 52-year-old woman, gravida-3, para-3, 3 years post-menopausal, presented with post-menopausal bleeding of “several weeks” duration. She ultimately underwent a biopsy on which a diagnosis of endometrioid adenocarcinoma, FIGO grade 1 was rendered. Imaging showed a left adnexal mass whose features were equivocal regarding benignancy. A decision was made to perform a total hysterectomy and bilateral salpingo-oophorectomy. An intraoperative pathologic assessment was performed, which showed the adnexal mass to be benign but the endometrial mass to be of large volume (a 9 × 6 cm soft polypoid mass that occupied the entirety of the uterine cavity) with myometrial invasion and lower uterine segment involvement. A bilateral pelvic lymphadenectomy was also performed. Microscopic examination of the permanent sections of the case showed a grade 1 endometrioid carcinoma of the endometrium, with 35% invasion of the myometrial wall thickness, focal lymphovascular invasion, and metastases to 2 of 16 pelvic lymph nodes . Approximately 40% of the tumor was comprised of columnar glands showing more nuclear stratification, more nuclear enlargement, and more prominent nucleolomegaly than the background glands (atypical areas). These areas also showed comparatively increased mitotic indices (average 17 MF/10 HPF) than the background glands (average 9 MF/10 HPF), from which they were spatially distinct. Immunohistochemically, the atypical areas showed a p53 aberrant immunophenotype, characterized by diffuse and marked nuclear positivity for p53 in more than 90% of lesional nuclei. The p53-aberrant areas were also p16-diffusely positive, vimentin-positive, Napsin A-negative, estrogen receptor positive, and progesterone receptor-positive . The remainder of the tumor (60% of tumoral volume) displayed a p53-wild type immunophenotype, and were p16-mosaic positive, vimentin-positive, Napsin A-negative, estrogen receptor positive, and progesterone receptor-positive. As such, the p53-aberrant and p53-wild type areas showed an identical immunophenotype with the exception of the latter being p16-mosaic positive. Foci of lymphovascular invasion and myometrial invasion showed a p53-wild type immunophenotype and were identical in immunophenotype to the other p53-wild type areas within the tumor. Areas of background hyperplasia showed a p53 wild type immunophenotype. The endometrioid carcinoma at its primary site showed minor squamous differentiation, and no solid components in both the p53-wild type and p53-aberrant areas.
+The 2 lymph nodes with metastatic disease each showed a distinct biphasic pattern, comprised of both p53-wild type and p53-aberrant areas in foci that were spatially apposed but not intermixed. The p53-aberrant areas were identical in morphology and immunophenotype to the “atypical areas” of the endometrial tumor described above. The p53-wild type tumoral areas were comprised of glands with less columnar configuration and more non-specific cytoplasmic clarity. However, they showed foci of squamous differentiation and were otherwise immunophenotypically identical to the p53-wild type areas within the endometrial tumor . All components of the tumor at both the primary and metastatic sites showed loss of MSH2 and MSH6 with retained expression of MLH1 and PMS2. The patient declined germ-line testing, and underwent adjuvant chemotherapy. The case is too recent for meaningful follow-up.
+All immunohistochemical studies were performed on 4 μ-thick, unstained slides of formalin-fixed, paraffin-embedded tissue sections using the Ventana Benchmark automation and the Ultra View detection kit (Ventana Medical Systems, Tucson, AZ) and the following primary antibodies: Estrogen receptor (ER; Clone SP1; prediluted, Ventana), Progesterone receptor (PR; clone IE2; prediluted; Ventana), p53 (clone DO-7; dilution 1:40; Ventana), Napsin-A (polyclonal, prediluted; Cell Marque, Rocklin, CA), Vimentin (clone V9, dilution 1: 1000, Ventana), p16 (Clone JC8, prediluted, Santa-Cruz, Dallas, TX), MLH1 (clone G168–15, prediluted, Biocare Medical, Concord, CA), PMS2 (Clone A16–4; dilution 1:25; BD Biosciences, San Jose, CA), MSH2 (clone FE11, prediluted, Biocare Medical), and MSH6 (clone BC/44, prediluted, Biocare Medical).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2423_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2423_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d53ce7cde0f274c70d8618633436d8b1d7e4236d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2423_en.txt
@@ -0,0 +1,5 @@
+A 12-year-old Amhara boy from the Northwest Gondar Amhara regional state complained of left flank swelling for the last 3 months. Three days before admission he started to experience pain in his left flank, which was associated with high grade fever, chills, rigor, and vomiting. At the time he had no urinary or respiratory symptoms. Maternal pregnancy course and medical history were noncontributory, and he had an attended birth at a health center; his past medical history was unremarkable. He has seven siblings, none of whom had similar symptoms. His mother had no history of radiation exposure, use of traditional medicine, or chemotherapy during pregnancy.
+No dysmorphisms were noted in his general appearance. His vital signs were: pulse rate (PR) 142 beats/min, respiratory rate (RR) 33 breaths/min, temperature (T) 38.5 °C, and blood pressure (BP) 105/65 mmHg. Anthropometric measurements showed severe stunting. An abdominal examination revealed distended abdomen, asymmetric with bulging left flank, visible horizontal line, upward umbilical slit, and absent rectus abdominis muscles. His abdomen was soft with a tender cystic, bimanually palpable mass on the left flank measuring 13 × 11 cm. Both testes were undescended . He also had scoliosis and developmental dysplasia of the hips with waddling gate.
+Urinary analysis demonstrated many red blood cells (RBCs) and positive leukocyte esterase. He had a normal renal function test with creatinine of 0.72 mg/dl and blood urea nitrogen (BUN) of 44 mg/dl, normal hemoglobin of 12.7 gm/dl, and normal electrolyte. Ultrasound showed a large cystic mass in his left kidney area with echo debris. His right kidney had normal echo texture and size. An X-ray of his hips showed bilateral developmental dysplasia of the hip (DDH; Fig. ). Our facility does not have the capacity to perform a genetic study to support the diagnosis of PBS.
+His left kidney is cystic and enlarged; there is no parenchyma tissue, both testes are intraperitoneal just below the kidneys, tortuous left renal vein, enlarged bladder reaching above umbilicus, and left megaureter . A bilateral orchidectomy and left nephrectomy were done.
+After surgical removal of cystic mass and testes, he was given intravenously administered antibiotics for treatment of pyelonephritis for 14 days. Subsequently he showed significant improvement and was discharged home with an appointment for follow up to consider hormonal replacement therapy and possible abdominoplasty. His parents were also counseled about the PBS and the care they can give him at home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2428_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2428_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a610c1586add15645f6381ed2762ad693be44880
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2428_en.txt
@@ -0,0 +1,4 @@
+A 42-year-old man presented with a 13-year history of intractable tonic seizures that were indicative of right parietal lobe brain tumor. Plain computed tomography (CT) of the head revealed a tumor 40 mm in diameter and consisting of calcification and cyst formation located in the right parietal region. Magnetic resonance imaging (MRI) revealed an area of marked signal hypointensity around the solid component on T2 and T2 *-weighted imaging. These findings were thought to represent the calcification seen on CT, or perhaps hemosiderin deposition due to old hemorrhage. The tumor was located adjacent to the lateral ventricle, and the posterior part of the lateral ventricle was slightly enlarged toward the tumor. Normal choroid plexus of the right lateral ventricle was located in the normal position, and continuity of the normal choroid plexus to the tumor was not confirmed . Cerebral angiography did not show any tumor staining or vascular abnormalities. The provisional diagnosis was cerebral cavernous angioma with hemorrhagic episode.
+A right parietal craniotomy was performed using a navigation system and motor-evoked potentials. A yellowish, granulomatous, moderately hard, slightly lobulated avascular tumor was located in the right parietal lobe, with scant hemosiderin deposition identified within the lesion. The margin of the tumor was covered with predominant gliosis. At the deepest part of the tumor, the tumor was firmly adhered to the subependymal layer of the lateral ventricle. During dissection of the adhered area, the ventricular ependyma was penetrated and the body of the lateral ventricle was visualized through the cavity of the removed tumor. The normal-appearing choroid plexus was placed within the posterior part of the lateral ventricle and continuity of the normal choroid plexus and the tumor was not confirmed. The lateral wall on the lateral ventricle showed a normal appearance and continuous coverage with ependymal . The tumor thus originated completely in the cerebrum parenchyma and was firmly adhered to the wall of the lateral ventricle.
+Pathological examination of the tumor revealed a papillary structure with a single layer of well-differentiated columnar epithelium in the lesion. Part of this lesion growth had infiltrated the cerebral parenchyma. In addition, activated macrophages were prominent around the cerebral parenchyma and were considered to represent a reactive lesion related to an old hemorrhage. Immunohistochemical examination was accomplished with the antibodies detailed in . Vimentin was strongly immunoreactive. Neural Cell Adhesion Molecule (N-CAM, CD56), Epithelial Membrane Antigen (EM) and Cytokeratin 7 (CK7) exhibited focal immunoreactivity. Cytokeratin 20 (CK20) and prealbumin were not immunoreactive. Glial Fibrillary Acidic Protein (GFAP) was strongly immunoreactive. Podoplanin exhibited focal immunoreactivity in a few reactive cells . Mindbomb Homolog 1 (MIB1) labeling index (MIB1-LI) was 0.4%. Based on these findings, histological diagnosis was CPP with hemorrhagic episode.
+The patient showed no postoperative neurological deficits, and cranial MRI confirmed complete removal of the tumor. Postoperatively, seizures were well controlled using antiepileptic drugs.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2433_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2433_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..65a636122a622c14724c92fa66ff1262a933a066
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2433_en.txt
@@ -0,0 +1 @@
+A 71-year-old Caucasian woman was treated in our Gamma Knife center for a meningioma of the sphenoid jugum. The treatment was performed with Leksell Gamma Knife Icon® (Elekta Instruments, Stockholm, Sweden) and was planned as a hypofractionated irradiation including five daily fractions of 5 Gy. The restraint method chosen was the use of a thermoplastic mask Orfit® (Orfit Industries, Wijnegem, Belgium) [, ]. The mask was made 5 days before the first irradiation. During mask making, the mask was warmed by soaking in a water bath and then applied and molded directly on our patient’s face for 20 minutes . At this step of the procedure, she complained of a burning and tingling sensation on her face, especially on her forehead. During the following 4 days, she continued to have a stable cutaneous reaction in the form of redness, tickling, and edematous swelling of her face. She was treated with a local antihistamine cream on her face, with moderate improvement in the symptoms. On the first day of treatment, during the first irradiation session, she complained again of a major sensation of burning and edema of the face. A clinical examination showed a serious allergic reaction on her face, associated with an atopic edema. She was treated with 125 mg of intravenously administered corticoids, followed by high doses of orally administered antihistamines and corticoids during the following 5 days. With this medication, the allergic reaction was controlled until the end of treatment 4 days later. During all irradiation fractions we kept using the thermoplastic mask but we inserted a thin sheet of paper between the internal surface of the mask and our patient’s forehead to reduce the surface area of contact between the mask and our patient’s skin.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2445_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2445_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e9048acbf283198ca573d4637793c4e9cf0c2bc5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2445_en.txt
@@ -0,0 +1,2 @@
+A 38-year-old Chinese female who visited the hospital for physical examination due to discomfort in the area of her right kidney, and a solid mass in the right kidney was found for 4 months. The patient had microinvasive adenocarcinoma of the left lung 4 years prior, without obvious abnormalities in the right lung and other lobes of the left lung. The patient did not smoke and had no family history of major diseases. No obvious abnormality was found by laboratory examination. Ultrasound examination showed an isoechoic area at the lower pole of the right kidney, with a size of 1.6 × 1.3 cm, a clear boundary, and an uneven echo; it was slightly convex locally, and the blood flow signal could be seen . Enhanced CT of the lower abdomen revealed a solid space occupying the right kidney, and CCRCC was considered . Based on imaging findings, robot-assisted laparoscopic nephron-sparing partial nephrectomy was performed. Grossly, the tumour was a well-circumscribed lesion measuring 2.0 cm × 1.0 cm × 0.7 cm under the renal capsule, with a greyish yellow and greyish red colour. The tumour was submitted for histologic examination. Histologically, the tumour consisted of three different structures: a CCRCC-like region, a haemangioblastoma-like region, and a focal leiomyomatous stroma component . The CCRCC-like region accounted for approximately 60%, and the tumour cells were arranged in acinar or glandular tubular shapes, with homogeneous pink staining in a few acinar cavities but without papillary architecture. The cell cytoplasm was transparent or slightly eosinophilic, and the boundary was vivid . Most of the nuclei were located at the base, and some were irregular in shape. Nucleoli could be seen in some cells (WHO/ISUP grades 1 to 2, Fig. C). Among the cancer cells, we also observed oval or polygonal cells with a flaky distribution and obvious capillary network. The tumour cells varied in size and had a pale or eosinophilic cytoplasm that sometimes contained sharply delineated fine vacuoles and hyaline globules. The stroma was leiomyomatous, mainly located around the tumour; some areas were loose and edematous and devoid of cells, with a rich mesh of capillaries . The tumour cell nuclei with inconspicuous nucleoli showed light-moderate nuclear atypia and pleomorphism. Neither mitotic figures nor necrosis was present . Focal haemorrhage, haemosiderin deposition, and psammoma bodies were observed. Some areas showed prominent delicate vascularity, such as a haemangioblastoma, which transitioned with the CCRCC-like area .
+Immunohistochemical results showed that the CCRCC-like region was diffusely strongly positive for AE1/AE3, vimentin, CAIX , PAX8 , PAX2, CK7 , and CAM5.2, partly positive for HNF1α, and negative for CD10, α-inhibin, NSE, S-100, CD34, and TFE3. The haemangioblastoma-like region was diffusely positive for vimentin and CAIX; partly positive for PAX8, PAX2, α-inhibin , and S-100; mostly positive for NSE; and slightly positive for HNF1α. CD34 staining highlighted the complex capillary network . The Ki67 index was approximately 1–2% in these two areas. SMA was strongly positive in the leiomyomatous stroma . The whole-exon sequencing (WES) results of the tumour sample showed missense single-nucleotide variations (SNVs) in TSC2 (NM_000548: exon 4:c.T311C:p. L104P) and SETD2 (NM_014159:exon 3:c.C721G:p.P241A). The patient recovered well and was discharged after surgery. She has not received other treatments after the operation. She was in good condition and had no evidence of recurrence or metastasis at the 18-month follow-up after the operation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2459_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2459_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b4b527703a947102594e14c709a54371f3f85b9f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2459_en.txt
@@ -0,0 +1,7 @@
+A 37-year-old Chinese woman was diagnosed as hormone receptor-positive and HER2-positive infiltrating duct carcinoma in her left breast.
+The patient felt a painless lump in the left breast during a physical examination. After several examinations, she underwent breast-conserving surgery, and sentinel lymph node biopsy was resultingly found to be 1/4 positive.
+The patient’s prior medical history was unremarkable. The patient did not demonstrate any history of drug allergies and had no history of ear, nose, and throat (ENT), migraine or other central nervous system diseases.
+The patient gave birth at the age of 25 and breastfed her infant. She experienced regular menstrual cycles and had no family history of cancer.
+A physical examination of the patient revealed a 1.0 cm × 1.0 cm non-tender mass in the upper outer quadrant of the left breast. Her physical examination confirmed no signs of ENT diseases, central nervous system diseases or cerebral metastasis. And she had a body mass index (BMI) of 30.4.
+Laboratory examinations (routine blood analysis, liver biochemical analysis, renal function, tumor markers, etc.) were normal.
+The patient’s lungs, bones and liver were normal. Imaging examination did not demonstrate any evidence of distant metastases. A cerebral magnetic resonance imaging scan revealed no sign of intracranial or skeletal cranial metastases or any vascular disorders .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2468_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2468_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bcd8a2963503b1f4f0066d25c7e6617da01e3e97
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2468_en.txt
@@ -0,0 +1,5 @@
+A previously healthy 29-year-old male with no medical history of respiratory illness, recurrent throat infections, or hospital admissions presented to the emergency department with a 3-day history of progressively worsening sore throat, odynophagia, and dysphagia. On presentation day, he started experiencing mild hoarseness and shortness of breath, especially when lying supine, which prompted seeking medical attention. On further questioning, the patient was not taking any prescribed medications and had no known drug allergies. He reported continuous e-cigarette use starting 2 days prior to the development of symptoms, minimal alcohol intake, and no use of recreational drugs.
+The patient received intravenous Dexamethasone In the emergency department, which immediately improved his shortness of breath. A throat culture was negative for group A, B, and C Streptococcus. COVID-19 was ruled out with a PCR nasal swab. The total peripheral white blood cell count was mildly elevated, but the rest of the renal and metabolic panels were normal. A lateral soft tissue radiograph of the neck showed a poorly defined and thickened epiglottis with a classic thumb sign, indicating acute epiglottitis .
+Considering his respiratory concerns, the Otolaryngology team was consulted. On examination, the patient was afebrile and was not experiencing trismus or stridor. Direct bedside laryngoscopy showed an enlarged, erythematous, and swollen epiglottis, partially obstructing the supraglottic region . Arytenoids were noted to be edematous bilaterally with normal vocal cord mobility.
+The patient was admitted to the hospital for airway monitoring and was started on intravenous Ceftriaxone and oral Metronidazole. He was also given another dose of intravenous Dexamethasone and was asked to stop using his e-cigarette.
+The patient’s condition improved significantly after 2 days, and a repeat laryngoscopy showed resolution of the swelling in the epiglottis . The patient was switched to oral Amoxicillin for 10 days and was discharged from the hospital.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_249_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_249_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cd2bd09d73608a3d7094576cd92476c9fc00f685
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_249_en.txt
@@ -0,0 +1,5 @@
+In December 2000, a 49 year-old woman underwent left mastectomy for a stage IIA invasive ductal breast carcinoma with low proliferative activity (Ki 67 < 5%), negative hormone receptors and HER2 overexpressed (score 3+ at immunochemistry). In her medical history there were no cardiovascular comorbidities and she had no family history of cardiovascular disease.
+From February to July 2001 she received an adjuvant chemotherapy with cyclophosphamide 600 mg/sqm, methotrexate 40 mg/sqm and 5-fluorouracyl 600 mg/sqm days 1,8. Subsequent follow-up was negative until September 2005 when a local left axillary relapse was resected. Histological and biological features of the relapse did not change. Surgical resection was followed, from January to February 2006, by radiation therapy on the left chest wall (5000 cGy with fractioned dose of 200 cGy/day). In November 2010, a PET-CT scan was performed to test for progressive increase in serum biomarkers. It showed multiple secondary localizations: lymph-nodal metastases (left axillary, mediastinic, iliac and lombo-aortic), liver metastases (third segment), and bone lesions (left seventh rib and left femur acetabulum). Liver biopsy confirmed hormone receptors negativity and HER2 overexpression (score 3+). The patient was absolutely asymptomatic (ECOG 0). A screening echocardiogram (January 2011) found no pathological findings and a normal left ventricular ejection fraction (LVEF 64%). At that point, first line chemotherapy with weekly paclitaxel (80 mg/sqm) associated with weekly trastuzumab (loading dose of 4 mg/kg followed by maintenance dose of 2 mg/Kg) was initiated and paclitaxel was withdrawn at the second administration because of hypersensitivity reaction and replaced with docetaxel (100 mg/sqm every three weeks). A supportive therapy with bisphophonates (zoledronic acid 4 mg i.v. every 28 days) was also administered for bone metastases. In March 2011, after three months of treatment (fourteen administrations of weekly trastuzumab), the patient referred asthenia, tachycardia, increasing dyspnea for mild efforts and palpitations. Within few days clinical conditions rapidly worsened and the patient was admitted to the emergency room for cardiogenic shock (heart rate 150 beats per minute, blood pressure 70/50 mmHg, severe oliguria, pulmonary congestion, NYHA 4, AHA D). An angio-CT scan excluded a pulmonary thromboembolism and the patient was admitted to a cardiac intensive care unit where an echocardiogram revealed a severe global biventricular dilatation and dysfunction (LVEF about 15%). Despite a maximal supportive therapy with inotropic agents and diuretics, shock persisted. Therefore an intraortic balloon pump was implanted with a very slow but progressive hemodynamic improvement and a resumption of diuresis. In absence of previous clinical experiences or data from the literature describing of similar serious clinical presentation using trastuzumab alone (without current or previous history of anthracyclines exposure), a myocardium biopsy was performed finding inflammatory areas of uncertain etiology but not compatible with a myocarditis. After approximately two months of hospitalization the patient was progressively weaned by inotropic agents and infusional diuretic therapy, and a heart failure pharmacological treatment was orally introduced (bisoprolol 2,5 mg, enalapril 2,5 mg, ivabradine 15 mg, canreonate 50 mg, furosemide 100 mg). After four months and with a slow pharmacological up-titration, we observed a progressive clinical improvement and an increase and stabilization of biventricular function (LVEF 45% on September 2011). In May 2012, a PET-CT scan showed lymph-nodal, liver and skeletal disease progression, at which point a second line chemotherapy with vinorelbine (25 mg/sqm, days 1,8) was initiated. In July 2012, after two cycles of chemotherapy, a further tumor assessment documented visceral disease progression. Therefore, with awareness of the high risk due to recent severe cardiogenic shock and after discussion with the patient and her family, we decided to resume trastuzumab therapy along with cardiac therapy. Weekly trastuzumab (2 mg/kg) was resumed with a clinical and echocardiographic cardiac monitoring. Soon thereafter, radiological evaluations (PET-CT scan and total body CT scan) showed a partial response of visceral disease. Trastuzumab and vinorelbine therapy was continued until June 2013 when, considering the positive response and the appearance of grade 2 neuropathy, vinorelbine was interrupted and trastuzumab was continued every 21 days (6 mg/Kg) until April 2014 with no further signs or symptoms of heart failure. External beam radiotherapy on left ileo-pubic branch (March 2012, 30 Gy) and on the second cervical vertebra (January 2013, 2000 cGy for 5 fractions) were performed for palliative purpose. Zoledronic acid every 28 days was continued during the whole period. Serial echocardiograms performed during trastuzumab treatment did not reveal LVEF drop maintaining in the range of 50–55%.
+In January 2014 the patient presented diplopia, left eye squint, postural instability and leg weakness. A CT scan and MRI (February 2014) revealed the presence of four cerebral and cerebellar lesions (right cerebellar tonsil, left frontal and parietal lobe, quadrigeminal plate). The patient underwent stereotactic gamma-knife radiosurgery on February 2014 followed by whole brain irradiation for suspected leptomeningeal involvement (3000 cGy for 12 fractions). In April 2014 trastuzumab was interrupted and a new line of chemotherapy with capecitabine 3000 mg/day (1–14 every 21 days) associated with tyrosine kinase inhibitor (TKI) lapatinib 250 mg 4 tb/day was started. Subsequent radiological assessment (August 2015) documented a complete remission of lymph-nodal and liver neoplastic disease and radiologic stability of bone metastases.
+In November 2014 the patient was hospitalized for acute renal failure secondary to dehydration, fainting and recurrent vomiting. After discharge, she complained of severe asthenia, anorexia and weight loss. Consequently, chemotherapy with capecitabine was suspended and lapatinib was continued as monotherapy for about a year during which she never reported cough, dyspnea, chest pain and other symptoms suggestive of heart failure (NYHA II, AHA C). In November 2015, echocardiographic examination showed no relevant changes compared to the previous ones. We found an interesting pattern of LVEF trend along with trastuzumab treatment – discontinuation – and resumption .
+Over the following three months, the patient experienced a rapid deterioration of general clinical conditions, with progressive and definitive bedrest and altered conscience, suggesting a meningeal disease progression. In January 2016, the last ultrasound examination showed a progressive liver disease. The patient died on February 24, 2016 from neoplastic disease progression.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_24_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_24_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1f6f962c08f99d50c71e5c891bf65cc6a36f73f9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_24_en.txt
@@ -0,0 +1,4 @@
+A 35-year-old woman was admitted to the hospital with a 10-month history of headache, 6-month history of diplopia, 4-month history of hearing loss, and 1-month history of back pain. No fever, tumors, or exposure history of specific infections were noted. No significant family history of malignancy was found. Neurologic examination revealed normal cognitive performance, limb motor function, reflexes, sensory and cerebellar functions. Difficulty in bilateral eyeball abduction, diplopia, and mild bilateral facial paralysis were noted. There was hearing loss in both ears by gross hearing assessment. Signs of meningeal irritation, including Brudzinski and Kernig signs, were positive, and nuchal rigidity was present.
+Cerebrospinal fluid (CSF) pressure was significantly elevated, with a slight increase in leukocytes that mostly comprised mononuclear cells and decreased glucose concentration. No pathogenic microorganisms were found by next-generation sequencing. Enhanced brain magnetic resonance imaging (MRI) showed an abnormal signal on the ventral side of the pons and enhancement . Enhancement was also observed in the thickened dura of the upper cervical spinal cord . MRI of the thoracic and lumbar spinal cord showed thickening and enhanced spinal pia mater signals at the thoracic 1–12 and lumbar 1–2 levels.
+Considering the possibility of meningeal carcinomatosis, an examination of CSF was conducted , in which small clusters of atypical nuclei were noted, which were suspected to be tumor cells. Further immunohistochemical special staining results were CK (-), CK7( +), ki-67(-), and AB/PAS ( +), suggesting that the origin of the tumor cells might be the epithelium. No tumors were found on systemic positron emission tomography-computed tomography (PET–CT). No cutaneous melanocytic nevi were found in a careful examination of the patient’s skin. Histological examination of the subarachnoid meninx of the thoracic spinal canal in thoracic 6 level was performed. The specimen showed a cystic lesion covered by simple and pseudostratified, ciliated columnar epithelium, which was rich in mucin-producing cells highlighted by Alcian blue staining. Malignant characteristics were observed in some areas, including increased cellular density and pleomorphism with hyperchromatic nuclei. Immunostaining showed that the cells were positive for epithelial membrane antigen, cytokeratin, and carcinoembryonic antigen but negative for glial fibrillary acidic protein (GFAP), thyroid transcription factor (TTF)-1, and cancer antigen (CA)125. An increased proliferation labeling index (MIB-1, Ki-67) was observed in the areas of malignant transformation (about 20% of nuclei). A diagnosis of the neurenteric cyst with focal malignant features was considered. Malignant Rathke's cleft cyst was considered as a differential diagnosis; however, there was no granulomatous change or squamous metaplasia in the patient. Malignant endolymphatic sac tumor was also considered as a differential diagnosis; however, no petrous bone abnormalities were noted.
+The patient refused radiation treatment and intrathecal or systematic chemotherapy and selected palliative treatment with ventricular abdominal drainage. After the ventricular abdominal drainage surgery, the headache was alleviated, but other symptoms still persisted. Until we submitted the case report, she was bedridden and in an extremely weakened state.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_250_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_250_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9ca38bd35a3e39265be4c29c96226b2ca1e48e11
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_250_en.txt
@@ -0,0 +1,9 @@
+A 43-year-old woman, 156 cm in height and 69 kg in weight, who was employed as a cashier in a bakery, was admitted to the department of pain medicine for pain in both of her legs.
+The pain had persisted for 3 d, with substantial movement restriction. The patient denied any history of trauma or vaccine injection. She had initially undergone an ultrasound examination of her lower limbs, which had ruled out arteriovenous thrombosis. Despite receiving therapy comprising non-steroidal anti-inflammatory drugs and rest, under the assumption that her pain was caused by muscle strain, the pain and swelling increased and the patient developed a fever and chills.
+The patient had no history of diabetes.
+The patient did not report having experienced any injury or trauma, and had no recent history of infection, foreign travel, or immunosuppression.
+We admitted the patient to investigate the etiology of her fever and pain. Upon physical examination her temperature was 39.1°C, pulse rate was 90 beats/min, and blood pressure was 100/65 mmHg. Her visual analog scale score was 8 cm. No wounds or breaks in the skin were noted on her lower extremities. She had tenderness in both her thighs and left knee joint, as well as in her bilateral gluteus media and small gluteus muscles. Both of the patient’s thighs were swollen and had a sensation of warmth, although no erythema, ecchymosis, or fluctuance were noted in these areas. Respiratory, neurological, and cardiovascular examination results were all normal.
+A hematological examination conducted upon the patient’s admission to hospital revealed leukocytosis [white blood cell (WBC) = 19.67 × 109/L] and neutrophilia (neutrophils = 17.92 × 109/L; 91.1%). Her hemoglobin concentration was 83 g/L, C-reactive protein (CRP) concentration was 192 mg/L (normal value: < 7 mg/L), erythrocyte sedimentation rate (ESR) was 96 mm/h (normal value: < 20 mm/h), and her creatine kinase concentration was 306 IU/L (normal value = 24–170 IU/L). Routine urine and stool cultures, liver and kidney function, electrolyte levels, and myocardial enzyme profile were all within the normal range. Tests for autoantibodies associated with rheumatic diseases were negative.
+Plain radiographs revealed no bony abnormalities of the knee joint. A lower limb venous ultrasonography excluded phlebothrombosis. A computed tomography (CT) scan of the thorax, abdomen, and pelvis revealed no abnormalities. As we suspected that the patient might have pyomyositis, magnetic resonance imaging (MRI) was performed, which revealed widespread infiltrative edema within the vastus lateralis muscle, indicative of myositis with a possible abscess. We observed no signs or symptoms of knee joint effusion, osteomyelitis, or infiltration.
+After obtaining blood cultures, we started the patient on empirical antibiotic therapy with ceftriaxone. She remained febrile during her first 3 d of hospitalization, and after 4 d of antibiotic treatment her temperature decreased to normal levels. Blood cultures taken upon presentation revealed no growth after 3 d. Subsequent laboratory tests revealed improvements in leukocyte (11.31 × 109/L) and neutrophil (9.06 × 109/L) concentrations.
+Because we suspected that the patient might have pyomyositis and as 7 d of antibiotic treatment alone did not significantly relieve the swelling or pain in her legs, a repeat MRI of the thighs and hip joint was performed with enhanced contrast. This revealed multiple pockets of pus in the vastus lateralis and gluteal muscles . We performed needle aspiration of these abscesses with ultrasound guidance and local anesthesia, draining about 40 mL (30 mL from the left leg and 10 mL from the right) of purulent material. The purulent content was sent for culturing. The patient’s condition improved after aspiration. Physical examination revealed a reduction in muscle tenderness and localized indurations. A follow-up ultrasound done 3 d after aspiration revealed the accumulation of residual fluid measuring 1.5 cm × 1.2 cm. The patient declined a second round of aspiration. Staphylococcus aureus was observed in the aspiration culture.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2512_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2512_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c0ff654551d4cc618ab8da626dca0a1d24ece5c3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2512_en.txt
@@ -0,0 +1,6 @@
+Written informed consent was obtained from the patient for the presentation and publication of this case report.
+A 40-year-old, 56-kg Korean woman (gravida 4, para 2) was scheduled for an emergency cesarean section at 35 weeks and 3 days of gestation for preterm labor. Her medical history included one abortion and two prior cesarean sections for placenta previa.
+In the preoperative laboratory tests, her hemoglobin (Hb) was 11.4 g/dl and platelet count was 247,000/μl. Other laboratory findings, including coagulation tests, were within the normal range. On her ultrasound examination, the placenta was suggestive of placenta previa totalis, with possible placenta accreta .
+In the operating room, spinal anesthesia was performed at the L3–4 intervertebral space of the patient. After confirming the spontaneous flow of cerebrospinal fluid, 10 mg of 0.5% heavy bupivacaine and 10 μg of fentanyl were intrathecally injected using a 27-gauge (G) needle. The maximum sensory blockade level of anesthesia was T4. To prepare for arterial blood pressure monitoring, a 22 G angiocatheter was inserted into the right radial artery. Two 18 G intravenous lines were secured in both arms.
+Three minutes after starting the operation, a female baby (2,590 g) was delivered with Apgar scores of 7 and 8 at 1 and 5 min, respectively. After the baby was delivered, the patient’s blood pressure suddenly decreased to about 60/40 mmHg and her heart rate was 70 beats/min. Massive bleeding was found in the surgical field. Her Hb level was 6.8 mg/dl at that time. The surgeon diagnosed the degree of placental adhesion as percreta, which had invaded the bladder and surrounding tissues. The bleeding was so extensive that the surgeon decided to perform a hysterectomy. Because of profound hypotension with a reduction in consciousness, the anesthetic method was changed to general anesthesia. Tracheal intubation was performed to secure the airway with rapid sequence intubation. An additional intravenous line was secured at the right external jugular vein, and rapid volume infusions and transfusions were performed using a rapid blood infuser (FMS 2000® fluid management system, Belmont Instrument Corp., USA). Despite attempts to ligate the uterine arteries, bleeding obscured the surgical field and resulted in further hemodynamic instability. The surgeon wished to perform a uterine artery embolization for bleeding control but it was difficult to maintain stability of the vital signs while transferring the patient to the intervention room. We, therefore, decided to implement a REBOA in the operation room to prevent hypovolemic shock. The acute care surgeon accessed the left femoral artery for the REBOA using a 7-French sheath (standard kit, Terumo, Vietnam) and inserted a balloon catheter (occlusion balloon catheter, Tokai Medical Products, Inc., Japan). After measuring the distance to the navel, 25 cm in this patient, they slid the balloon tip up to 25 cm from the punctured site and placed the balloon approximately between the infrarenal aorta and the bifurcation of the aorta. It was difficult to obtain radiologic confirmation of the balloon position because of the patient’s unstable vital signs. After balloon occlusion was accomplished, the systolic blood pressure immediately improved from 65 mmHg to 100 mmHg and the surgical field also improved . REBOA was intermittently performed during the surgery and the balloon was sometimes partially deflated to identify the focus of the bleeding. During complete and partial inflation, ligation of both the uterine artery and internal iliac artery were performed. And the bleeding control was in progress by removing surrounding tissues where the placenta was invaded. The total duration of the occlusion was 75 min (divided over several occlusion times). The total operative time was 263 min and the total anesthesia time was 290 min. The estimated amount of blood volume lost was over 20,000 ml. Massive transfusions, including 36 units of packed red blood cells, 26 units of fresh-frozen plasma, and 10 units of platelets were administered.
+Upon admission to the intensive care unit after embolization of the branch of the internal iliac artery, the patient was hemodynamically stable without any inotropes or vasopressors. No further transfusions were performed after surgery. The patient’s Hb was 12.2 g/dl, platelets were 89,000/μl, and prothrombin time (PT, international normalized ratio) and activated partial thromboplastin time (aPTT) were 13.9 s (1.23) and 39.1 s, respectively. The patient was extubated the same day and the femoral artery sheath was removed the next day. At postoperative day two, she was transferred to the ward and subsequently discharged on day 15 without complications. Neither the mother nor the baby experienced any complications after discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2513_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2513_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ad51fe8faf57a696a0a93f3ca30b484ddee344d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2513_en.txt
@@ -0,0 +1 @@
+A 36-year-old male, right-handed, with no prior medical history, sustained a road traffic accident as a pedestrian struck by a vehicle. He was injured on the right side of his body. He was admitted immediately to our hospital. Upon arrival, he was conscious and hemodynamically stable. Clinical examination showed a visible deformity of his right arm with diffuse traumatic ecchymosis. There was pain, tenderness and an open wound over anterior aspect of the right shoulder measuring 5 cm with moderate soft tissue injury corresponding to grade II of the Gustilo classification. There was no distal neurovascular deficit. Radiographs indicated an anterior dislocation of the shoulder with ipsilateral transverse fracture of the middle third of the shaft humerus . Thus, the patient was urgently carried to the operating theatre. Under general anesthesia closed reduction of the shoulder dislocation was performed manually without difficulty. Then, the humeral shaft fracture was stabilized using Hackethal's bundle nailing after debridement of the wound . The right limb was immobilized in a plaster slab. The next day, the patient developed severe pain and swelling in the right arm and forearm, associated with paresthesia and loss of sensation in the hand. He was unable to flex all fingers. Furthermore, radial and ulnar pulses were present but weak. Therefore, the diagnosis of compartment syndrome was clinically obvious without measuring compartment pressures. The patient was returned to the operating room for decompression. Indeed, we performed a lazy S fasciotomy of the anterior aspect of the forearm and arm. The superficial fascia was released and the deep fascia was opened . Postoperatively, there was no drainage system and the limb was immobilized with a plaster splint. The pain was relieved after the fasciotomy, the neurologic functions were recovered, and the swelling was subsided. Whereas, the primary closure of the wounds was impossible after repeat surgical debridement with removal of devitalized tissues. Hence, skin grafting was performed on 10th day . The upper limb was immobilized for 3 weeks while the wound healed. A passive rehabilitation was undertaken. At 4-month follow-up, the bundle nailing was removed and radiographs revealed good fracture union. At the latest follow-up of 10 months, he had a useful range of motion compared with the contralateral limb with a slight restriction in elbow flexion. Additionally, the Constant score was approximately 80/100 and the patient had returned to normal activities.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2517_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2517_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8af897a6042e396e1051e64d4c42364fa2fe6ec7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2517_en.txt
@@ -0,0 +1,6 @@
+A 68-year-old Caucasian man with glaucoma who was receiving chronic therapy was referred to our institution with a diagnosis of post-operative endophthalmitis in the left eye. The patient had inflammation in the left eye that had started a few days earlier and was associated with impaired vision. Two weeks before presentation he had undergone cataract surgery combined with a glaucoma shunt implant at another eye clinic.
+Upon presentation, he had a corrected distance visual acuity (CDVA) of 20/80 in the right eye, a cortical and nuclear cataract and filtering bleb that had developed after previous glaucoma surgery. Upon presentation, he had a corrected distance visual acuity (CDVA) of 20/80 in the right eye, a filtering bleb and a cortical and nuclear cataract developed after the previous glaucoma surgery performed two years earlier.
+A glaucomatous optic disc excavation was present and the visual field was significantly narrowed in the inferior nasal area. He was receiving therapy with bimatoprost eyedrops in this eye.
+His CDVA in the left eye was 1/200, and he showed marked conjunctival injection, corneal edema, inflammatory aqueous cells (Tyndall 3+) and fibrin on the front face of the intra-ocular lens (IOL). The glaucoma shunt implant (EX-PRESS® Glaucoma Filtration Device; Alcon Laboratories, Fort Worth, TX, USA) was in site with a non-inflamed filtering bleb. There was dense vitritis, and it was impossible to visualize the retina and the optic disc. A 25-gauge pars plana vitrectomy (PPV) was performed using a CONSTELLATION® vitrectomy system (Alcon Surgical, Tokyo, Japan), and infusion fluid (BSS PLUS®; Alcon Surgical) was devoid of any antibiotics. At a site 4.0mm from and parallel to the limbus, three trocars were inserted at a 30° angle (one in the inferonasal area for the infusion), creating tunnel sclerotomies. Initially, a vitreous sample (with the infusion channel closed) was collected using the vitrectome, then the remaining vitrectomy with hyaloid removal was completed. The vitreous cavity was filled with silicone oil, and ceftazidime and vancomycin were injected intravitreally. All the sclerotomies were sutured because of the risk of leakage.
+During surgery, the retina appeared to be covered by an abundant fibrinous exudation. After surgery, the patient’s CDVA was 1/30, and therapy with topical vancomycin (50mg/ml) and ceftazidime (50mg/ml) eyedrops six times per day was started. The IOL and the glaucoma valve were left in place because the patient strongly expressed this desire, given the low visual acuity of the other eye. Cultures taken from the aqueous and vitreous were negative, and his early post-operative course was uneventful and without signs of significant inflammation, except for a thin layer of fibrin on the front face of the IOL. He was discharged some five days after surgery, and he continued the therapy at home and returned for scheduled checks. During these checks, his CDVA was 1/20 and there were no signs of inflammation in the anterior chamber; however, the retina could not be easily evaluated, owing to fibrin plaque on the surface of the IOL.Forty-five days after this surgery, he experienced acute, increasing pain in the left eye with severe inflammation, corneal edema, anterior chamber inflammation (Tyndall 4+) and hypopyon occupying three-fourths of the anterior chamber . He underwent a new anterior chamber washout with aqueous sample and a vitrectomy with silicone oil tamponade.
+Two days after his second surgery, an increase of intra-ocular pressure was observed (treated with topical and systemic therapy) associated with the formation of a thick white plaque on the anterior surface of the IOL that prevented observation of the retina and the optic disc. His CDVA at this time was 1/200. Systemic therapy with fluconazole (400mg/day) and amphotericin B 0.15% eyedrops (six times per day) was started, which led to progressive reduction of the exudation in the anterior chamber. One week later, Acremonium falciforme species were identified in cultures obtained from samples, and the systemic therapy was switched to intravenous voriconazole 6mg/kg every 12 hours for the first day, then 4mg/kg intravenously every 12 hours for 10 days, followed by 200mg orally every 12 hours. This therapy led to a further reduction of the exudation in the anterior chamber. After seven days, it was possible to evaluate the red reflex of the retina, which revealed a slight improvement of CDVA to 1/60.Ten days later, the patient presented with liver function test impairment and sharp pain in the left orbital region that radiated to the same side of the head due to extension of the inflammatory process to the orbit and peri-orbital tissue. A magnetic resonance imaging (MRI) scan showed that there was evidence of left orbital inflammation with inhomogeneous appearance of the eyeball and peri-bulbar inflammation, which was more evident at the lacrimal gland . A faint hyperintensity of the optic nerve in T2 and slight signs of inflammation at the apex of the left orbital cavity were reported . At this time, therapy with systemic diclofenac and oral prednisone (25mg twice daily for two weeks) was started, which led to significant pain reduction. The condition of the left eye showed a gradual further improvement, but it was necessary to stop the systemic antifungal therapy after 22 days because of liver toxicity. The topical drugs were continued unchanged. One month later, unremitting pain in the orbital region reappeared; therefore, systemic antifungal therapy (voriconazole 6mg/kg intravenously every 12 hours for the first day, then 4mg/kg intravenously every 12 hours for 10 days, followed by 200mg orally every 12 hours) combined with pain therapy (acetaminophen 500mg/, codeine 30mg/day and gabapentin 300mg/day) was restarted, which led to progressive reduction of the patient’s ocular and peri-orbital pain.Immediately after this therapy, the patient showed significant ingravescent neurologic symptoms with visual hallucinations, postural instability, slight ideomotor slowdown, retropulsion and dynamic ataxia. Brain MRI excluded vascular lesions, but this examination highlighted enhancement of the left temporal muscle associated with ectasia of contiguous vessels, it was an evident index of inflammation . His electroencephalography results were normal, and lumbar puncture was performed to exclude infectious processes of the brain. Cerebrospinal fluid was clear, but showed albumin cytological dissociation. Once infectious or inflammatory processes were excluded, the cause of neurological symptoms was attributed to a toxic effect induced by the recently introduced analgesic therapy. After one week, we observed an improvement in neurologic symptomatology, but it was indispensable to maintain therapy with paracetamol, codeine and gabapentin. During this period, while the patient’s left eye began to show signs of phthisis, CDVA in his right eye decreased to 20/100 due to worsening of the cataract that was associated with progressive impairment of the optic nerve.After three months, voriconazole was suspended because of an increase in the cholestasis and hepatic cytolysis indices, but topical therapy was maintained for nine months. During this period, the patient was observed with close follow-up. He had no more signs of ocular inflammation; however, the white plaque on the anterior surface of the IOL did not disappear , and his pain was controlled with decreasing doses of analgesic oral therapy. The left eye’s condition deteriorated slowly into phthisis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2529_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2529_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..33f6284fbec0f663a0237e02744bbcc7381be82b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2529_en.txt
@@ -0,0 +1,3 @@
+A 13-year-old and 6-month-old girl was brought to our attention because she was hospitalized twice in our hospital . The first complaint was “fever and vomiting for 2 days with abnormal mental behavior for 1 day”. The fever peaked at 39.2℃. 1 day earlier, she suddenly babbled, had disorientation of persons and places, was markedly irritable, and alternated with delirium indifference. Cerebrospinal fluid routine, biochemical, pressure, virus, and culture were negative. Cranial MRI suggested multiple punctate abnormal signal shadows in the white matter of the frontoparietal brain on both sides, considering the possibility of intracranial infectious lesions, diagnosed as “viral encephalitis”. After 10 days of treatment with acyclovir antiviral, dexamethasone anti-inflammatory, supplemented with mannitol dehydration to lower cranial pressure, the above symptoms soon disappeared. However, a review of liver function showed that alanine aminotransferase (ALT436U/L; reference range 5 ~ 40U/L) and aspartate aminotransferase (AST96.7 U/L; reference range 5 ~ 40 U/L) indicators were elevated, suggesting liver function impairment, and liver ultrasound indicated liver enlargement, so acyclovir was discontinued and liver-protective treatment was given, while hepatitis virus was perfected and blood ammonia was sent. However, because the blood ammonia needed to be sent for out-of-hospital testing at that time, which was a cumbersome process, and because the parents believed that the child’s liver function and condition had improved significantly, they temporarily refused. After 1 week of hepatoprotective treatment, liver function and head MRI were normal, so the child was discharged on oral hepatoprotective medication. More than two years later, the child was readmitted with “vomiting for 1 week and headache with poor mental response for 3 days”, after having been treated for 1 week at an external hospital for a proposed diagnosis of “viral encephalitis” with poor results, and was then referred to our hospital. History taken: The patient was G2P1, with no abnormalities recorded during birth. Her parents were healthy and non-consanguineous Chinese, but her mother had an unexplained miscarriage at 28 weeks of gestation in G1. The patient showed appropriate growth and normal psychomotor milestones, but with academic failure. Physical examination: drowsiness, poor mental status, normal development, non-specific cardiopulmonary and abdominal examination, negative neurological examination. The blood ammonia concentration was 287umom/L and hyperammonemia was considered at the moment. The EEG suggested a slow background, but the cerebrospinal fluid examination was not abnormal. In combination with an abdominal CT suggesting a slightly hypodense liver and brain MRI findings: abnormal nodal signal in the white matter of the brain , genetic metabolic disease was considered. Further refinement of the blood genetic metabolic screening showed elevated blood alanine (757.06umol/L; reference range 148.8 ~ 739.74µmol/L) and decreased blood citrulline (4.26umol/L; reference range 5.45 ~ 36.77umol/L). Urine organic acid gas mass spectrometry showed normal whey acids and urea, suggesting impaired urea cycling. Immediately after admission, the child was given a low protein diet, arginine to promote ammonia excretion (100 ~ 200 mg/(kg-d)), coenzyme Q10 (10 ~ 20 mg/(kg-d)) and levocarnitine (30 ~ 200 mg/(kg-d)) to regulate metabolism, lactulose to improve ammonia metabolism, vitamin B complex to promote nerve repair, and intravenous fluids to The child was given intravenous fluids to promote urinary ammonia excretion. After 1 week of treatment, the child’s headache and vomiting resolved significantly and she was discharged with instructions to follow a strict low-protein diet and to recheck her blood ammonia regularly. During hospitalization to clarify the type of urea cycle disorder, further refinement of whole exome sequencing after seeking parental consent identified compound heterozygous mutations in CPS1 (NM_001875), a missense mutation (c.1145 C > T, p. Pro382Leu) and an unreported de novo non-frame shift mutation (c.4080_c.4091delAGGCATCCTGAT, p.Lys1360_I le1364delinsLys), respectively.
+CPS1 is localized on chromosome 2q34 and contains 43 exons spanning over 120 kb and encoding 1500 amino acids . We performed mutation screening using high-throughput sequencing technology, and all detected CPS1 mutations were lineage verified by Sanger sequencing, aligned with the human genome (GRCh37 / hg19) reference sequence provided by the UCSC database, and compared with the currently known human CPS1 sequence (National Center for Biotechnology Information, transcript number NM_001875). The database of mutant loci and single nucleotide polymorphisms (dbSNP) , the Human Gene Mutation Database (HGMD) and the Millennium Genome Database for comparative annotation. Finally, two compound heterozygous mutations were found in CPS1 of this child, the missense mutation c.1145 C > T (p.Pro382Leu) (NM_001875) and the non-frame shift mutation c.4080_c.4091delAGGCATCCTGAT (p.Lys1360_Ile1364delinsLys) (NM_001875), where c.1145 C > T is a reported pathogenic mutation in CPS1D , while the non-shifted mutation c.4080_c.4091delAGGCATCCTGAT is found in OMIM, UCSC, HGMD, dbSNP, 1000 Genome, ExAC and gnomAD publications and public databases are new and not reported. The missense mutation c.1145 C > T results in an amino acid change from the non-polar amino acid proline (P) to the non-polar amino acid leucine (L), and the non-shift mutation c.4080_c.4091delAGGCATCCTGAT would result in an amino acid deletion at positions 1361–1364 (isoleucine-leucine-isoleucine-glycine), resulting in a protein length change. The pathogenicity of these two mutant loci was further analyzed using various prediction tools (SIFT, Polyphen2_HDIV, PROVEAN, MutationTaster, M-CAP, REVEL, GERP, phyloP20way, phastCons20way), Fig. A shows the pathogenicity using Mutation Taster for the pathogenicity prediction. Two variants were classified as “possibly pathogenic” according to the variant classification criteria of the American College of Medical Genetics and Genomics (ACMG 2015), and these variants were verified by Sanger sequencing in a family with a mother carrying the c. 4080_c.4091delAGGCATCCTGAT heterozygous mutation and a father with the c.1145 C > T heterozygous mutation , but without clinical manifestations, were consistent with an autosomal recessive disease pathogenesis pattern. Protein structure maps were generated using Swiss-pdb Viewer 4.10.The CPS1 protein structure of the missense mutation c.1145 C > T is shown in Fig. , and the CPS1 protein structure of the non-frame shift mutation c.4080_c.4091delAGGCATCCTGAT is shown in Fig. , with a theoretical 25% risk of disease in either fetus at the time of parental birth.
+Although the child complied with a low protein diet for a short time after discharge and had regular blood ammonia checks, due to poor compliance, he was rushed to our PICU more than 8 months after his second discharge due to vomiting and coma after a large high-protein diet (hot pot), and in combination with the cause of this onset and the underlying disease of CPS1D, the emergency blood ammonia was 301 µmol/L (reference range 11.2 ~ 48.2umol/L). As the child was in a critical condition and in a coma, he was immediately given haemodialysis 7 times (1 time/day), fluid infusion, arginine and sodium benzoate to promote ammonia excretion, levocarnitine to promote metabolism, lactulose to reduce ammonia build-up in the intestine and B vitamins, as well as a ban on oral feeding and low amino acid intravenous nutrition. The child’s consciousness turned clear on the 7th day of treatment, the blood ammonia completely decreased to normal on the 43rd day, and he was discharged from the hospital on the 46th day. No hospital admissions for hyperammonemia at follow-up to date.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2530_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2530_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a3ce75d2bd9c6d22294025a131605a22f6bac1bb
--- /dev/null
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+A 78-year-old male was admitted to our hospital with sudden onset headache and left-sided motor weakness. He was a well-educated retired engineer with a medical history of hypertension. A neurological examination revealed left-side homonymous hemianopia and motor weakness with the modified medical research council scale 2. There was a mild sensory impairment to light touch, pain, and temperature on the left face, arm, leg, and trunk. The proprioception was impaired in his left toe and finger. Tactile and auditory extinction were absent. Computed tomography (CT) of the patient’s brain showed a hemorrhage of the right basal ganglia extending medially to the thalamus and laterally to the external capsule with an approximate volume of 50 cm3 . Considering his past medical history and the anatomical location of the hemorrhage, we diagnosed the hypertensive basal ganglia hemorrhage and treated him with anti-hypertensive medications.
+On the second day of hospitalization, the patient started to report the phantom arm. Beside his left paretic arm, he felt another arm protruding from his left shoulder. He could not see or touch this phantom arm, but he felt it very vividly. He reported that the phantom arm resembled his paretic arm in size and shape . The phantom arm was not triggered by any specific condition; rather, it was persistently perceived. Closing his eyes or looking at his real arm did not influenced this false perception. Examination revealed that he could intentionally move his phantom arm. He stated that the movement was independent of his paretic arm and the strength was the same as his unaffected right arm. He could wave, grip or touch objects with his phantom hand. However, when we asked him to hold a ball with his phantom hand, he felt like the ball kept slipping out of his hands. Also, when we asked him to pretend using chopsticks with his phantom hand, he stated that it was clumsy because he was using the non-dominant hand. He also could not reach an object that was located far away from him with his phantom arm. He did not experience any involuntary movements of the phantom arm. When we put the glove on his paretic hand, we stated that he was wearing a globe on his paretic hand but not on his phantom hand. Passive movement of his paretic arm did not elicit any movement in the phantom arm. He did not complain of any pain or sensory discomfort in either the paretic arm or the phantom arm.
+He was alert and oriented to time, place, and person with the Mini-Mental State Examination score of 30/30. He knew that having three arms is not normal and insisted that the phantom arm was not real. He showed no sign of seizure, and the electroencephalography showed that he had normal brain activity. A follow-up neurological examination revealed no deterioration, and brain CT showed no significant changes in the hemorrhage.
+We diagnosed the SPL as a complication of the right basal ganglia hemorrhage. His phantom arm persisted for 3 weeks, and it gradually faded away.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2531_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2531_en.txt
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index 0000000000000000000000000000000000000000..1d622440c9c27c84bbe2d1fc7274096dfbb33aa6
--- /dev/null
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+A 72-year-old Japanese woman with a 10-year history of T2DM had symptoms of diarrhea and persistent pain in left lower abdomen for 2 days and visited the emergency room in Kawasaki Medical School. She had an approximately 10-year history of hypertension and dyslipidemia. At that time, she was taking 4 mg/day of benidipine hydrochloride and 20 mg/day of azilsartan for the treatment of hypertension, and 25 mg/day of alogliptin and 500 mg/day of metformin for T2DM, and 2.5 mg/day of rosuvastatin for dyslipidemia. She had no remarkable family history. She was a housewife and she did not smoke tobacco or drink alcohol. She had no past history of digestive disease or obstetrics and gynecology disease. She had mild tenderness to palpation in her abdomen. Her height and body weight were 150.0 cm and 69.5 kg, respectively. Her vital signs were as follows: blood pressure 150/87 mmHg, heart rate 110 beats/minute, and temperature 36.4 °C. Inflammation markers were markedly elevated: white blood cell (WBC), 20,110/μL (neutrophil, 89.0%); C-reactive protein (CRP), 16.12 mg/dL. Anemia and mild hypoalbuminemia were observed although their causes remained unknown: red blood cell, 304 × 104/μL; hemoglobin (Hb), 9.3 g/dL; total protein (TP), 6.8 g/dL; and albumin (Alb), 3.2 g/dL. Her liver and renal function were within normal range as follows: aspartate aminotransferase (AST), 14 U/L; alanine aminotransferase (ALT), 9 U/L; gamma-glutamyl transpeptidase (γ-GTP), 8 U/L; lactate dehydrogenase (LDH), 202 U/L; creatinine (Cre), 0.81 mg/dL; blood urea nitrogen (BUN), 7 mg/dL; Na, 134 mEq/L; K, 3.8 mEq/L; Cl, 99 mEq/L; Cre clearance, 66.9 mL/minute; and urinary Alb, 15.1 mg/g·Cr. As shown in Fig. , her abdominal computed tomography (CT) on admission revealed a large tumor with calcification in left side of intrapelvis (upper middle panel) which was not observed in abdominal CT 1 year before (upper left panel). She had abdominal CT 1 year before by a urologist because bladder diverticulum was suspected at an annual medical checkup with abdominal ultrasonography. The tumor size was as large as 65 mm in diameter. In addition, as shown in Fig. , MRI showed a large tumor in left side of intrapelvis at the same lesion site observed in CT. An axial T1-weighted (T1W) image through the pelvis showed a markedly dilated fallopian tube posterior to the left ovary (upper left panel). Axial T2-weighted (T2W) image showed a slightly higher intensity (upper right panel). Axial diffusion-weighted (DW) image and contrast-enhanced T1W image showed a high intensity lesion at the same place (lower left and right panels). Based on these findings, we finally diagnosed her as having pyosalpinx.
+On admission, she had symptoms of diarrhea and persistent pain in left lower abdomen, but there were no findings in physical and neurological examinations. Her glycemic control was relatively good: HbA1c, 6.6%; glycoalbumin, 23.6%. In addition, her HbA1c levels were around 6% for over 1 year with the medication (metformin 500 mg, alogliptin 25 mg). However, during the acute phase of infection, we treated her with intensive insulin therapy using insulin aspart and insulin glargine. Tumor makers were within normal range: carcinoembryonic antigen (CEA), < 1.0 ng/mL; cancer antigen (CA) 19-9, 6.0 U/mL; and CA-125, 11.0 U/mL. Pathogenic bacteria were not detected. Her Treponema pallidum hemagglutination (TPHA) was positive but rapid plasma reagin (RPR) for Treponema pallidum was negative. Candida antigen and β-D-glucan were negative. Neisseria gonorrhoeae deoxyribonucleic acid (DNA) and Chlamydia trachomatis DNA in the urine were negative. Although pathogenic bacteria were not detected, we started antibiotics therapy for pyosalpinx (13.5 g/day of tazobactam/piperacillin and 500 mg/day of levofloxacin) . We discussed the necessity of surgery such as laparoscopy with gynecologists, but finally we selected antibiotics therapy without laparoscopy because her symptoms and laboratory data were very much improved. Her laboratory data 14 days after starting the antibiotics were improved and became within normal range (WBC, 5500/μL (neutrophil 47.4%); CRP, 0.04 mg/dl); we stopped antibiotics . Laboratory data were within normal range even after stopping antibiotics. T2DM was well controlled with orally administered anti-diabetes drugs (metformin 500 mg, alogliptin 25 mg, and gliclazide 10 mg): HbA1c, 6.0%; glycoalbumin, 16.5%. The tumor gradually reduced in size: 25 days later (upper right panel, Fig. ), 3 months later (lower left panel, Fig. ), and 6 months later (lower middle panel, Fig. ) compared to that on admission (upper middle panel, Fig. ); however, the tumor did not disappear completely even 6 months later. Finally she was discharged without any symptoms and/or problems. After discharge, she had no symptoms and/or problems, and her inflammation markers remained within normal levels for at least 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2540_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2540_en.txt
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index 0000000000000000000000000000000000000000..705ae098fe6778b7e69a30807c8a16516de881ec
--- /dev/null
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+A 23-year-old woman with no relevant past medical or surgical history was referred from a local hospital after complaining of right upper quadrant pain for several weeks. On physical examination, right upper quadrant tenderness was the only abnormal finding during the first visit. Initial laboratory findings were also unremarkable, except for a high level of carbohydrate antigen 19-9 (CA19-9; 20,300 U/ml). Abdominal computed tomography (CT) and magnetic resonance imaging (MRI) revealed focal dilation of the right intrahepatic bile duct and a low contract effect tumor measuring 42 mm in hepatic segments 1 and 8; ICC was suspected . The tumor was attached to the inferior vena cava (IVC) and had invaded the right portal vein (PV) leading to cavernous transformation instead of canonical PV. Positron emission tomography (PET) showed fluorodeoxyglucose (FDG) uptake in the primary liver tumor and para-aortic lymph nodes . We consider the cases those in which surgical resection could not be achieved even by aggressive surgical procedures, including combined vascular resection as unresectable ICCs. On the basis of these findings, the patient was diagnosed with initially unresectable ICC with para-aortic lymph node metastasis and subsequently treated with a combined chemotherapy regimen of gemcitabine (GEM 1000 mg/m2) and cisplatin (CDDP 25 mg/m2). This combination was intravenously administered on days 1 and 8 and was repeated every 3 weeks under a downsizing regimen.
+After eight courses of combination chemotherapy over 5 months, CT, MRI, and PET imaging demonstrated an effective response to chemotherapy. The size of the primary tumor had decreased to 18 mm (55% reduction), and the tumor was no longer attached to the IVC . FDG uptake in the para-aortic lymph nodes almost disappeared , and the level of CA19-9 decreased to 738 U/ml . The effect of downsizing chemotherapy was partial response (PR) in RECIST criteria. The TNM staging of pre- and post-chemotherapy were T3N1M1 stage IVb and T1N0M0 stage I in UICC criteria, respectively. Nevertheless, the PV cavernous transformation did not improve. We thus concluded that this PV cavernous transformation had originated from a congenital anomaly . After discussion with the patient and her family, we decided to perform radical surgical resection to achieve the cure of disease. Right hemihepatectomy and dissection of lymph nodes, including the para-aortic lymph nodes, were performed. During right PV resection, the PV cavernous transformation was preserved to maintain collateral flow through the PV as much as possible . The margins of the right bile duct showed no evidence of malignancy during intraoperative frozen section analysis.
+Microscopic pathological examination showed that R0 (no residual tumor) resection had been successful and that more than 50% of the tumor cells had been replaced with fibrosis (Evans’ criteria IIb) . No viable tumor cells were visible in the para-aortic lymph nodes that showed FDG uptake in the initial PET scan. However, there was slight extracapsular invasion in the para-aortic nerve . According to the pathological findings (well differentiated tubular adenocarcinoma, pT3, pN0, pM1 (OTH, para-aortic nerve)), UICC stage of this patient was defined as stage IVb. The patient suffered from bile duct stricture as a postoperative complication. After re-suture of the stump of the bile duct with enough patency in reoperation, the patient made a satisfactory recovery and was discharged on postoperative day 11. The patient is alive 31 months after the initial treatment (24 months after operation) with a local tumor recurrence.
+In surgical resection for ICC, R0 resection is one of the most favorable prognostic factors [, ]. The prognosis of R1 and R2 (microscopic and macroscopic residual tumor) resection is comparable to the prognosis of patients who do not undergo surgical resection and those who receive only palliative treatment . Furthermore, the number of lymph node metastases is another important prognostic factor in ICC. Patients with more than three lymph nodes metastases have more unfavorable outcomes than patients with one or two lymph node metastases (3-year survival: 0 vs. 50%, respectively) .
+Many patients are diagnosed initially with unresectable tumors due to locally advanced or metastatic disease, silent clinical symptoms, involvement of blood vessels, extension into both hepatic lobes, or rapid disease progression . The optimal treatment for patients with locally advanced unresectable or metastatic disease is yet to be determined. Recently, systemic chemotherapy has contributed to improvements in overall survival. In the UK, a phase III randomized controlled trial demonstrated that the median survival time (MST) of overall survival (OS) with GEM plus CDDP combination therapy was significantly improved compared to that with gemcitabine alone (11.7 vs. 8.3 months, respectively, p < 0.001) . For unresectable BTC, GEM plus CDDP combination therapy is recommended as a standard therapy.
+A previous report looked at the effectiveness of downsizing chemotherapy (distinguished from neoadjuvant chemotherapy) and subsequent so-called “conversion surgery” for initially unresectable BTC . We also recently reported that in 10 of 39 (25.6%) locally advanced unresectable BTC patients, the size of the tumor was reduced by downsizing chemotherapy, and conversion surgery was successfully performed as a result. Additionally, this downsizing chemotherapy and conversion surgery strategy led to longer survival than that with chemotherapy alone (MST: 17.9 months for chemotherapy plus surgical resection vs. 12.4 months for chemotherapy alone) . Although there is a certain bias in patient selection, this could represent a promising treatment for initially unresectable locally advanced BTC.
+The efficacy of neoadjuvant chemotherapy against potentially resectable BTC is uncertain. A previous report indicated that neoadjuvant therapy can improve survival by controlling regional extension . Contrary to this, another report suggested that neoadjuvant chemotherapy decreased the survival rate compared to that on immediate resection . Prospective studies are needed to establish neoadjuvant chemotherapy as a treatment for potentially resectable BTC.
+PV cavernous transformation is the angiographic appearance of numerous collateral vessels around the PV owing to various reasons. These are classified as idiopathic causes (e.g., congenital malformation, or following hepatobiliary surgery) or secondary causes (e.g., liver cirrhosis, thrombosis, tumor) . In this case, there were no hepatofugal collateral pathways caused by splenomegaly, a gastric or esophageal varix, or any hepatopetal collateral pathways. Furthermore, intraoperative findings suggested that the cavernous transformation was due to a congenital etiology, as the obstruction site was distant from the tumor and was soft under palpation. Unfortunately there is no previous CT or portography, however, it is speculated that the etiology of congenital PV cavernous transformation may result from portal vein malformation, or portal thrombosis for omphalitis or pylephlebitis.
+Until October 2016, we experienced 15 cases of surgical resection for initially unresectable BTCs including this case. The periods of downsizing chemotherapy to surgical resection were varied; 22.7 ± 11.1 weeks (mean ± standard deviation). Among all 15 patients, N0 (no lymph node metastasis) was pathologically diagnosed for 9 patients and N1 (positive for lymph node metastasis) for 6 patients, and R0 resection was performed for 12 patients and R1 resection for 3 patients, respectively. According to Kaplan-Meier method, the MST of OS was calculated and log-lank test was used to test for significant differences between N0 and N1 group, and between R0 and R1 group. The MST of OS in N0 group (34.3 months) was significantly longer compared with that in N1 group (12.4 months) (p = 0.031). The MST of OS in R0 group was also significantly longer than that in R1 group (30.9 months for R0 group vs. 4.1 months for R1 group, p = 0.012). Although the number of cases is limited, these results implicated that N0 and R0 resection are important favorable prognostic factors for unresectable BTC patients who have undergone surgery after downsizing chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2544_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2544_en.txt
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index 0000000000000000000000000000000000000000..6a2bf003f150032889c5cc892f10ce1e8ac0cbbb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2544_en.txt
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+A 42-year-old Thai man was referred to the Oral Medicine Clinic, Faculty of Dentistry, Chulalongkorn University, Thailand for the evaluation of ulcers in the mouth. The lesions had been present for more than six months and had been diagnosed as gingivitis.
+His medical history was significant, with a diagnosis of hypertension and diabetes mellitus for a year. He had been treated with atenolol at 50mg per day, for one year and enalapril at 10mg per day for one week. He was on a controlled diet for diabetes mellitus. He did not smoke or drink and his medical history was otherwise unremarkable. Our patient’s extra-oral examination (skin, genitalia, eyes) was unremarkable. An intra-oral examination revealed generalized erythema, desquamation, and multiple large ulcers of the gingival mucosa covered with yellowish slough tissue. We found multiple disrupted bullae on the labial mucosa, buccal mucosa, and ventral surface of the tongue (Figure ). Our patient was experiencing severe pain from these lesions and could not clean his mouth well or perform proper oral hygiene.
+Our patient’s blood test results revealed normal range findings for complete blood count, erythrocyte sedimentation rate, creatinine and liver function tests (aspartate aminotransferase and alanine aminotransferase). Based on our patient’s history and examination findings, the differential diagnosis included allergy induced by chlorhexidine mouthwash, erythema multiforme, or vesiculobullous lesions.
+Our patient was misusing chlorhexidine mouthwash by rinsing his mouth with it for longer than 10 minutes, so at our patient’s first visit, he was asked to stop the use of chlorhexidine mouthwash and was given diphenhydramine elixir mouthwash as a palliative treatment. This change resulted in the relief of pain after one week; however, the oral lesions were unchanged.
+An incisional biopsy was taken from the tissue adjacent to the ulceration on the left buccal mucosa for histopathologic and direct immunofluorescence studies. The histopathological section of the biopsy was stained with hematoxylin and eosin (H&E). H&E staining showed an ulcerated parakeratinized stratified squamous epithelium overlying fibrovascular connective tissue. The underlying connective tissue was edematous, and was infiltrated by acute and chronic inflammatory cells, including neutrophils, eosinophils, plasma cells, and lymphocytes. These features indicated a non-specific subacute inflammation.
+Direct immunofluorescence showed the deposition of IgG, IgA, and C3 in a homogeneous linear pattern at the dermoepidermal junction (Figure A-C). These findings can be associated with bullous pemphigoid, mucous membrane pemphigoid, bullous systemic lupus erythematosus, and epidermolysis bullosa acquisita. Our patient was given prednisolone 20mg every other day, with the dose increasing to a final level of 50mg per day after six weeks, with the lesions slightly improved; we then decided to stop prednisolone at the eighth week.
+From the overall history, clinical presentation, result of direct immunofluorescence and slight response to prednisolone, we suspected a drug-induced condition, which might be caused by our patient’s current medication. Our patient was referred to his physician to discuss changing medications or to stop atenolol treatment altogether. Our patient discontinued atenolol use and was given enalapril at 10mg per day instead. We recommended the use of sodium bicarbonate mouthwash to our patient.
+At one-month follow-up after atenolol cessation, the oral lesions showed a dramatic improvement; however, asymptomatic desquamative lesions of the attached gingiva remained. Our patient continued using sodium bicarbonate mouthwash. At three-month follow-up, all lesions were clear. We continued to follow-up our patient at six months, and one and two years with no recurrence of lesions observed. Figure shows the patient’s oral condition at the two-year follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2571_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2571_en.txt
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index 0000000000000000000000000000000000000000..2b5592819d1643387e2fe0c0e3a393bda55751d4
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+A 55-year-old male, with no past medical history, was referred to our department for lower urinary tract symptoms. The patient has neither pain nor hematuria. Physical examination and blood tests were normal. Cytobacteriological examination of the urine was sterile. A routine renal ultrasound (US) showed a 36 mm cortical mass on the low pole of the left kidney with no dilation or deformation of the renal pelvis calyces. The ureters were normal. Subsequent computed tomography (CT) revealed an exophytic lesion in the lower pole of the left kidney, measuring 36 × 23 × 39 mm, well demarked, with peripheral enhancement, and a central fluid collection . No intratumoral calcification was identified. No invasion of perinephric fat tissues or adjacent structures, such as renal vein or inferior vena cava (IVC) was noted. No metastasis or lymphadenopathy was evident. On magnetic resonance imaging (MRI), the mass was iso intense to the kidney in T1 weighted image and hyper intense with restricted diffusion in T2 weighted image. T2 weighted image also demonstrated a hyper intense peripheral signal associated to an exocentric, heterogenous and irregular hypointense signal in the center of the tumor .
+The diagnosis of renal cell cancer was very likely, the patient underwent an open surgery. It was an 80% exophytic tumor lying on the lower pole of the left kidney, a clampless partial nephrectomy was performed. The postoperative course was uneventful and the patient was discharged on the fourth postoperative day.
+Laboratory examination showed a well circumscribed, white, firm tumor confined to the lower pole which measuring 4 × 4 × 3 cm. There was no macroscopic capsular involvement.
+Microscopic examination showed a well mesenchymal neoplasm surrounded by fibrous tissue occasionally separated by strip-like bands of collagen. The proliferation was composed of long spindle cell with acidophilic cytoplasm and vesicular nuclei, round to oval, organized in a patternless architecture with a combination of alternating hypocellular and hypercellular areas separated from each other by thick bands of hyalinized collagen. It also showed a thin-walled, hemangiopericytoma-like vessels . Mitotic activity and atypia have not been observed. Immunohistochemical staining was positive for CD34 and Bcl-2 and HMB45 stain was negative . Based on the histological and immunohistochemical features, the diagnosis of SFT of the kidney was established.
+Nine months after discharge the patient had a Chest-abdomen-pelvis CT follow up with no evidence of tumor recurrence or metastasis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2576_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2576_en.txt
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index 0000000000000000000000000000000000000000..df358e56329f96416f842ce8ca79de4a6501a5a4
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+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2576_en.txt
@@ -0,0 +1,2 @@
+A 24-year-old Caucasian man with fever and upper quadrant abdominal pain over the previous 20 days was admitted to our hospital. Before admission, ciprofloxacin and metronidazole, followed by cefixime had been prescribed. Six years prior, the patient had been diagnosed with PSC, UC, suspected retroperitoneal fibrosis, bile sludge and splenomegaly. For this, he was prescribed ursodiol 300mg BID and mesalamine 4g per day. At that time, investigations included exploratory laparotomy and a biopsy of the perihepatic, retroperitoneal tissue which excluded malignancy. Over this six-year period, the patient presented with recurrent episodes of cholangitis, the serum level of aminotransferases remained substantially normal while there was a progressive worsening of cholestatic test results and a progressive liver enlargement along with fibrosis. Specifically, gamma glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP) increased from 141UI/L to 344UI/L and 847UI/L to 2534UI/L, respectively. Hepatic tissue stiffness, measured by FibroScan®, progressed from 12.6 to 17.3kPa. The patient was never treated with immunosuppressive therapy or corticosteroids. One month before admission, an upper endoscopy was performed which excluded esophageal varices. One week before admission, a magnetic resonance of his abdomen and bile ducts revealed further enlargement of the liver, spleen and the tissue surrounding his hepatic hilum , posterior to the pancreas head. The latter caused a compression of his second duodenal tract and a wrapping of the splenic and hepatic arteries. Beading and narrowing of the intra-hepatic and common bile ducts resulted in more extension and a narrowing of the pancreatic duct was also reported.
+At admission, our patient had a fever of 38.8°C and physical examination revealed tenderness of his epigastrium and right upper hypochondrium. Results from blood tests are reported in Table . Microbiological blood and urine investigations were negative for bacteria. A chest radiograph was normal while an abdominal sonography revealed an enlarged liver, thickened choledocus, dilatation of the intra-hepatic biliary tree, splenomegaly and lymphadenopathy of the hepatic hilus. A colonoscopy showed erythema of the colonic mucosa from the rectum to the cecum, with areas of increased erythema and telangiectasia in the ascending colon. Random biopsy showed focal atrophy of the colonic mucosa with edema and chronic inflammatory infiltrates, but specific investigations for CMV were not carried out. Imipenem 500mg IV four times daily was administered. Three days later, due to our patient’s persisting fever and abdominal pain, imipenem was substituted with tigecycline 50mg IV BID. Further blood and urine cultures for bacteria were negative. Both the erythrocyte sedimentation rate (ESR) and C-reactive protein level (C-RP) remained high, whereas the white blood cell (WBC) and neutrophil counts decreased and the procalcitonin level was 0.38ng/ml. The fever persisted while the upper abdominal pain subsided slightly. Investigations for HIV, Toxoplasma gondii, CMV, measles, parotitis and hepatitis C virus (HCV) all were negative, while results for varicella zoster virus, human herpes virus, Epstein Barr, rubella, and parvo virus B19 indicated previous infection. CD4?+?T lymphocytes were 1055mm3 (20.3%) and CD3?+?T lymphocytes were 3193mm3 (67%). Mycobacterium tuberculosis interferon gamma release assay (QuantiFERON®–TB Gold, Cellestis Limited, Carnegie, Victoria, Australia) showed negative results. Twelve days after admission, teicoplanin 400mg die, gentamicin 80mg TID, metronidazole 500mg TID were prescribed, while tigecycline was stopped. Two days later, deoxyribonucleic acid (DNA) Cytomegalovirus (Q-CMV Real Time, Nanogen Advanced Diagnostics, Torino, Italy) was detected in the blood with ≤253 copies/mL. Three days later, this value increased to 6189 copies/mL, while 1431 copies/mL were evidenced from a urine sample, the CMV pp65-antigen (Indirect Immunofluorescence, anti-CMV pp-UL83, Argene, France) was also positive, and CMV serology indicated acute CMV infection . Our patient’s fever rose to 39.2°C and his abdominal pain extended to the right lower abdominal quadrant with radiation to the right groin and right testicle. Ultrasound suggested acute appendicitis and he underwent surgery . Histology showed inflammatory infiltrates, including lymphocytes and neutrophils, while histochemistry was positive for CMV early antigens (Monoclonal Mouse Anti-Cytomegalovirus Clone CCH2?+?DDG9, Ventana Medical System, Roche, USA) . Real time reaction and shell vial culture of the appendix tissue also were positive. Microbiological investigations for bacteria and fungi showed Peptococcus spp. and Candida albicans. Teicoplanin, gentamicin and metronidazole were administered for a total of 12 days along with intravenous ganciclovir 5mg/kg twice for 15 days. After discharge, oral valganciclovir 900mg BID was prescribed for 10 days. After this, the CMV nucleic acid in the blood and urine was negative while ESR and cholestatic liver test results remained abnormally high .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2581_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2581_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e0ce70f6c3df35568823038a8788149e62419b9f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2581_en.txt
@@ -0,0 +1 @@
+A 56-year-old woman with no infectious history was evaluated for palpitation. She had regular pulse rhythm and no heart murmur. Electrocardiography, Holter, electrocardiography, and chest X-ray findings were normal. Transthoracic echocardiography revealed an 8- × 8-mm mass on the posterior side of the anterior mitral leaflet with minimal mitral insufficiency . The left ventricular motion and dimensions were normal. Transesophageal echocardiography demonstrated similar findings. Computed tomography showed no systemic embolism. Because a valve tumor was suspected, surgical resection was attempted to prevent a possible systemic embolism. During surgery, we found that the lesion was not a tumor, but an aneurysm-like bulge on the anterior leaflet without chorda elongation . Triangular resection and ring annuloplasty were performed, and the patient’s postoperative course was uneventful. Pathological examination showed myxomatous change, fibrosis, and hyalinization, confirming a diagnosis of degenerative disease. Now, her condition has been good without any mitral valve abnormality including regurgitation at postoperative 10 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_258_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_258_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e4657e55c2e9986cd6e9735a9a6fd1577ca4c3ce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_258_en.txt
@@ -0,0 +1,4 @@
+A 46-year-old obese woman presented to an outside hospital in August of 2005 with significant abdominal pain and diarrhea. Computed tomography (CT) revealed a 17 × 13 cm mass in the left upper quadrant that appeared to arise from the body and tail of the pancreas. The patient was taken to the operating room at an outside institution, but the mass was deemed unresectable due to reported involvement of the SMA, stomach, and colon. Wedge biopsy of the mass was consistent with pancreatic VIPoma. Over the next 2 years, the patient was treated with long-acting somatostatin with some improvement in her symptoms. The patient, however, developed repeat episodes of upper and lower gastrointestinal bleeding with associated anemia and ongoing transfusion requirements. Repeat CT scan revealed thrombosis of the splenic vein with numerous large splenic and gastric varices consistent with sinistral portal hypertension. In the summer of 2007, the patient underwent a failed transjugular intrahepatic portosystemic shunt (TIPS) procedure at an outside institution. The patient was therefore referred to the Johns Hopkins Department of Interventional Radiology for variceal embolization.
+The patient's case was reviewed at the Johns Hopkins multi-disciplinary pancreas tumor board. A repeat three-dimensional (3-D) pancreas protocol CT scan revealed an 18 × 12 cm mass abutting the liver, stomach, spleen, left adrenal, colon and invading the distal duodenum – proximal jejunum at the ligament of Treitz. The splenic vein was occluded. Large collateral vessels surrounded the mass and were associated with extensive gastric collaterals . The mass displaced the SMA and SMV, but these vessels were patent and uninvolved . As such, there were no obvious contraindications to resection and surgery was recommended.
+Given the size of the mass and the associated extensive varices, the patient underwent preoperative proximal splenic artery embolization . Twenty-four hours following this, the patient was taken to surgery where she was found to have a very large mass arising from the body and tail of the pancreas that invaded the left diaphragm, stomach, left adrenal, fourth portion of the duodenum – first portion of the jejunum, transverse colon, and spleen. In order to better expose the SMV at the inferior border of the pancreatic neck, the right colon and root of the small bowel mesentery were mobilized in the fashion of Cattell and Braasch. The SMA medial to the SMV was exposed as it coursed into the small bowel mesentery. The tumor was noted to closely abut and displace both the SMV and SMA, but the vessels were not encased. After developing the retro-pancreatic plane over the SMV – portal vein, the pancreatic neck was transected. The mass was subsequently resected en bloc with a portion of the left diaphragm, entire stomach, spleen, left adrenalectomy, fourth portion of the duodenum – proximal jejunum and transverse colon. Gastrointestinal continuity was restored using a Roux-en-Y method with a hand sewn end-to-side esophago-jejunostomy, a duodeno-jejuneal anastomsis (50 cm distally), and a stapled colo-colonic anastomosis. The pancreatic remnant was closed with pledgeted sutures. Estimated blood loss was 500 ml. Final pathology confirmed a VIPoma originating from the pancreatic body with invasion of the stomach, spleen, small bowel, and colon . All margins were uninvolved by tumor. The patient is alive and disease-free.
+The patient tolerated the procedure well. On post-operative day four, a swallow study demonstrated a normal post-surgical esophago-jejunal anastomosis with no evidence of leak. The patient was discharged home on post-operative day ten tolerating a post-gastrectomy diet. She received no adjuvant therapy and is currently alive and disease-free at 6 months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2600_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2600_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cdc1eeaed9b72f35583f73d25a751f83f8ebe53f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2600_en.txt
@@ -0,0 +1,3 @@
+A 17-year-old Caucasian male presented at our outpatient clinic with a one-week history of painless gradual visual loss in both eyes. Two months prior to the visual symptoms, the patient had a SARS CoV-2 infection (B.1.1.7 subtype), confirmed by polymerase chain reaction (PCR) test. He had mild symptoms and was otherwise healthy and reported no other concurrent infections or any other extraocular/systemic symptoms.
+On first presentation, best corrected visual acuity (BCVA) was counting fingers on the right eye and 0.1 Snellen on the left eye. Slit lamp biomicroscopy revealed 0.5+ cells in the vitreous in both eyes. Dilated fundus examination revealed creamy confluent yellow-white lesions in the macula in both eyes . Fundus autofluorescence imaging (FAF) revealed slightly hypoautofluorescent spots and patches with faint hyperautofluorescent halos around them . Optical coherence tomography (OCT) showed areas with hyperreflectivity of the outer retinal layers with absence of the ellipsoid zone and the impression of a flat serous retinal detachment. The scans in the choroid under the lesions showed hyperreflectivity and the disorganization of the regular vessel structure, suggesting chorio-retinal infiltrates . Fluorescein angiography (FA) showed early hypofluorescence in the affected areas with hyperfluorescence in late phases , indocyanine-green angiography (ICGA) showed both early and late hypocyanescence . There were no neurological symptoms or signs. The clinical findings were consistent with acute posterior placoid pigment epitheliopathy (APMPPE). A full diagnostic workup (hematology, serum biochemistry, renal and liver function tests, serum angiotensin convertase enzyme, hemoglobin A1c) was initiated including blood tests for additional potential relevant infectious causes (tuberculosis, treponema), all of which came back negative. Chest x-ray showed no pathologies.
+Due to the severely affected vision in both eyes, the patient was started on 50 mg oral prednisolone daily, after which vision began to improve rapidly. At the next follow-up, one week after the initial presentation, BCVA was 0.5 on the right and 0.15 on the left eye. One week later, we began gradual tapering of the prednisolone dose. Over the course of the next few weeks, vision improved to 0.6 on both eyes and the lesions began to appear more demarcated and pigmented with paracentral atrophy. Two months after symptom onset, when prednisolone had been tapered to 12.5 mg per day, the impression of continued inflammatory activity and new lesions in the retinal periphery of both eyes suggested relentless placoid chorioretinitis (RPC) . This prompted a rheumatologic consultation with the aim of switching the patient to steroid-sparing therapy. Simultaneously, an MRI scan was performed, that showed no pathologies and hepatitis B and C tests were negative. Based on the rheumatological consultation and a discussion with the patient, adalimumab treatment with 40 mg every other week was initiated with a continued dose of 12.5 mg prednisolone daily followed by slow tapering of the steroid. Over the course of the next few months, vision improved to 0.9 on both eyes. At month 7 after baseline, the patient had a second PCR-confirmed SARS CoV-2 infection (subtype unknown), that had no further impact on the ocular course. Five months after the start of the adalimumab treatment (at month 9 after onset), the steroid was discontinued and there were no signs of active inflammation. The patient has been followed for a total of 21 months since presentation, at the last visit, 12 months after the discontinuation of the systemic steroid, there was no visible activity suggesting inflammation and vision was 0.9 on the right and 1.0 on the left eye with no subjective visual complaints and with good tolerance of the immunosuppressive treatment. Once the patient has demonstrated no relapses on adalimumab monotherapy for 18–24 months, we plan to increase the dosing interval, thus tapering the immunosuppressive treatment under close clinical observation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2606_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2606_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2dba0d452a3090128869734971aa985bdb54f72f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2606_en.txt
@@ -0,0 +1,4 @@
+A 23-year-old primigravida Asian woman was referred at 33 weeks of gestation for several abnormal ultrasound findings, including small gastric bubble, talipes equinovarus, and polyhydramnios. On the first visit, the estimated fetal body weight was 1627 g (−1.5 SD), and the amniotic fluid index was 30.7 cm. The fetus had macroglossia, talipes equinovarus, and levocardia without cardiac structural abnormalities. The parents had no physical features and reported no past or family history. The mothers of the parents also had no history of miscarriages.
+The result of G-banding by amniocentesis performed at 32 weeks revealed a marker chromosome . Fluorescence in situ hybridization (FISH) was performed to examine the origin of the chromosome using whole chromosome painting (WCP) and nucleolus organizer region (NOR) probes. Both WCP5 and NOR were positive; therefore, the marker chromosome was determined to be derived from chromosome 5 and an acrocentric chromosome. From the G-banding findings, the derived region of chromosome 5 was pter→p13, and the karyotype was diagnosed as 47, XY, +mar. ish +mar(WCP5+), which included the critical region of 5p13 duplication syndrome. Array comparative genomic hybridization should be done to further confirm the origin of the marker chromosome, but consent could not be obtained.
+Amnioreduction was performed three times during the pregnancy, at 35, 38, and 39 weeks of gestation, for symptomatic polyhydramnios. At 39 weeks and 5 days, a 2462 g male infant was delivered after induction of labor. Immediately after birth, remarkable hypotonia was seen, and respiratory care was needed. APGAR scores at 1 and 5 minutes after birth were one and seven points, respectively. The infant’s physical features included enlarged head circumference, saddle nose, posterior neck thickening, low-set ears, macroglossia, cleft of the soft palate, micrognathia, and talipes equinovarus of both feet. After an examination of the infant, hypoplasia of the corpus callosum, atrial septal defect, and hypothyroidism were detected. On postnatal day 1, a mass shadow of the right lower lung field was detected through a chest X-ray . Computed tomography was performed to confirm the mass and revealed a bilateral CDH . At 5 months after birth, deterioration of the respiratory condition due to laryngomalacia was managed by tracheotomy. At 8 months, cardioplasty and gastrostomy were performed for impaired swallowing function. During the operation, a defect was identified in the muscle of the medial-ventral diaphragm, and a membranous sac was formed in the right thorax. The liver and right adrenal gland were herniated into the right thorax, which may have caused the levocardia. However, only a medial muscle defect without herniation of organs was detected in the left side diaphragm. The bilateral pulmonary hypoplasia was mild, and the hernia sac simultaneously closed. At 10 months, the patient was discharged and transferred to a care hospital. The patient died of aspiration pneumonia and paralytic ileus at 17 months of age.
+The postnatal karyotyping of peripheral blood was the same as that of prenatal karyotyping. Examination of their karyotype, especially regarding the presence of balanced reciprocal translocations, was offered to the parents. However, they declined the karyotyping examination.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2621_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2621_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..72eb6be9602ec8443ec0e3b3e3a09a1e5fd636a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2621_en.txt
@@ -0,0 +1,5 @@
+An 87-year-old man presented with appetite loss and was referred to a neighborhood hospital. His medical history included angina pectoris after percutaneous coronary intervention, aortic valve stenosis, chronic heart failure, and stage 4 chronic kidney disease. He was taking antihypertensive and antiplatelet drugs (100 mg aspirin and 75 mg clopidogrel). Plain computed tomography (CT) of the abdomen and pelvis revealed an incidentally large infrarenal abdominal aortic aneurysm (AAA).
+The patient was transferred to our university hospital for further treatment. Contrast-enhanced CT was performed to examine the anatomical features of the AAA. The maximum aneurysm diameter was 55 mm × 65 mm. The proximal neck was 24 mm in diameter and 28 mm in length with an angulation of 40°. The right and left common iliac arteries were 16 mm and 16 mm in diameter, respectively, which were within the instructions for use and anatomically suitable for EVAR. In addition, the left kidney was supplied with double renal arteries, the inferior branch of which originated immediately above the aneurysm. The branch was then sacrificed.
+EVAR with the Endurant stent graft (Medtronic Endovascular; Santa Rosa, CA, USA) was performed using a mobile C-arm imaging system. The bilateral common femoral arteries were surgically exposed under sedation and regional anesthesia. A 4F catheter was placed just above the renal arteries through the left brachial artery for intraoperative angiography. The main body (28 mm × 16 mm × 166 mm) was positioned through the left common iliac artery, by which the left inferior renal artery was consequently sacrificed. The main body was extended to the right common iliac artery with a contralateral leg (16 mm × 24 mm × 124 mm). Balloon inflation with a compliant aortic occlusion balloon (Coda Balloon Catheter, Bloomington, IN, USA) was performed in the proximal neck, component junction, and bilateral distal neck but not excessively. Angiography revealed an endoleak in the proximal sealing zone. An aortic cuff was placed inside the proximal neck zone, because the type IV endoleak was indistinguishable from type Ia endoleak. Completion angiography showed that the endoleak had almost disappeared and the procedure was completed.
+A color duplex ultrasound was performed 7 days after the operation instead of a contrast-enhanced CT because of severe renal insufficiency and revealed a regular row of pulsatile blood flow from the main body and left leg (Additional file : Movie 1A and Additional file : 1B; Fig. A, B). The blood flow appeared to be bleeding from the stent suture lines because of its regularity. Type IV but not type IIIb endoleak was suspected, likely due to stent suture line fabric breakage. However, it was not treated surgically or endovascularly but was followed by CT because of the patient’s poor general health status and the expectation of spontaneous resolution of the leak. The patient was transferred from our hospital to a neighborhood hospital.
+Six months later, the patient was readmitted to our hospital because of recurrent fever of unknown origin. Contrast-enhanced CT showed a deformation and enlargement of the aneurysm sac as well as oozing of the contrast medium on the main body and left limb , suggestive of persistent type IIIb endoleak. However, the patient was considered unsuitable for further surgical intervention because of his deteriorating general health condition. He experienced subdural hematoma due to a fall during his hospital stay and died of uncontrolled subdural hematoma 7 weeks after readmission. Autopsy was performed with the informed consent of his family; it showed no visible abnormal erosion or hole on the graft fabric, suggesting that tiny fabric breakage may have existed along the stent suture line at the time of the manufacturing process.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2648_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2648_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1df2f6189c09183638271ea6d30ea3d7b15f9f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2648_en.txt
@@ -0,0 +1,4 @@
+A 19-year-old male was admitted to the Department of Plastic, hand and reconstructive surgery due to persistant dysaesthesia of the median nerve-supplied area and a soft tissue laceration of the palmar wrist following a wakeboarding accident three days before. As an intermediate wakeboarding athlete starting to wakeboard one year ago, he was wakeboarding on the largest German artificial wakeboarding circled nylon cable system on a lake with a speed of 40 km/h, when the automatic nylon cable system stopped immediately due to an overlapping wire. The male wakeboarder dived in the lake and got struck in the loose nylon cable system with his trunk and the hand. He managed to get off with the trunk still caught with his wrist in the nylon cable, when the nylon cable system was activated by chance and he was pulled 1/4 of the radius of the lake with a speed of 40 km/h, suffering a strangulation of his wrist with immediate numbness of the median-nerve supplied area of the left hand. Furthermore, he had a laceration of the palmar aspect of the wrist covering 0.5 × 5 cm tissue size.
+At admission in a rural hospital, the two-point discrimination was > 15 mm for the entire interdigital nerves N1–N7 of the left hand as sensory loss in the median-nerve supplied area. The ulnar nerve was found without any pathology. Furthermore, he could not perform a wrist flexion, while wrist extension was possible. The capillary refill was 1s for all five fingertips. No distinct pain in the snuff box area was evident on admission. The left elbow joint had full range of motion, supination and pronation was limited due to persistent pain at the wrist level. Resting on a plaster, he was transferred three days after the initial injury with persistent clinical lesion of the median nerve in our department.
+Conventional x-ray of the hand and the wrist found regular articulation without an evident bony lesion. No disruption of the scapular-lunar ligament was noted. Computer tomography of the wrist and the hand proofed regular bony structures . In the operating room dorsal compartment pressure of the forearm was 19 mmHg, at the palmar compartment of the flexor carpi ulnaris muscle 16 mmHg, which were both normal. The median nerve, 72 hours after the initial strangulation injury, appeared with hyperaemia and moderate swelling and limited haematoma in the carpal tunnel more according to a median nerve contusion. The palmar branch of the median nerve was surrounded by a significant haematoma, which was evacuated. The ulnar nerve was inspected and found without any significant signs of injury or haematoma.
+The laceration area was excised completely and the skin could be closed primarily without compression with one subcutaneous drainage being inserted. On postoperative day 1, the patient regained the sensory function of the hand following 72 hours of acute carpal tunnel syndrome with median nerve contusion with remaining dysaesthesia of the thenar skin supplied by the palmar branch of the median nerve. On postoperative day 5 the patient was discharged home after an uneventful postoperative course. He complained of minor dysaesthesias in the mentioned thenar area with recurrent intensity and was advised to recovery for a total of four weeks before returning to sport.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2661_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2661_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6cb859f00f8b0fb86b0822b3e188c67a7c360cca
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2661_en.txt
@@ -0,0 +1,4 @@
+A 65-year-old Asian female (Height: 5 feet 4 inches; Weight: 52.5 kg; Occupation: retired teacher) referred to our clinic March 8th, 2013. Her family and social history was as follows; she lived alone and had quit cigarette smoking 10 years ago, with no alcohol or illicit drug use. Her mother had a history of colon cancer. She had a past medical history of a left breast mass that had required resection and radiation therapy. Three weeks before being admitted, the patient had presented an initial episode of cystitis. This was treated by a single dose of fosfomycin, which led to regression of the clinical symptoms. One day before hospitalization, she presented sudden onset of clinical signs of pyelonephritis: dysuria, urgency, frequency, urinary incontinence, suprapubic pain and elevated temperature (37.7°C). Urinalysis revealed positive leukocyte esterase, with 50-60 white blood count and 18-22 red blood count per high-power field. Her serum creatinine level was 125.3 umol/L and hemoglobin level was 10.7 gr/dL. There were no other significant laboratory findings.
+Urine samples were taken and cultured using both Columbia blood agar (Acumedia Manufacturers, Inc., US.) and MacConkey agar (Teknova Inc., US.). Microscopic examination of Gram stained smears of the urine revealed Gram-negative rods. Yellow colonies of the microorganism were detected on all culture media after overnight incubation. No other bacteria were detected. The isolate was identified as E. hermanii after assessment using the API 20E system (bio-Merieux, Lyon, France) for biochemical properties and enzyme activities.
+This isolate was forwarded to the local laboratory and biochemical testing and sequencing of the 16S rRNA gene confirmed the isolate as E. hermanii. The upstream primer used for the amplification of the 16S region in the E. hermanii genome was 5′-AGAGTTTGATCCTGGCTCAG-3′. The downstream primer was 5′-ACGGCTACCTTGTTACGACTT-3′. The nucleotide sequence of the 16S rRNA gene was 99.86% identical to that of E. hermanii T91, according to the NCBI GenBank database. Bacterial cultures were grown aerobically at 37°C in an incubation chamber.
+Antimicrobial susceptibility testing was performed using minimum inhibitory concentration (CLSI) broth microdilution minimum inhibitory concentration (MIC) method . The organism was found to be susceptible to piperacillin-tazobactam (MIC ≤ 4 mg/L), ceftazidime (MIC ≤ 1 mg/L), cefazolin (MIC ≤ 4 mg/L), cefixime (MIC ≤ 0.25 mg/L), aztreonam (MIC, 4 mg/L), gentamicin (MIC ≤ 4 mg/L), tobramycin (MIC ≤ 1 mg/L), imipenem (MIC, 2 mg/L), meropenem (MIC ≤ 0.25 mg/L) andamikacin (MIC ≤ 1 mg/L); and resistant to amoxicillin (MIC ≥ 16 mg/L). Antibiotic treatment was initiated with oral cefixime (400 mg every 24 hours). The symptoms were relieved within 72 hours after therapy. A urine sample was taken seven days after antibiotic therapy. E. hermanii was no longer isolated.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2667_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2667_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2b68c8f2864e6c4a572138f5a8e1647b81d383d2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2667_en.txt
@@ -0,0 +1,5 @@
+A 50-year-old woman with past history of hypothyroidism (on 25 μg levothyroxine) presented to emergency department with history of acute chest pain for 1 day prior to admission and an episode of syncope 15 min prior to admission. There was no significant drug history or history of an emotional or physical stimulus prior to admission. On examination the patient was in shock and had a feeble pulse with a rate of 150/min and a systolic blood pressure of 60 mm of Hg. General physical examination was notable for prominent pigmentation over the tongue and skin creases on hands . Cardiovascular examination was unremarkable. The initial electrocardiogram revealed monomorphic ventricular tachycardia with a rate of 160/min . The same was cardioverted via 200 J biphasic DC shock. Electrocardiogram after cardioversion revealed a sine-wave pattern consistent with hyperkalemia . Calcium gluconate and other anti-hyperkalemic measures were instituted, and gradually, there was resolution of the sine-wave pattern. The subsequent electrocardiogram obtained had sinus rhythm with T-wave inversions in anterior and inferior leads with a prolonged QTC of 530 ms . Her blood pressure responded to intravenous saline and minimal dose of noradrenaline and subsequently was 120/60 mm of Hg. The urine output was adequate at 100 mL/hour. Bedside echocardiography demonstrated regional wall motion abnormalities with a hypokinetic and ballooned apex corresponding to left anterior descending artery. The left ventricular ejection fraction was 35% with a normal systolic pulmonary artery pressure of 35 mm of Hg (Additional file : Video 1). There was no left ventricular outflow gradient. The working diagnosis at this stage was acute anterior wall myocardial infarction, and accordingly dual antiplatelets, statins and low molecular weight heparin were instituted.
+The initial laboratory investigations were significant for hyperkalemia (7.8 mEq/L) and hyponatremia (128 mEq/L) with a preserved renal function (creatinine-1.0 mg/dL). There was microcytic and hypochromic anemia with a hemoglobin of 11 mg/dL. The cardiac biomarkers were modestly elevated consistent with acute myocardial injury with a cardiac troponin I of 0.73 ng/mL (range 0.0–0.03 ng/mL). Her thyroid function tests were also deranged with an elevated thyroid-stimulating hormone of 67.70 mIU/L [–] and low T3 (2 pmol/L) and T4 (10 pmol/L). Despite adequate anti-hyperkalemic measures, the serum potassium remained elevated (5.8–6.5 mEq/L) for the next 48 h; however, the electrocardiogram changes of hyperkalemia had reverted.
+The patient was managed conservatively for the next 24 h but still required persistent inotropic support and intravenous fluids for maintenance of blood pressure. There was significant postural dizziness, and a postural fall of 50 mm of Hg was present at 3 min. Her levothyroxine was escalated to 75 μg daily. In view of these postural symptoms, skin changes and significant electrolyte abnormalities in the background of normal renal parameters, suspicion of adrenal insufficiency was kept, and investigations were performed accordingly. The subsequent 8 am cortisol was 0.429 mcg/dL consistent with adrenal insufficiency. To identify the cause of adrenal insufficiency, a cosyntropin test was performed, and the subsequent 8 am cortisol was 0.423 mcg/dL consistent with primary adrenal insufficiency. The diagnosis of APS II was established.
+The patient had remarkable improvement in her hemodynamics after initiation of intravenous 50 mg hydrocortisone every 6 h. The postural blood pressure fall resolved after 48 h and hyperkalemia also resolved. To rule out coexistent coronary artery disease, an invasive coronary angiogram was performed which revealed normal coronaries and the presence of apical hypokinesia on left ventricular angiogram . The echocardiogram showed improvement in cardiac function with an ejection fraction of 45% and regional wall motion abnormalities. The cardiac troponin I fell to 0.13 ng/mL (range 0.0–0.03 ng/mL). The diagnoses of TCM were established in accordance with the International Takotsubo Diagnostic Criteria . Antiplatelets and statins were subsequently withdrawn, and she was discharged on 50 mg metoprolol, oral prednisolone 10 mg twice daily and 75 μg levothyroxine.
+At one month of follow-up, the patient was asymptomatic and there was normalization of her left ventricular ejection fraction (Additional file : Video 3). Currently, the patient is doing fine at 6 months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2668_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2668_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ba595b9d183fadc4802b3a950dc7e81463cc4502
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2668_en.txt
@@ -0,0 +1,5 @@
+It is a case report of a 13-year-old girl appeared to the outpatient department with the history of swelling over her right hand for 5 months. It was gradually progressive in nature and situated over the dorsum and medial aspect of the hand. There was no history of trauma or such type of lesion elsewhere in the body or the in the family. There were no any associated features, i.e. pain, fever, or any sign or symptoms influencing her general health. On examination, there was a swelling, which was firm in consistency and occupying the dorsal and inner side of the fifth metacarpal. Local temperature was not raised and the skin was mobile and there was no any feature suggestive of inflammatory pathology. On deep palpation, it was tender and the range of movement was restricted.
+The routine hematological examination was within normal limit. The radiology revealed that there was an osteolytic fusiform expansible lesion involving to the whole distal 2/3rd of the fifth metacarpal and the articular surface too. The cortical is was paper thin, breached, inflated, and without the periosteal reaction and the tumor radiograph had “soap bubble” appearance. Hence, the provisional (clinicoradiological) diagnosis of aneurysmal bone cyst and GCT was conceded. The chest X-ray was also sought and it was within the normal limit. The core-cut biopsy sent and it conferred the diagnosis of GCT .
+Our technique is free osteoarticular metatarsal transfer, described by the Maini etal. The dorsal approach was used for the enbloc resection. Incision also included the previous biopsy track. The fifth metatarsal was removed except the base of it along with the partial resection of surrounding muscles . While removing the mass in enbloc, the capsule and collateral ligament of the fifth metacarpophalangeal joint left. The fourth metatarsal (same side) was harvested from the foot along with its capsule and collateral ligament of the metatarsal-phalangeal joint. The required length of the metatarsal was measured preoperatively, and it was osteotomized out from the base , and the capsuloligamentous of the metatarsal sutured to the counter capsuloligamentous structure at the recipient site to reconstruct the metacarpal-phalangeal joint. The metatarsal was fixed with the leftover base of the metacarpal by the K-wires and the volar slab applied . At the 14thpost-operative day, the sutures removed and the exercise started gradually.
+At each follow-up, the clinical and radiological assessment was done. The Union at the junction of the metatarsal and the base of the leftover metacarpal occurred in the 6weeks and no obvious changes noticed at the transferred metatarsal. Initially, the movements had both extension and flexion lag, so the meanwhile electric stimulation given. At the end of the 6months of follow-up, the movements are painless and almost up to normal except the terminally restricted at the flexion. It ranges from 0° to75° flexion at the metacarpophalangeal joint ( and ). The patient was able to grasp any object and has pretty good grip strength.
+After the 2years of follow-up, after the surgery, the procedure is fulfilling our expectations and corroborates the reliability of this method. During the initial follow-up, the patient had the mild-to-moderate pain over his foot while walking and unable to dorsiflex his fourth toe. However, now, she is free from pain or any complaint such asdeformity or difficulty in walking. However, there is still slight weakness of fourth toe’s dorsiflexor. Finally, she is happy and has no any complaints.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_266_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_266_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..404d78a9e8ded0049ee4b889657e978c4c736560
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_266_en.txt
@@ -0,0 +1,2 @@
+A 41-year-old woman with end stage renal disease (ESRD) from ADPKD was referred to our tertiary care center for urgent renal replacement therapy. Considering her actual state, the very long distance from hemodialysis centers and the possible opportunity for a future renal transplantation we concluded to start with peritoneal dialysis. Before starting PD we applied several sessions of hemodialysis using a subclavian temporary cathether. Two weeks after the peritoneal cathether implantation she started peritoneal dialysis. She continued on PD for two years but after a grave episode of peritonitis accompanied with a septic state, dialysis failure, long hospitalization, she was transferred urgently to hemodialysis. Her transplantation plans failed because her mother, the only possible donor died from a heart attack. She was maintained on regular HD, but her dialysis care was complicated by recurrent vascular access thrombosis. The first fistula functioned only 3 months and the second, third and fourth fistula were immature and not functioning. Both grafts didn’t function and were clotted till the first days. During this time the catheters were her vascular access of necessity with all the difficulties and hazardous situations that they bring with them. The third graft that was performed in Turkey, was clotted till the first days then was done the thrombectomy and then clotted again. The salvage procedures failed again. During this time the ongoing of hemodialysis was compromised from the recurrent septic states with seizures and bacteremia especially in the first hour of hemodialysis sessions. We usually used the cathether antibiotic locking in the end of hemodialysis with cephazolin or gentamicin but she gradually went on severe malnutrition due to long term infectious states and inefficient hemodialysis. She was supported with parenteral nutrition, more frequent HD sessions and intravenous antibiotics. This long calvary of suffering continued to the extent that only one access site was available for her routine renal replacement treatment.
+A thorough thrombophilia screen confirmed the presence of antiphospholipid antibodies, while antinuclear antibody and anti ds-DNA antibodies were negative. A diagnosis of APAS was made and she was anticoagulated with warfarin. The surgeon created the left femoral graft. It was used only after 4 weeks with extreme precautions. From 1.5 years it is still working and functioning well. Now she has a better quality of life, better hemoglobin levels, URR and she is free of temperature, seizures and rigid catheters that were her nightmare. Now she is not anxious, but for how much time? What if this AVG doesn’ t function any more? What to do with her? A lot of answers?
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2692_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2692_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d356c1382565429c14d4f4c4b8a27f403f59945e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2692_en.txt
@@ -0,0 +1,5 @@
+A 63-year-old woman was transferred to our medical facility for the evaluation of bilateral adrenal enlargement that was incidentally discovered during an abdominal examination after cholecystectomy. The patient was hypertensive and was taking an angiotensin II receptor blocker (candesartan) and a calcium channel blocker (nifedipine); she had a blood pressure of 142/82 mmHg. The referral source tests showed hypokalemia, and the ARR was very high. Thus, we initially considered a diagnosis of PA.
+However, further investigation revealed that the patient had been diagnosed with hypertension at the age of 30 years and with left hemiplegia, alongside right intracerebral capsular hemorrhage at the age of 37 years. A physical examination revealed the patient’s height as 166.2 cm, weight as 74 kg (body mass index 26.8 kg/m2), poor breast development, no beard, slightly low voice tone, no baldness, and female phenotype. The axillary and pubic hairs were poorly developed. Family history showed hypertension in both parents, but not juvenile hypertension. Her parents were non-consanguineous, and none of her siblings had disorders of sex development. She was neither married nor had a partner. Her blood pressure at the onset of the intracerebral hemorrhage was unknown, but her hypokalemia had been approximately 3.0 mmol/L for more than 5 years. Based on the information in her medical questionnaire, menarche occurred at approximately 13 years of age with regular menstrual cycles thereafter, and menopause occurred at the age of 48 years. The patient underwent blood tests for an analysis of the adrenal, gonadal, and pituitary hormones as well as the biomarkers of the renin-angiotensin-aldosterone system .
+Blood tests showed high levels of adrenocorticotropic hormone (ACTH), follicle-stimulating hormone (FSH), and luteinizing hormone (LH), low levels of cortisol, dehydroepiandrosterone sulfate, and testosterone, high ARR, and hypokalemia. Computed tomography of the abdomen and pelvis showed bilateral adrenal gland enlargement (the adrenal glands were 46.5 ⋅ 33.2 ⋅ 30.5 mm on the left and 19.9 ⋅ 43.1 ⋅ 23.2 mm on the right), immature urethral spongiosa, prostate-like structures, immature intra-abdominal testes, and testicular veins, but no ovaries or uterus . The high FSH and LH were thought to be due to gonadal insufficiency.
+Subsequently, as 17OHD was strongly suspected, further evaluation was recommended. Thereafter, a short synacthen test, karyotyping, and CYP17A1 gene analysis were performed. In the short synacthen test, the intravenous administration of synthetic ACTH (250 µg) did not markedly increase cortisol (baseline 80 nmol/L; after 60 min, 91 nmol/L) and 17-hydroxyprogesterone (baseline 4.0 nmol/L; after 60 min, 4.8 nmol/L) levels compared to the baseline levels, suggesting that the pathway catalyzed by 17α-hydroxylase was impaired.
+The patient’s karyotype was 46, XY. Genetic analysis revealed heterozygous mutations in the CYP17A1 gene as follows: (1) c.157_159delTCC, p.Phe54del and (2) c.1118 A > T, p.His373Leu. Therefore, the patient was diagnosed with 17OHD. We informed the patient of the diagnosis with ethical considerations. After the diagnosis, the patient stopped taking antihypertensive medication and was started on oral hydrocortisone (15 mg/day), which is the cornerstone of CAH treatment. Hydrocortisone was taken internally, 10 mg in the morning and 5 mg in the evening. After the appropriate treatment, the blood pressure and serum potassium normalized without antihypertensive therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2695_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2695_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1dd5098b8c12014590164fa12cd305886bfebad9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2695_en.txt
@@ -0,0 +1,2 @@
+A 77-year-old man presented with multiple pancreatic tumor lesions with a maximum diameter of 13.8 mm. The lesions had been identified by periodic ultrasonographic check-ups. He had undergone laparoscopy-assisted right nephrectomy for renal cell carcinoma 11 years previously and had since been free of tumor recurrence. His medical history also included dyslipidemia; however, he had no history of diabetes. Laboratory data showed no remarkable changes, including changes in tumor markers. Contrast-enhanced computed tomography (CT) revealed multiple (at least 10) hypovascular tumors located in the whole pancreas and swollen regional lymph nodes . Endoscopic ultrasonography depicted these lesions as hypoechoic tumors, and fine-needle aspiration proved that they were pancreatic metastases from renal cell carcinoma. Extrapancreatic organ metastasis was not detected by positron emission tomography. Thus, TP with regional lymph node dissection was performed as a curative treatment. The pancreas was soft. The operation time was 425 min, and the blood loss was 510 mL.
+Arterial blood gas analysis at the end of the operation was within normal limits (pH, 7.37; pCO2, 36.0 mmHg; HCO3, 20.5 mEq/L; and base excess, − 3.9). After the patient had recovered from general anesthesia, he was transferred from the operating room to the intensive care unit. His vital signs and consciousness were normal immediately after this transfer. Fifteen minutes after entering the intensive care unit, however, he suddenly and completely lost consciousness and stopped breathing with no prodrome. His oxygen saturation dropped to 34% despite oxygenation at 3 L/min using a face-covering mask; therefore, high-flow oxygen was administered. He spontaneously regained consciousness after 4 min. Arterial blood gas analysis during this episode revealed mild metabolic acidosis (pH, 7.34; pCO2, 42.6 mmHg; and HCO3, 22.1 mEq/L). His lactate (2.6 mmol/L) and glucose (233 mg/dL) concentrations were higher than upon completion of the operation. Intravenous administration of fentanyl was terminated because of the concern that it may prevent spontaneous ventilation. Ten minutes after recovery of consciousness, the acidosis became exacerbated (pH, 7.29; pCO2, 44.5 mmHg; and HCO3, 20.8 mmHg). The patient’s lactate (3.1 mmol/L) and glucose (246 mg/dL) concentrations increased further. Twenty minutes after the first episode, he lost consciousness and stopped breathing again. Because his consciousness did not improve (unlike the first episode), reintubation for forced ventilation was performed. Blood gas analysis showed severe acidosis and hyperglycemia (pH, 7.21; pCO2, 55.9 mmHg; HCO3, 21.4 mmHg; base excess, − 6.7; lactate, 2.9 mmol/L; and glucose, 302 mg/dL). His serum ketone (β-hydroxybutyrate) concentration after the second episode of TLOC was high (0.713 mmol/L). Head CT after reintubation revealed no remarkable change. An electrocardiogram and transthoracic echocardiogram revealed no arrhythmia or abnormal cardiac function. Continuous electrocardiographic monitoring and arterial pressure measurement throughout the episodes showed no arrhythmia or cardiac shock. Continuous insulin infusion was initiated immediately after the second episode of TLOC. The patient’s blood glucose and pH returned to the normal range, and he regained consciousness and spontaneous ventilation. The patient’s clinical course is summarized in Fig. . Estimated concentration of fentanyl at the central nerve system and plasma analyzed by Tivatrainer (version 9.1, Digital River GmbH Scheidtweilerstr, Cologne, Germany) is shown in Fig. . The next day, he was extubated without needing reintubation. An electroencephalogram recorded on postoperative day (POD) 10 revealed no signs of epilepsy or other neurological diseases. Head magnetic resonance imaging and angiography on POD 11 were devoid of sites of infarction or signs of epilepsy, and the blood vessels in the head and neck were clearly depicted without narrowing. On POD 31, the patient was discharged from the hospital with no severe postoperative complications besides the above-mentioned episodes. The final pathological diagnosis was metastases of clear cell renal cell carcinoma to the pancreas and surrounding lymph nodes with a negative surgical margin. He underwent no adjuvant therapy, and he was alive without recurrence 6 months after surgery. At the time of this writing, he had experienced no loss of consciousness since then.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2712_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2712_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..714de8943e361e41b878a44dc85ac6b69482a207
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2712_en.txt
@@ -0,0 +1,3 @@
+A 76-year-old male patient came to our hospital with complaints of pain, swelling, and difficulty in flexing and weight-bearing in the left knee. The patient had a history of fall from bike 15 days back and took treatment at the local hospital for the same in the form of above knee slab and was referred to our hospital. There was no history of any head, chest, and abdominal injury and the patient was not a known case of hypertension and diabetes. The patient had a history of coronary artery bypass graft surgery 6 years back and is on tablet Ecosprin since then. On local examination, tenderness was present over the lateral tibial condyle, skin condition was good, and range of motion was restricted. X-ray of the left knee was taken, which was suggestive of the left tibia lateral condyle split fracture (Schatzker type 1) with severe osteoarthritis of the left knee ( and ). The patient was managed initially with above knee slab and limb elevation. As the patient was having osteoarthritis with fracture, we planned for primary TKR with stemmed tibial component. Surgery was postponed for 15 days because of patient medical fitness issues.
+After getting the fitness for surgery (40 days after the trauma), the patient was operated in supine position through medial parapatellar approach using tourniquet. After the femur preparation, tibial preparation was started with removal of fibrous tissue at the fracture site, anatomical reduction of fracture, and maintaining the reduction with reduction forceps till the completion of the tibial preparation to prevent the displacement of fracture fragment. Cemented TKR was done using Zimmer implant of femoral component size E, tibial component of size 4 with stem extension of 12 mm diameter × 155 mm length and articular surface height of 10 mm ( and ). As the fracture was properly reduced to anatomical position and there was only fracture split, no depression, the augmentation was not required. Wound was closed in layers and the patient was given long knee brace postoperatively. Partial weight-bearing and knee range of motion were started after 3 days and full weight-bearing was started after 3 weeks. Eight months post-operative X-rays ( and ) showed healing of lateral condyle fracture and without any loosening of implants. The patient is having good knee range of movements and no pain on weight-bearing at present ( and ).
+At present 1.2 years follow-up, the patient is comfortable with no pain and difficulty in walking. Functional outcome is good as per Oxford knee score. Shorter follow-up period is the limitation of this case report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2716_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2716_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b157a3e5f043867f3420d8cb823b68167b518d2b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2716_en.txt
@@ -0,0 +1,3 @@
+A 14-year-old girl had one episode of seizure five months prior to admission. She was diagnosed to be having multiple intracranial neurocysticercosis lesions and started on carbamazepine therapy. After three months of treatment, she noticed intermittent distortion of vision (metamorphopsia), seeing black spots and floaters in both the eyes. Subsequently, she developed progressive painless vision loss from both the eyes. There was no history of diabetes mellitus, hypertension or tuberculosis. Ophthalmological examination did not show orbital swelling, redness of eye, excessive lacrimation and other signs of ocular or orbital inflammation. There was no evidence of adnexal, orbital or extraocular muscle involvement. Intraocular pressure was normal on both sides. Though, the pupils were slightly dilated, reaction to light and accommodation was normal. Visual acuity was limited to perception of light in both the eyes. Bilateral detailed indirect ophthalmoscopic examination revealed evidence of subretinal cysts, retinal hemorrhage and retinal detachment. Surprisingly vitreous hemorrhage was also detected in both the eyes. Rest of the neurological examination was unremarkable.
+Hemogram, serum biochemistry and x-ray chest were normal. Human immunodeficiency virus (HIV) was negative. Enzyme linked immunosorbent assay (ELISA) was strongly positive for Taenia solium. Ocular B-scan ultrasonography (USG) revealed septations and debris in vitreous in both eyes. It also showed cystic lesion with small peripheral solid nodular area in subretinal space in both eyes [Figure (a)]. Orbital computed tomography also depicted the vitreous hemorrhage with retinal detachment in both the eyes. Magnetic resonance imaging (MRI) of orbits showed heterogeneous hyperintensity in posterior chamber of eyes [Figure (c), (d)]. Ocular B-scan USG, orbital computed tomography and MRI orbit were consistent with vitreous hemorrhage and retinal detachment in both the eyes (right more than left). Subretinal cyst was located at the posterior pole of both the eyes. MRI brain revealed multiple small cystic intraparenchymal lesions in bilateral cerebral and cerebellar hemispheres, basal ganglia, thalami and brainstem. MRI T1-weighted image showed isointense to hypointense lesions. Fluid attenuated inversion recovery (FLAIR) and T2-weighted images showed hyperintense lesions with surrounding edema. Postcontrast T1-weighted image showed multiple ring enhancing lesions [Figure (a-f)].
+A clinical diagnosis of vitreous hemorrhage due to ocular cysticercosis was made and it was further supported by various imaging modalities. The patient underwent retinal surgery for cyst extraction. A complete cyst excision was possible from right eye, but on left side, cyst got ruptured during intra-operative procedure. Gross examination of pathological specimen revealed a thin walled, transparent, globular cyst with eccentrically placed small scolex [Figure (b)]. Histopathological examination (stained with hematoxylin and eosin) showed the invaginated scolex with suckers, spiral canal and hooks thereby confirming the cysticercus cellulosae. A short course of oral steroid was given to the patient after cyst excision. At the time of discharge from hospital, she was able to count finger at one foot from right eye, but still had only perception of light from left eye. She was continued on carbamazepine (200 mg thrice a day) for seizures. At one-year follow up, seizures are well controlled. Visual acuity (Snellen chart) is 6/60 in right eye and complete loss of vision in left eye. Ophthalmoscopic examination shows partial retinal re-attachment and optic disc pallor in the right eye, whereas optic disc atrophy is present in left eye.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2718_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2718_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c7b5a01ffd957e56b29905bb3e4cc52fdc4bde7c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2718_en.txt
@@ -0,0 +1,3 @@
+A 15-year-old girl presented to the surgery unit with pain in the right hypochondrium and underwent appendicectomy for acute appendicitis with paralytic ileus. At laparotomy an enlarged mesentric lymph node was noted which was excised and sent for histopathological examination together with the appendicectomy specimen.
+Grossly, the excised mesenteric lymph node measured 2.5×1.5×1 cm. It was nodular on external examination. A cut section revealed multiple cysts varying in size from 0.5 to 0.8 cm in diameter containing shiny grey-white material. Microscopic examination showed numerous parasites with characteristic morphology scattered throughout the node . The parasites had an outer vesicular wall composed of three layers: an outer cuticular layer, a middle cellular layer and an inner reticular layer along with invaginated scolices which showed a rudimentary body with spiral canal. Some of these parasites were surrounded by host reaction in the form of palisaded histiocytes, fibrosis and calcification in places. The appendicectomy specimen measured 4×1 cm and showed changes of acute diffuse suppurative appendicitis.
+Subsequent to the histopathology report the patient underwent a further thorough physical examination that revealed no evidence of subcutaneous or muscular swelling. Further radiological and other investigations did not reveal cysticercus infestation anywhere else in the body. We were unable to confirm that the parasite was T. solium by serology, staining of the tissue by immunofluorescence assay or immunohistochemistry.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2725_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2725_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..17df2ad23de124e17f7499ff36834fd77485fd45
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2725_en.txt
@@ -0,0 +1,14 @@
+A 50-year-old female patient, known case of hypertension (HTN) and taking normatin as a medication, was in her usual state of health until 6 months prior to admission when she started to complain from headache, tinnitus and vertigo. She sought medical advice and was treated as otitis media (according to the patient).
+Before ten days from her admission to our hospital, she had episodes of imbalance while she was walking and recurrent vomiting.
+Once again, she sought medical help and, after a brain CT and a brain MRI were done, the doctors found a left cerebellar tumor . In the upcoming days, she was referred to our hospital in April 2019 for further evaluation and surgical management.
+The patient came to our hospital by her own (using public transportation) because there were no facilities for the tumor management in other places and there was no need to being transported by ambulance.
+We did a physical examination focused on a neurological examination due to her symptoms and diagnosis. The patient was conscious, oriented and alert, with a Glasgow coma scale (GCS) of 15/15.
+The cranial nerves were intact, and she was positive for cerebellar signs. She also was positive for the Romberg sign, had an ataxic gait and could not perform the tandem gait.
+The patient then underwent surgery in which a midline suboccipital craniectomy with microscopic gross total resection (GTR) of the left cerebellar tumor and a cranioplasty under neuromonitoring was performed successfully.
+The surgery was smooth and without intraoperative complications with an estimated blood loss of 500 cc.
+After the surgery, the patient was transferred to the ICU in good conditions with stable vital signs, conscious, oriented, alert and a GCS of 15/15. The cranial nerves were intact, she was able to move all limbs freely and the wound was dry and clean. Afterwards, she was discharged in good conditions, with stable vital signs and no complications or sequela.
+According to the histology department, the specimen that they received in formalin consisted of a multiple pieces and fragments of a grayish tissue measuring in aggregate 7.5 × 5 cm grossly. Further microscopic investigations of the histologic sections showed a biphasic tumor with a mixture of neurocytes and lipidized cells in which the neurocytes were arranged in density cellular sheets of monotonous cells with scanty and often clear cytoplasm, rounded to oval nuclei and salt-and-pepper chromatin. Lipidized cells were clustered and resembling mature adipocytes.
+Rare mitotic figures were noted and were investigated. The tumor cells were positive for synaptophysin and neuron specific enolase (ESN) immunostains, focal for glial fibrillary acidic protein (GFAP) and negative for epithelial membrane antigen (EMA).
+With all these histological findings, it was concluded that the sample was consistent with a cerebellar liponeurocytoma, WHO grade 2.
+After a month from the operation, the patient came to the out-patient clinic for follow-up in which we could see that she was in good conditions, with no complains and the cerebellar signs were gone. Since there was no residual tumor left after the surgery and there were no symptoms showing us cerebellar involvement, there was no need for our patient to take radiotherapy once she was discharged.
+Since the patient did not come to us again, we suspect that she is not complaining from any other symptom in the neurosurgical field.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2758_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2758_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a783c8d914fb412cd4473895d7b94839adcc1989
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2758_en.txt
@@ -0,0 +1,5 @@
+A 69-year-old woman was diagnosed with immunoglobulin (Ig) A lambda-type MM and was treated with 8 cycles of chemotherapy bortezomib-dexamethasone (VD) and lenalidomide-bortezomib-dexamethasone (RVD lite) as well as autologous peripheral stem cell transplantation. She underwent complete remission (CR). After 15 months, she presented with neck pain and paralysis in her left arm. Spinal magnetic resonance imaging (MRI) showed extramedullary infiltration in the left C4 and C5 spinous processes and multiple lytic lesions in the upper thoracic vertebra, indicating a recurrence of MM. Systemic treatment was started with daratumumab, bortezomib, and dexamethasone (D-Vd) and focal irradiation (30 Gy/10 Fr) for spinal lesions. During this time, brain MRI was used to screen for intracranial lesions.
+Brain MRI with contrast medium revealed a thickened dura mater in the left middle fossa. No abnormal findings were observed in the adjacent skull base. Since the lesion was small and asymptomatic, 3 months of chemotherapy were administered and a follow-up imaging was performed. On MRI , the lesion of the left middle fossa showed remarkable expansion, arising from the dura mater. Since the mass was expanding rapidly, tumor resection with the histopathological examination was planned.
+However, a week after MRI, she developed an acute onset of headache followed by disturbance of consciousness and right-sided hemiparesis. She was brought to the emergency room by ambulance. On arrival, she was unable to follow commands and exhibited aphasia and right-handed hemiparesis. A computed tomography (CT) scan revealed a large intracerebral hemorrhage with a significant mass effect in the left temporal region. CT scan revealed an enhancing region that extended intraparenchymally, a slight enlargement of the tumor itself was also observed. At this time, no apparent abnormal findings were observed in the adjacent skull base of the middle fossa.
+An urgent operation for both the hematoma evacuation and tumor resection was performed. After a temporal craniotomy and dural incision, the intraparenchymal hematoma was promptly evacuated. A reddish rather soft mass was observed directly connected to the hematoma, which arose from the dura mater of the middle fossa. The tumor was detached from the dura mater of the middle fossa followed by gross total removal of the tumor. Since there were no tumor invasion and no connection between the outer layer of the dura mater and adjacent sphenoid bone in the middle fossa, these structures were intentionally preserved. Finally, duroplasty was performed, the bone flap was returned, and the skin was normally closed. The resected tumor was sent for a histological examination. Hematoxylin-eosin staining showed diffuse proliferation of the plasmacytoid cells with clumped nuclear chromatin and eccentric eosinophilic cytoplasm . Additional immunohistological studies revealed proliferating CD138-positive cells, which are markers of the plasma cells, and a positive immunoreactivity to IgA lambda . These intraoperative and pathological findings indicated that the dura mater originated from the intracranial MM.
+The postoperative course was uneventful and her hemiparesis and aphasia resolved immediately. Postoperative MRI confirmed a thorough tumor and hematoma evacuation. Two weeks after the surgery, the patient was referred for further oncological treatment. Multimodality treatment was initiated consisting of proteasome inhibitor carfilzomib and dexamethasone (Kd), intrathecal chemotherapy (15 mg methotrexate, 40 mg cytarabine, and 4 mg dexamethasone), and radiation with 30 Gy/10 Fr for the tumor bed. The patient was discharged from the hospital without any observable neurological deficit. She remained in a CR state for 6 months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2759_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2759_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aeb1c5af6ab6ab20a1b65d5468f436dc3a200ef1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2759_en.txt
@@ -0,0 +1,2 @@
+A 66-year-old Maori man presented to our hospital with a history of an enlarged left testicle of 10 weeks’ duration. His clinical examination revealed nontender swelling of the left testicle. His alpha-fetoprotein (AFP) and beta-human chorionic gonadotropin (BHCG) levels were within normal limits. His lactate dehydrogenase (LDH) concentration was mildly elevated at 267 U/L (normal range 120–250 U/L). Ultrasonography of his testes demonstrated an enlarged left testicle measuring 7 × 5.5 × 4.3 cm with an estimated volume of 87 ml. A large, heterogeneous mass involved the entire testicle with increased vascularity . The patient’s right testicle measured 3.7 × 2.5 × 1.8 cm with an estimated volume of 8.8 ml. He underwent left orchiectomy. The macroscopic specimen consisted of well-circumscribed nodular lesions of varying sizes, with the largest measuring 45 × 15 mm and containing solid and gelatinous components . Sections of the specimen showed tumor composed of sheets of small, blue, round cells divided into nodules by fibrous septae . Immunostaining showed the tumor to be cytokeratin 20 (CK20)-positive with a typical paranuclear dotlike staining pattern . The stain showed a positive result for CD56, a neuroendocrine marker , as were CD117 and CK (paranuclear dots). The result was negative for CK7, placental alkaline phosphatase (PLAP), CD30, CD20, AFP, S100, SOX10, prostate-specific antigen (PSA), chromogranin, and thyroid transcription factor 1 (TTF-1). The Ki-67 level was >50 %. This immunostaining pattern raised the possibility of metastatic MCC.
+The patient presented again to our hospital 3 months later this time with a right testicular mass. Tumor markers, including LDH, AFP, and BHCG, were within normal limits. Ultrasonographic imaging demonstrated a new lesion in the right testis measuring 3 × 2.6 × 2.3 cm. He underwent a right orchiectomy, and sections of the specimen showed diffuse infiltration of small, blue, round cells. Immunostains were positive for CD117, CD56, synaptophysin, CK20 (dotlike), and cytokeratin AE1/AE3 (dotlike). The tumor cells were negative for inhibin, PLAP, PSA, S100, CD30, CD45, CD3, CD20, TTF-1, and napsin A. The Ki-67 level was 80 %. This pattern was consistent with a poorly differentiated neuroendocrine tumor in keeping with metastatic MCC. Detailed histology reports can be found in Additional files and . A primary site was not identified, and a staging computed tomographic scan did not show evidence of other metastases. The patient received six cycles of adjuvant carboplatin and etoposide chemotherapy. He remained disease-free 18 months following completion of chemotherapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2763_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2763_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc57b41bdc1b642b6c13b31a9c20b0aa0a4df8b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2763_en.txt
@@ -0,0 +1 @@
+A 38-year-old white Arabian woman, gravida 1, parity 0, abort 1, sought medical advice in our outpatient clinic with complaints of lower abdominal pain that had started 2 days earlier. The pain had first started as mild cramps, which then suddenly intensified nearly 2 hours before her presentation to our clinic, spread to her groin and femur, more prominent on the right side, and became an ongoing pain. The patient had not had any complaints of pain until 2 days earlier in her anamnesis, and she stated that her nausea had started together with the intensification of pain, but she had not vomited. In her medical history, the patient stated that a doctor she had sought medical advice from for infertility about 3 years ago had recommended bilateral salpingectomy and in vitro fertilization treatment due to hydrosalpinx, but the patient did not undergo these procedures. She had undergone no previous abdominal operation. In the patient’s physical evaluation, we measured TA 110/70 mmHg, pulse rate 95 beats/minute, and no fever. The patient’s abdominal examination revealed significant defenses and rebounds in the lower abdominal quadrants, and significant sensitivity was detected in the upper and middle quadrants. Cervical movements were painful during the gynecologic examination. Transvaginal and abdominal ultrasonographic (US) examinations revealed that the uterus was normal, both ovaries were separated and normal, and two irregular cystic masses of 35 mm and 40 mm (possibly hydrosalpinx) were observed in the region close to the left adnexal lobe, and minimal free fluid was seen in the pouch of Douglas. Laboratory test findings were as follows: white blood cell count 9.46 × 103/mm3, hemoglobin 9.3 g/dl, hematocrit 28.67%, and β-human chorionic gonadotropin (β-hCG) detected as negative. Tumor marker values were within normal limits (CA 125, 8.6 U/ml; CA 15-3, 12.08 U/ml; CA 19-9, 9.73 U/ml; carcinoembryonic antigen, 1.57 ng/ml). A decision was made to perform emergency surgery because acute abdominal findings were apparent, with the patient describing severe pain, clinical findings progressing, and adnexal pathology being detected by US. As preoperative diagnoses of the patient, ovarian cyst rupture and ectopic pregnancy were suspected, and fallopian tube torsion was also suspected due to the normal appearance of the ovaries and the appearance of hydrosalpinx by US. The diagnosis of ectopic pregnancy was excluded because of the negative β-hCG finding. The patient underwent laparotomy with a Pfannenstiel incision. The uterus and both ovaries were normal in abdominal observation. Hydrosalpinx was found in the right tube, and it was torsioned around itself four times and necrotic . In the left tube, hydrosalpinx and 1.5 times torsion around itself were observed. The left tube was torsioned exactly at the junction of the distal hydrosalpinx and the normal proximal tubal region. There was no apparent necrotic appearance in the left tube, possibly due to the fact that circulatory disruption was not complete . Both tubes had hydrosalpinx, and the fimbrial ends were blunt and obliterated. Bilateral salpingectomy was performed on the patient because the right tube had a prominent necrotic appearance, and there was a significant hydrosalpinx in both tubes. The patient was discharged on the second postoperative day without any complaints and without any complications. Histopathological examination revealed bilateral hydrosalpinx with hemorrhagic infarction findings consistent with torsion.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2767_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2767_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ba8f27a74192687bcd66e0dedb4de9d3aeeb9493
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2767_en.txt
@@ -0,0 +1,8 @@
+A 26-year-old male presented with 1 week of fevers, chills, headache, nausea, vomiting and diarrhea. Upon evaluation in the emergency department, he was febrile to 39.2 C, hypotensive to 75/35 mmHg, tachycardic at 126 beats per minute, with an oxygen saturation of 96% on 6 L nasal cannula. His labs were notable for leukocytosis (white blood cell count 17.1/nL), lymphopenia (absolute lymphocyte count 0.73/nL), acute kidney injury (creatinine 1.9 mg/dL), lactic acidosis (lactate 4.1 mmol/L), and elevated troponin levels (troponin T 0.218 µg/L, normal range < 0.09 µg/L). SARS-CoV-2 PCR was negative but SARS-CoV-2 IgG was positive. Point of care ultrasound showed severely reduced biventricular function. He was admitted to the cardiac care unit and given intravenous diuresis and inotropes for the management of cardiogenic shock (Additional file ).
+Further admission laboratory assessment was notable for elevations in transaminases, procalcitonin, NT-proBNP, ferritin, D-dimer, ESR, and C-reactive protein . Chest x-ray showed opacification of the right lower lung field, a left lower lobe opacity, and borderline enlarged cardiac silhouette . Electrocardiogram showed sinus tachycardia with right axis deviation . An echocardiogram demonstrated a left ventricular ejection fraction of 20% with global hypokinesis, mildly dilated left ventricle, biatrial enlargement, hypokinetic and dilated right ventricle, moderate to severe mitral regurgitation due to leaflet tethering, severe tricuspid regurgitation, small pericardial effusion, and an estimated pulmonary artery systolic pressure of 53 mmHg with a right atrial pressure of 15 mmHg (Additional files and : Video 1).) .
+On the evening of admission, bedside pulmonary artery catheter was placed with the following hemodynamics: RA 17 mmHg, RV 36/15 mmHg, PA 35/24 mmHg with mean 28 mmHg, PCWP 24 mmHg, mixed venous O2 saturation 53%, cardiac output 3.5 L/min, cardiac index 1.9 L/min/m2, system vascular resistance of 1440 dynes/s/cm−5. Cardiac output was calculated based on Fick’s formula using an assumed oxygen consumption. Pulmonary Artery Pulsatility Index (PAPi) was 0.7 (normal PAPi > 1.0 ), consistent with right ventricular dysfunction and biventricular shock.
+Milrinone was initiated after PA catheter measurements were consistent with biventricular shock and intravenous diuretics were continued. In light of his ongoing hypotension, norephinephrine was initiated to maintain a MAP ≥ 65 mmHg. Given the patient’s ongoing cardiogenic shock and rapid decline, the decision was made to treat empirically for fulminant giant cell myocarditis and MIS-A as his COVID-19 diagnosis was 5 weeks prior. As such, he was empirically treated with 1000 mg of solumedrol and intravenous immunoglobulin (IVIg) therapy.
+An endomyocardial biopsy was subsequently performed . Histologic assessment showed interstitial edema and inflammatory infiltrate consisting predominantly of interstitial macrophages with scant T lymphocytes. Rare subendocardial myocytes with ischemic injury as highlighted by immunostain for C4d were seen. No eosinophils, giant cells or vascular thrombi were present. Given the macrophage predominant histology in combination with the remainder of his findings, a diagnosis of MIS-A was made. Steroid dosing was de-escalated to 2 mg/kg daily and IVIg was continued for 2 days.
+Despite antibiotic therapy and improving hemodynamics, the patient remained hypoxemic on 6 L nasal cannula with a rising D-Dimer (8147 ng/mL). A computed tomography scan was performed on hospital day 6 demonstrating multiple bilateral segmental and subsegmental pulmonary thromboemboli. The patient was transitioned from prophylactic to therapeutic heparin with rapid resolution of hypoxemia. Bilateral lower extremity venous duplexes showed no evidence of deep venous thrombosis.
+By hospital day 7, the patient was tapered off milrinone. He was transitioned to apixaban, and guideline-directed medical therapy was initiated with metoprolol succinate, sacubitril-valsartan and spironolactone. Repeat echocardiogram prior to discharge showed an LVEF 75% with normal RV size and function, no more than trace valvular regurgitation and a small pericardial effusion (Additional files and : Video 2). His renal function returned to normal (0.9 mg/dL) without requiring renal replacement therapy and liver enzymes continued to downtrend.
+The patient is doing well following discharge at 1 and 3 months with unlimited exercise tolerance and no evidence of arrhythmias or hemodynamic compromise. Repeat echocardiogram showed preserved biventricular function. He will have a cardiac MRI to further characterize the effect of myocardial injury and he is restricting vigorous exercise. He was referred to cardiac rehabilitation and remains on the same medications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2789_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2789_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f837fc1af7efdfd7b525e8d9e940f75e30bc3dc3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2789_en.txt
@@ -0,0 +1,8 @@
+A 75-year-old woman with a diagnosis of pancreatic mass was admitted for surgery.
+A 75-year-old Chinese woman was admitted because of paroxysmal exacerbation of acute abdominal pain for 1 d with no apparent cause. The pain was not responsive to changes in body position and did not radiate to the other side. The patient did not complain of nausea, sour regurgitation, or abdominal fullness but did note slight fatigue.
+The patient had hypertension for the previous 10 years, which was well controlled by drug therapy.
+The patient had a more than 10-year history of hypertension that was under fairly satisfactory control via medication.
+Abdominal physical examination showed a flattened belly, normal borborygmus, and epigastric tenderness and rebound pain, with a negative Murphy’s sign.
+Blood biochemistry tests revealed the following: Elevated blood amylase (742 U/L; chromatometry reference range: 35-135 U/L), undetectable blood lipase (chromatometry reference range: less than 79 U/L), low albumin (32.2 g/L; reference range: 40-55 g/L), low calcium (2.06 mmol/L; reference range: 2.25-2.75 mmol/L), low platelets (98 × 109/L; reference range: 100-300 × 109/L), and highly elevated CA242 (over 150 IU/mL; reference range: 0-20 IU/mL), CA50 (289.6 IU/mL; reference range: 0-20 IU/mL), and CA199 (627.4 IU/mL; reference range: 0-37 IU/mL).
+A plain CT scan showed a mass in the body and tail of the pancreas, with little exudation . The morphology of the pancreas was disrupted, indicating edema, hyperemia, and fat liquefaction. The stomach appeared normal . Two days later, contrast-enhanced CT showed a cystic solid mass surrounding splenic vessels in the caudal pancreas, indicating a pancreatic malignant tumor . Multiple hepatic cysts, cholecystitis, and cholecystic polypus were also detected. The gastric antral wall was found to be thickened . Gastric endoscopy was performed 3 d later. The images showed chronic superficial and atrophic gastritis, a protruding lesion in the submucosal area of the antrum , and no Helicobacter pylori infection. Contrast MRI was performed the following day and indicated PC and uniform thickening of the antral wall . Due to the aforementioned imaging findings, we decided to perform operations to relieve PC and tried to figure out the nature of the gastric mass intraoperatively.
+The gastric mass under pathological examination post operation was a gray, solid, and tough nodule measuring 2 cm × 2.2 cm × 1 cm in the pylorus. Immunohistochemical staining showed that the tumor cells were positive for CK8, partially positive for Ki-67, and negative for CD147. Micrography showed multiple multifocal heterotopic pancreatic acini , mucus-excreting glands such as Brunner’s glands, and undifferentiated ducts surrounded by proliferative smooth muscles in the submucosal layer, which typically indicate GA with HP. The tissue in the other slice showed undifferentiated epithelial cells covered with thickened smooth muscle, indicating GA alone , with no signs of malignancy. Regarding the 3.5 cm × 2 cm × 3 cm pancreatic mass, distinct dysplasia of the acini and cells arranged in a mass without polarity indicated cancer cells. The nuclei were deeply basophilic, with common karyokinesis, enlarged in size, and increased in number compared to those in normal tissue .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2792_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2792_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a04166b609c7c74beecb5c7660a6a4fd509358a2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2792_en.txt
@@ -0,0 +1,8 @@
+A 49-year-old man with schizophrenia was brought to our hospital as an emergency case of idiopathic esophageal rupture. The patient underwent an emergency laparoscopic surgery. No abnormal findings were found in the abdominal cavity. Dissection was proceeded from the left side of the esophagus and an abscess was observed. Perforation placement was searched, but the perforation site could not be found. Before the end of surgery, the mediastinum was irrigated with saline solution and the esophagus was covered with lesser omentum.
+However, after the surgery, the patient developed a mediastinal abscess and pyothorax, and two blood cultures were positive for methicillin-resistant Staphylococcus aureus (MRSA). Thoracic drainage and antibiotics improved the mediastinal abscess and pyothorax; however, the patient’s back pain and low-grade fever persisted. Magnetic resonance imaging (MRI) of the thoracic spine showed abnormal signal and extensive contrast in the vertebral bodies at T9 and T10, and high signal fluid retention on T2-weighteding imaging of the intervertebral disk at T9–T10 . However, there were no findings of compression of the spinal cord. Based on the MRI findings, the patient was diagnosed with PS, and computed tomography (CT)-guided drainage was performed for disk drainage and detection of pathogenic bacteria. MRSA was detected in the bacterial culture of the intervertebral disk.
+The patient was treated with intravenous daptomycin (700 mg/day) for 10 days, intravenous teicoplanin (800 mg/day) for 5 weeks, oral sulfamethoxazole–trimethoprim (4 g/day), and oral minocycline (200 mg/day).
+The patient’s symptoms improved, and he was transferred to the hospital 3 weeks later. His oral antibiotic treatment was scheduled to continue; however, the patient stopped the medications at his own discretion.
+After 6 weeks, the patient presented again with high fever and back pain. PS recurrence was suspected. MRI and CT showed an intradiscal abscess at the T9–T10 level, anterior paravertebral abscess, and extensive vertebral body destruction . We diagnosed septic shock due to PS at the T9–T10 level.
+The patient underwent a two-stage operation: anterior vertebral debridement and fixation with iliac bone graft and10 days after first surgery, posterior fixation with instrumentation.
+Seven days after second surgery, the patient complained of increased right chest pain and shortness of breath. Chest X-ray showed a moderate pleural effusion in the right lung; however, electrocardiogram showed no obvious abnormality. Two days later, in the middle of the night, the patient’s right chest pain increased, his blood pressure dropped, and he had shock. Chest X-ray showed massive hemothorax in the right lung . The patient’s hemoglobin had dropped sharply from 8.1 g/L to 6.4 g/L. Chest CT and subsequent intercostal arteriography showed a pseudoaneurysm in the right eighth intercostal artery, which was considered to be the source of the bleeding. This presentation appeared to be ruptured mycotic aneurysms involving intercostal vessels. Following local anesthesia with 1% Lidocaine, the right common femoral artery was punctured utilizing a single-wall technique. A 4-Fr sheath was introduced, and 4-French shepherd’s hook catheter (Terumo Clinical Supply, Tokyo, Japan) advanced selectively into the right 8th intercostal arteries. Angiography confirmed the target aneurysms of the 8th intercostal artery. A 1.7-French microcatheter (Prograde-α; Terumo Clinical Supply) was inserted and the aneurysms were then embolized with a N-butyl cyanoacrylate (NBCA)/Lipiodol mixture (1:2) . There were no intraoperative complications.
+The patient was treated with intravenous daptomycin (700 mg/day) for 6 weeks, oral sulfamethoxazole–trimethoprim (4 g/day), and oral minocycline (200 mg/day). Then, the patient completed his course of antimicrobial therapy in the hospital without any complications .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2798_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2798_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c5dae972ec38ab4ccff07748b0f21ebd3dfc8b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2798_en.txt
@@ -0,0 +1,4 @@
+A 28-year-old healthy man sustained injury to the left lower leg due to a traffic accident. He was admitted to the local hospital and received a DR/CT examination . The patient suffered a left ankle fracture, clavicle fracture and dislocation. He underwent debridement followed by Vacuum Sealing Drainage (VSD) cover and fibula plate fixation surgery. He was moved to the ICU postoperatively. One week later, he underwent open reduction and internal fixation of clavicle fracture surgery. Postoperative healing of the left shoulder wound was satisfactory, but the left lower leg showed poor wound healing and a large-area skin defect, and the long bone remained exposed. The patient returned to our hospital for further treatment.
+The patient presented with stable vital signs and absence of any cardiopulmonary abnormalities; the wound covering the VSD had good negative pressure. There was a weak dorsalis pedis artery, toes showed restricted movement, the shoulder wound healed completely, dorsalis pedis pulse improved, the posterior tibial artery pulse remained unchanged, and the lateral margins of the left foot felt numb. General physical examination results were without exception.
+The blood test results of the patient showed white blood cell count of 12.36 * 109/ L, neutrophil percentage of 80.3 %, C-reactive protein of 53.66 mg/L, and calcitonin of 0.115 (0–0.05 ng/mL).
+Severe open wound to the left calf, Large skin defect on left calf, Extensive bone exposure in the left calf, Left medial malleolar defect Positive after admission to cephalosporins anti-infection treatment, 7 Ye Zao nucleoside detumescence, low molecular heparin calcium sodium anticoagulation. Four days after admission and debridement surgery, the patient had a large left leg skin defect, the tibia was exposed (area: 23 cm * 10 cm), the ankle area had defects, and the medial malleolus osseous was absent . Ankle joint debridement take part of the training for the inflammatory tissue + drug susceptibility, after thorough debridement, will narrow rear to lift ahead of soft tissue wound, finally use the VSD cover the wound. After 4 days of germiculture, results revealed the presence of enterococcus, and the patient received levofloxacin to fight infection. After 7 days, the VSD was dismantled, the wound and exposed bone area had become smaller, and the surrounding granulation tissue was fresh. The medication of the patient was changed . After 14 days, the patient underwent a second surgery, where intraoperative debridement was carried out on the wound again; ipsilateral thigh skin transplantation was undertaken and covered with VSD. The skin graft grew well, leaving the long bone exposed . After 4 weeks, the skin graft area was observed to be healing well. The exposed bone was ground intraoperatively and subjected to micropower drilling such that each hole was spaced 5 to 10 mm apart . Gentamicin bone cement (DuPuy Synthes, USA) was mixed with powder bone cement (40 g); polymethyl methacrylate reagent (DuPuy Synthes, USA) was added and fully mixed. The cement dough was placed to cover the bone shape and fixed with sutures . The bone cement was removed, and the tissue showed no signs of necrosis . Using an external fixator with the fibula plate, the fibula segment and trim were removed. The fibula ankle bone graft showed fusion and wound healing. The patient was followed up 1 month after discharge, and the affected area showed no infection, indicating recovery .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_283_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_283_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..21761f2382ea92124bfb8c70af7e992cada1da0e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_283_en.txt
@@ -0,0 +1,2 @@
+During August 2017, a 65year-old female was admitted to our department with histological finding of EPC of the right leg. One month before, she underwent surgical excision of a cutaneous lesion of the right leg. This lesion appeared brownish, exophytic, with ulcerated surface, more suggestive for a squamous cell carcinoma than an ulcerated nodular basal cell carcinoma. The histological examination revealed a poroid neoplasm extending into the reticular dermis with a thickness of 5 mm, 10 mitoses per 10 high-power field, absence of lymphovascular invasion and free margins with a clearing distance of 2 mm. shows the hematoxylin-eosin stain picture of the lesion.
+She had a past medical history of hysterectomy and bilateral salpingo-oophorectomy for uterine fibromatosis, kidney transplantation for severe chronic renal failure, high blood pressure, aneurysmal dilatation of the right common carotid artery, hypercholesterolemia, hyperparathyroidism and previous inferior myocardial infarction. Laboratory tests, including blood count, biochemical investigations and serum viral markers were normal. After multidisciplinary discussion and based on the sub-optimal clearing margin we performed a re-excision of the previous wound to ensure wider safety margins of at least 20 mm. It was also decided to perform a SLNB; the pre-operative lymph node scintigraphy showed the presence of two sentinel lymph nodes in the right inguinal site. The patient underwent enlargement of the surgical excision until 20 mm of free margin from the previous excision and SLNB of the two lymph nodes identified preoperatively. Recovery from surgery was uneventful and the patient was discharged from hospital on the first post-operative day. Histopathological examination found no signs of residual or satellite neoplasia in the surgical sample and the two retrieved sentinel lymph nodes were negative for metastatic disease. Patient is disease free 7 months after the operation and continues follow- up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2874_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2874_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0330c73de73ef33fd7df2a409c7d0a6fd588d92
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2874_en.txt
@@ -0,0 +1,5 @@
+We report the case of a 78y.o female patient suffering from trauma to the left shoulder due to a car accident with the car tumbling multiple times, X-rays and CT scan with 3D reconstruction done in the ER reveal a bipolar clavicular fracture, the distal third clavicle fracture Allman type II group IIB, and AC joint separation Rockwood type V, group III Allman medial clavicle fracture, on the ipsilateral reverse shoulder prosthesis; as well as 3rd to 7th ribs fracture that were treated conservatively.
+A shoulder immobilizer sling was placed initially, and she was scheduled for open reduction and internal fixation of the clavicle fracture.
+Patient was taken to the operating room, under general anesthesia, beach chair position with arm rest, scrubbing and draping done. Using two k-wires under fluoroscopy, reduction and fixation of the lateral part of the fracture to the midshaft of the clavicle. Incision over medial aspect of the clavicle, dissection reaching the bone, reduction and fixation with plate and screws construct. Instability remained over the lateral part so decision to open reduction and internal fixation with fiberwire and endobuttons was taken. Using a small incision over acromioclavicular joint and distal clavicle, reduction and fixation was done with two endobuttons and fiberwire in three planes. Closure was done in the usual fashion, shoulder immobilizer was placed and post operative radiographs were done . The patient was discharged three days postop.
+Postoperatively, the patient was immobilized for 3 weeks then, gentle passive range of motion was initiated for two weeks followed by progressive active range of motion. Follow up radiographs were done at one month post op .
+At three months post-op follow up, the percutaneous pins have been removed. The patient recovered most of her range of motion and is pain free, with satisfactory follow up imaging .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2888_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2888_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..889594e33de9099ee861253699d7450ee41952c8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2888_en.txt
@@ -0,0 +1,4 @@
+A 55-year-old man experienced allergic rhinitis for 2.5 years with no hepatitis or kidney disease. He became ill at the sight of greasy food on January 12, 2022 and sought care at a local health center on January 13, 2022. The specific therapeutical program he received was unknown, and the effect was unhelpful. His daily urination frequency and volume gradually decreased. He also had epigastric pain, generalized weakness, and hiccups and was admitted to a local hospital on January 16, 2022. The laboratory test results were as follows: white blood cell (WBC) count, 8.95 × 109/L (reference value 3.5–9.5 × 109/L); platelets (PLTs), 9 × 109/L (reference value 125–350 × 109/L); direct bilirubin (DBIL), 135.07 µmol/L; indirect bilirubin (IBIL), 20.99 µmol/L; albumin (ALB), 36.5 g/L(reference value 40–55 g/L); alanine transaminase (ALT), 8,453 U/L (reference value 9–50 U/L); aspartate aminotransferase (AST), 3,515 U/L (reference value 15–45 U/L); serum ammonia (AMON) 435.79 µmol/L (reference value 18–72 µmol/L); creatinine (Cr), 809 µmol/L (reference value 40–115 µmol/L); blood urea nitrogen, 32.82 mmol/L(reference value 2.00–6.90 mmol/L); amylase (AMYL), 184 U/L(reference value 0–96 U/L); prothrombin time (PT), 55.1 s (reference value 8.80–13.80 mmol/L); and activated partial thromboplastin time (APTT), 64.50 s (reference value 26.00–42.00 mmol/L). No obvious abnormality was observed in the remaining parameters. The local hospital made a diagnosis of acute renal failure, acute liver failure, coagulation dysfunction. Considering the seriousness of the patient’s condition, he was transferred to the intensive care unit of the local city hospital. And symptomatic and supportive treatment was given (specific therapeutic schemes were unknown). After 5 days of treatment, the patient continued to experience abdominal pain, abdominal distention, and anuria. Transaminase levels decreased significantly, but serum creatinine and bilirubin levels remained unchanged. The laboratory test results after treatment were as follows: DBIL, 176.70 µmol/L; IBIL, 17.08 µmol/L; ALB, 35.1 g/L; ALT, 637 U/L; AST, 87 U/L; AMON, 47.79 µmol/L; Cr, 681 µmol/L .
+For further diagnosis and treatment, he was transferred to our department at on January 22, 2022. To determine the cause of the disease, the doctor repeatedly asked the patient’s history. It was then revealed that the patient had followed folk medication and consumed Xanthii Fructus for 2 months, approximately 20 g (35–40 particles), once daily (at night, before going to bed). During the same period, no other drugs were taken, and no toxic animals, plants, or chemicals were consumed. Upon admission to our hospital, his vital signs were as follows: temperature, 36.6 °C; heart rate, 79 beats/min; respiratory rate, 20 breaths/min; blood pressure, 131/75 mmHg; and oxygen saturation, 99%. He appeared to be in severe pain and severe yellowing of the skin and white of the eyes . Heart and lung examinations showed normal findings. He also had a soft abdomen, tenderness of the upper abdomen, no rebound pain, and muscle tension, and the liver was palpable 2 cm under the rib margin. The spleen was not palpable under the ribs. Normal borborygmus was noted. Physiological reflexes were present, but no pathological reflexes, such as Babinski’s sign, were induced. The laboratory test results obtained in our department were as follows: WBC count, 14.05 × 109/L; PLT, 57 × 109/L; ALT, 573 U/L; AST, 138 U/L; AMON, 59 µmol/L; Cr, 514 µmol/L; serum myoglobin (MYO), 856.20 ng/mL (reference value 0–70 ng/mL), serum high-sensitivity troponin I (hs-CTNI), 22.70 ng/L; NT-PROBNP (BNP), 4,718 pg/mL; PT, 18.90 s, APTT, 43.90. No significant changes in electrocardiogram findings were observed. Chest computed tomography revealed inflammation of both lungs and manifestations of bilateral pleural effusion and hypoexpansion of the adjacent lung tissues. Abdominal computed tomography particularly revealed ascites and thickening of the gastric wall and part of the intestinal wall. Xanthii Fructus-related multiple organ dysfunction syndrome was diagnosed, and the treatment included nutritional support and daily administration of medications including lansoprazole (30 mg bid), magnesium isoglycyrrhizinate injection (Chinese Medicine Approval: H20051942, CTTQ, Lianyungang, Jiangsu Province, China) (0.2 g), furosemide (100 mg bid). Fresh plasma (200 mL) and cryoprecipitate (12 u) were also given. Continuous venovenous hemodialysis (Prismaflex ST100) was also administered.
+On day 2, his heart rate was 146 beats/min, and blood pressure was 112/67 mmHg. The patient was irritable. He continuously had a stomachache, which did not improve, but, instead, gradually worsened. The patient was administered phloroglucinol (40 mg IM) for pain relief and esmolol micropump for heart rate control.
+On day 3, the patient was delirious, drowsy and continued to have anuria. He developed sighing and open-mouth breathing. His blood pressure continued to drop to 38/21 mmHg, heart rate was 86 beats/min, and respiratory rate was 24 breaths/min, with 89% oxygen saturation. The laboratory test results were as follows: pH, 6.82; partial carbon dioxide pressure (PCO2), 64 mmHg; partial oxygen pressure (PO2), 277 mmHg; lactic acid (Lac), 7.80 mmol/L; K+, 7.5 mmol/L; WBC count, 17.44 × 109/L; PLT count, 56 × 109/L; DBIL, 233.6 µmol/L; IBIL, 94.1 µmol/L; ALB, 33.5 g/L; ALT, 338 U/L; AST, 101 U/L; Cr, 719 µmol/L; MYO, 6,114.00 ng/mL; hs-CTNI, 96.14 ng/L; BNP, 24,049 pg/mL; PT, 21.70 s; APTT, 43.50 s; Fib, 2.75 g/L; DD-i, 23.81 µg/mL. High-flow oxygen was administered, and IV norepinephrine was provided via micropump to increase blood pressure; additionally, the patient received an intravenous drip of nikethamide and lobeline to maintain breathing, intravenous drip of sodium bicarbonate to correct acidosis, and intravenous injection of calcium gluconate to reduce potassium levels. The pumping esmolol micropump was then stopped. After 30 min, the patient was still in coma (Glasgow Coma Scale score: 3 points), with blood pressure of 107/76 mmHg, heart rate of 113 beats/min, respiratory rate of 22 beats/min, and 100% oxygen saturation. Arterial blood gas analysis revealed the following: pH, 6.93; PCO2, 62 mmHg; PO2, 212 mmHg; Lac, 7.0 mmol/L; and K+, 6.90 mmol/L. The patient’s family gave up further treatment and arranged for discharge from the hospital. The patient died on the day of discharge .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2911_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2911_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b94f37a75660aa406a6b208363f6040c2c3190c4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2911_en.txt
@@ -0,0 +1,7 @@
+A 59-year-old white European man with a history of epilepsy, treated with valproic acid and carbamazepine, was admitted to our emergency department for a serious head injury after falling down the stairs at home. His family contacted our emergency department soon after the accident. An initial medical examination found a Glasgow Coma Scale (GCS) of 9/15 with no pupillary defect. His heart rate was 50 beats per minute. His blood pressure was 100/50 mmHg and his blood oxygen was 80 %.
+He underwent orotracheal intubation and vascular filling. A clinical examination revealed a large scalp wound, which was responsible for a significant blood loss, which continued until his arrival at our hospital despite a compression bandage. He was transferred to our emergency neurosurgery unit.
+On admission, he underwent a vascular filling (1.0 L of saline). A neurological examination found a GCS of 3/15 and his pupils were intermediate, symmetric, and reactive. The admission laboratory tests, summarized in Table , showed anemia, thrombocytopenia, hypoproteinemia and coagulation disorders.
+A brain scan without contrast (performed 2 hours after his head injury) showed an isodense, extracerebral, homogeneous SDH, 40 Hounsfield units (HU) approximately, with an estimated maximum thickness of 20 mm, situated along the right convexity . There was also a subarachnoid hemorrhage in the fold of the left convexity . The SDH had a mass effect with a 15 mm deviation of midline structures to the left and cerebral compression. In the bone window, the scan showed multiple fractures of the cranial vault in the layers above and below . This initial damage assessment revealed no other lesions. The patient became hypotensive. His blood pressure was 70/40 mmHg. He underwent hemodynamic support by continuous administration of norepinephrine (1 mg/hour) associated with 1.0 L of saline and 500 mL of Gelafundin (succinylated gelatin). Four units of packed red blood cells were administered with six units of fresh frozen plasma.
+He was immediately transferred to our operating room. A burr hole was first drilled through his right parietal bone to assess the consistency of the hematoma and relieve the cerebral compression as quickly as possible. Correction of coagulation disorders was carried out at the same time by our anesthetists. Fresh blood mixed with clots flowed through the burr hole, thus confirming the acute nature of the hematoma.
+In order to evacuate the hematoma, the incision was extended to carve a frontotemporoparietal flap giving access to the entire convexity and confirming the clotted appearance of the acute SDH. The flap was not put back in place when closing due to a life-threatening cerebral edema.
+He was admitted to our neurosurgical intensive care unit. The evolution was marked by the appearance of intracranial hypertension, which was refractory to medical treatment and led to the appearance of clinical signs of encephalic death, which was confirmed 72 hours after admission to our intensive care unit.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2912_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2912_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..734123da03d3d7a52cf3951cd755437679ef854a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2912_en.txt
@@ -0,0 +1,9 @@
+A 41-year-old healthy male who presented to the clinic with a symptomatic chronic right Grade 3 ACJ dislocation .
+He failed conservative treatment, including NSAID’s, rest, and physical therapy. His pain was located over her ACJ and worsened with increased activity. Due to his continued symptoms along with failed conservative treatment, surgical intervention was recommended. We agreed to pursue an arthroscopic-assisted ACJ reconstruction with allograft and joint fixation with a HP hook plate. We agreed that the HP hook plate will be removed at 6 months due to long- term complications such as impingement, irritation, and among others.
+In the operating room, a standard posterior arthroscopic portal was established. Arthroscope was inserted into the glenohumeral joint. A second portal was established in the anterior aspect of the shoulder under direct visualization. . Supraspinatus, infraspinatus, and teres minor were intact.
+At this time, ArthroCare wand was then used to release all soft tissues underlying the coracoid. . This was then debrided back and completed with the arthroscopic shaver. We were able to outline the coracoid back to its base, exposing the undersurface of it. At this time, using direct visualization, we established a second anterolateral portal. Two cannulas were placed. The first was in the first anterior portal and second was in the second anterolateral portal.
+At this time, intraoperative fluoro was brought in. A curvilinear incision centered over the clavicle was then made. . Dissection was carried down exposing the superior surfaces. Soft tissue was elevated both anterior posterior, which was in the main portion of the clavicle. Then, using fluoroscopic assistance, we were able to place a switching stick into the clavicle and lateral to the coracoid. This was dilated over. FiberStick suture was then inserted and the suture was retrieved out for graft passage. We then placed the switching stick posterior to the clavicle and medial to the coracoid. This was again confirmed under intraoperative fluoro. We were able to retrieve out Tiger stick suture passer. We then were able to shuttle in the posterior tib allograft nicely having the graft present on the undersurface of the coracoid .
+Next, we proceed with the distal clavicle excision. The distal end of the clavicle was exposed with electrocautery. Based upon pre-operative imaging, it was felt that 10 mm resection was indicated. The amount of resection was marked. This was confirmed to be appropriate on intraoperative fluoro. . Oscillating TPS saw was then use to perform resection. . The degenerative distal clavicle was removed.
+Following resection, we then under fluoroscopic evaluation confirmed that a 15 mm 7-hole HP hook plate was appropriate size . This helped reduce the clavicle nicely down appropriately. We then held the reduction with a ball-tip guide pusher. The graft was then crossed over in a crossing fashion and this was tied to itself using #2 FiberWire in a figure-of-eight fashion. The clavicle HP hook plate was then positioned appropriately, overlying the graft that was just tied. This acts as an adjuvant to ensure the graft position is stable. Three bicortical screws were placed medially. . One locking screw was placed laterally. Fluoroscopic evaluation showed appropriate reduction of the ACJAC joint with good length and position of the hardware.
+Post operatively, the patient denied any increased pain or instability. X-rays showed a well reduced AC Joint .
+At the 6-month post-operative mark, due to some superficial irritation from the plate, we surgically removed the HP hook plate and the AC Joint remained well reduced. Now 2 years out from surgery, there has been no reported complications in her outcomes.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2927_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2927_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aabb25cda7418936bd16970b0648182f4492aad1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2927_en.txt
@@ -0,0 +1,2 @@
+A 61-year-old man with mild obesity, treated for T2DM with empagliflozin 10 mg/d, metformin 2000 mg/d and recently 12 units/day of long-acting insulin, underwent elective hip replacement surgery. Pre-operative assessment was unremarkable, with a low estimated risk of anesthesia (ASA 2). No oral antidiabetic agents were administered the evening before surgery. The surgery performed on day 1 (D1) was uneventful, as was the stay in the HDU. The administration of empagliflozin, metformin and insulin in chronic doses was resumed on D2. The patient was transferred to a ward on D3. On D4, the patient felt unwell and vomited once, but his condition improved after administration of metoclopramide. The attending physician revealed no remarkable findings. Blood gas analysis was not performed. On D5, the patient still felt unwell but without any specific complaints such as chest pain or dyspnea. Glycemia was below 10 mmol/l. In the evening, the patient vomited again. One hour later he suddenly collapsed due to cardiac arrest by ventricular fibrillation. CPR was started immediately, with ROSC after 35 min. Post-arrest ECG and echocardiography suggested acute myocardial infarction. Immediate coronary angiography revealed several significant chronic coronary artery stenoses but no acute culprit lesion, consistent with only minimal troponin T elevations over the following days. The left ventricle ejection fraction was 30–35% and there were no echocardiography findings suggestive of pulmonary embolism. On admission to the ICU, the patient was anuric and required norepinephrine. He died on D8 due to severe post-hypoxic brain injury.
+On admission to the ICU one hour after CPR, a severe mixed metabolic acidosis was present with pH of 6.85 and base excess of -29 mmol/l . Lactate was only moderately elevated (5.8 mmol/l). An elevated beta-hydroxybutyrate concentration of 3.2 mmol/l. Corresponded to a mild ketoacidosis . Together with lactate and acetoacetate, whose concentration is about three times lower than that of beta-hydroxybutyrate, the total organic acid concentration was about 10 mmol/l. The anion gap was 18.1 mmol/l, i.e. 9.6 mmol/l higher than expected . Thus, the increase in the anion gap can be explained entirely by organic acids, with no other component. Subtracting this increase in anion gap still leaves a base excess of almost − 20 mmol/l, which must be explained by a non-anion gap hyperchloremic acidosis (admission Cl− was 117 mmol/l, see Table ). Overall, we found a mixed metabolic acidosis - lactic acidosis, ketoacidosis and hyperchloremic acidosis. We consider the lactic acidosis to be a consequence of cardiac arrest, but the other components of the acidosis, with base excess of -23 mmol/L after subtraction of the lactate, must have been present before CPR. We found no etiological explanation for the acidosis other than the SGLT2i-associated ketoacidosis. We hypothesize that SGLT2i gradually induced severe acidosis within 5 days of surgery, which triggered a malignant arrhythmia in the context of previously undiagnosed coronary artery disease. Here, we briefly review the pathogenesis of SGLT2i-associated acidosis and discuss some specific points of the presented case.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2932_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2932_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..02f33c2e60346ee58ca71501fb8efbf482cab8b7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2932_en.txt
@@ -0,0 +1,3 @@
+A 42-year-old woman fell from a height of 15 m. During pre-hospital evaluation, her Glasgow Coma Scale (GCS) score was 14, the right lower extremity was deformed, and the radial artery pulse was weakly palpable. On arrival at our institution, her GCS score was 13, blood pressure was 60/30 mmHg, heart rate was 140 bpm, and respiratory rate was 50 breaths per minute. As part of initial resuscitation, resuscitative endovascular balloon occlusion of the aorta (REBOA) was performed to prevent further hemodynamic deterioration due to lower extremity and pelvic traumas. During catheterization, however, her systolic blood pressure decreased to 30 mmHg, and she deteriorated to near imminent cardiac arrest.
+To prevent the aggravation of hypotension and risk of cardiac arrest, we performed RT and cross-clamping of the descending aorta through the left 4th intercostal space in the supine position. At the time of RT, a small hemopneumothorax and multiple rib fractures were observed. Hemopericardium or mediastinal hematoma was not identified. Her systolic blood pressure increased to approximately 90 mmHg after cross-clamping of the aorta, and cardiac arrest was averted; therefore, REBOA was completed, and direct aortic clamping was converted to balloon occlusion of the aorta to perform contrast-enhanced computed tomography (CT) under controlled balloon occlusion of the aorta.
+Contrast-enhanced CT showed bilateral pneumothorax, pulmonary contusion, bilateral multiple rib fractures, pelvic fracture, and right femoral diaphyseal fracture. Extravasation of contrast media from the descending aorta was also observed . Based on the initial radiological findings of the left intrapleural cavity and mediastinum, avulsion of one or more aortic branches due to cross-clamping of the aorta during RT was suspected. Although her hemodynamic status improved after transcatheter arterial embolization of the aortic branches with coils, she developed hypovolemic shock after 6 h despite continuous blood transfusion. Repeat CT showed extravasation adjacent to the descending aorta. Therefore, we decided to perform TEVAR for controlling the hemorrhage occurring at the site of avulsion of the aortic branches. The stent-graft (Conformable GORE TAG 21 × 100 mm, Gore Medical, Newark, DE, USA) was deployed to adequately cover the avulsion of the aortic branches, and extravasation from the aorta eventually disappeared . Complications of TEVAR, including paraplegia and other thrombo-ischemic events, did not occur. She was discharged on the 59th hospital day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2938_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2938_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..16566c4cafd11bc5b1a2f85b2cbfb3dfa05ac73f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2938_en.txt
@@ -0,0 +1,2 @@
+A 53-year-old Japanese woman was admitted to Niigata Rheumatic Centre, Shibata city, Japan. She had been diagnosed with MS associated with right optic neuritis and thoracic myelitis when she was 25 years old and treated with high-dose prednisolone (PSL). The myelitis had relapsed three times when she was 36, 37 and 40 years old and treated with high-dose PSL. Oligoclonal IgG band was found in cerebral spinal fluid (CSF) and IgG and myelin basic protein in CSF were elevated (4.9 mg/dL and 1.2 mg/dL, respectively). Brain T2 weighted magnetic resonance imaging (MRI) showed high intensity area beside left lateral ventricle indicating asymptomatic plaque lesion due to MS. High intensity area was also shown in T2 weighted MRI of cervical spinal cord. Anti-aquaporin 4 antibody was negative. Slight right hemiparesis remained, and she needed a cane to walk outside. The MS achieved remission and PSL was stopped for 9 years. When she was 50 years old, polyarthritis developed, and rheumatoid factor and C-reactive protein (CRP) levels were high. She was diagnosed with RA. The PSL was restarted at 7.5 mg daily and methotrexate (MTX) was begun. Because the MTX could not be increased over 8 mg/week because of mild elevation of transaminases, tacrolimus (3 mg daily; TAC) was added to MTX and leukocyte apheresis was performed. However, the RA activity remained high: the CRP was 2.3 mg/dL and the disease activity score (DAS28ESR) was 4.94 (moderate disease activity). Furthermore, joint space narrowing of both knees and ankles had progressed obviously over 1 year. Because anti-TNF therapy can exacerbate demyelinating disease, the anti-IL-6 receptor antibody tocilizumab (TCZ) was started at 8 mg/kg every 4 weeks. At the second administration of TCZ, the CRP was <0.1 mg/dL and the DAS28ESR was 2.0 (complete remission). The MTX and TAC were tapered and stopped in 6 months, and the PSL was tapered to 0.5 mg daily in 1 year. The health assessment questionnaire disability index (HAQ DI) in 1 year was 1.88 and functional disability was remained. At the 5-year follow-up, she remained in remission with TCZ.
+Serum interferon (IFN) -γ was negative (≤0.1 IU/mL) and serum high sensitivity TNF-α was within normal range (1.6 pg/mL) before starting TCZ therapy. Both of them kept the same levels for a year. Serum IL-6 level was elevated, 51.2 pg/mL (normal range; ≤4.0 pg/mL) before starting TCZ therapy and it was 57.1 pg/mL a year later.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2945_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2945_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..925aed326f68505f92bc1c3c8d3b8efa84310854
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2945_en.txt
@@ -0,0 +1,4 @@
+A 63-year-old male presented with dorsal pain of a 3 month duration. He had undergone gross-total resection of an invasive mixed AB thymoma (Masaoka-Koga II–III) 21 years ago, followed by local radiotherapy (52 Gy). After staying disease free for 12 years, he developed three pleural nodules; subsequent biopsy demonstrated pleural recurrent thymoma that was then treated with gamma knife radiosurgery (13 × 300 cGy in each lesion). The pleural lesions remained stable for the next 10 years. The patient was referred to our institution at the time radiographic spinal cord compression at T8-T9 level was discovered in addition to pleural thickening involving both hemithoraces . Examination did not evidence any neurological deficits.
+The magnetic resonance imaging showed an irregular, dumbbell-shaped lesion at the T8–T9 level with an intraspinal component occupying 60% of the canal, displacing the cord toward the left .
+The spinal and foraminal components of the tumor were removed through a one-level laminectomy with right-sided foraminotomy and medial T8–T9 facetectomy . The right T8 root was encased by an epidural solid tumor mass . Following gross total resection, a small dural hole was repaired at the right-sided T8 exiting nerve root . Intraoperatively, neurophysiologic recordings remained stable . The patient's postoperative course was uneventful. Postoperative MRI confirmed complete removal of the spinal tumor component . He declined postoperative adjuvant chemotherapy. Six months postoperatively, he remained neurologically intact without pain.
+The histological analysis revealed an admixture of neoplastic epithelial cells and nonneoplastic small lymphocytes. The morphological and immunostaining features of the tumor corresponded to metastatic thymoma .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2951_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2951_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f77fed9cd23758a73dc95133514d132de5905f4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2951_en.txt
@@ -0,0 +1,8 @@
+We report the case of a 43-year-old man who was admitted to our hospital with severe intake reduction due to early satiety.
+The patient complained of severe abdominal pain, accompanied by nausea and vomiting, after heavy consumption of spirits with a high alcohol concentration 20 d prior. The local hospital diagnosed acute pancreatitis. After receiving medical treatment, such as medications to inhibit acid and inhibit pancreatic enzyme secretion, the patient was discharged with improvement. However, two weeks later, the patient experienced severe intake reduction due to early satiety and left upper abdominal pressure, and computed tomography (CT) showed multiple pseudocysts around the pancreas. The local hospital diagnosed PPC, and conservative treatment was ineffective.
+He had no previous history of gallstones.
+The patient had a history of drinking more than 20 years and drank approximately 500 mL/d of high-concentration liquor.
+The left upper abdomen showed a large mass with clear boundaries and poor motion.
+The patient’s leukocyte count was 9.72 × 109/L, his neutrophil ratio was 77.5%, and his C-reactive protein level was 73.49 mg/L. His pancreatic amylase level was slightly elevated (84 μ/L), while his blood amylase level was within normal limits.
+On 13 February 2023, contrast-enhanced CT showed multiple cystic foci in the abdominal cavity and low-attenuated, homogeneous fluid collections, with a maximum diameter of 89 mm × 76 mm .
+EUS revealed multiple cystic masses with hyperechoic necrosis and arterial vessels, the maximum size of the cysts was 56 mm × 36 mm, and the necrotic collection was not completely wrapped .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2960_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2960_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7c0c15a4dcae087396f53cc0d8fda37901c70a5f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2960_en.txt
@@ -0,0 +1,6 @@
+A 62-year-old woman presented to our emergency department with progressive shortness of breath and cough for 3 days. Initial physical examination revealed that the patient was tachypneic, and vital signs were temperature 37.7° C, heart rate 110 beats per minute, blood pressure 100/55 mm Hg, and oxygen saturation 85% on room air. Chest auscultation revealed clear lung fields and a pansystolic murmur over the right lower parasternal area. Her history was significant for end-stage renal disease managed with regular haemodialysis by a right-sided double-lumen tunnelled catheter. At this time, the differential diagnosis included pulmonary embolism, fluid overload, and SARS-CoV2 infection.
+Computed tomography pulmonary angiography was performed and revealed bilateral segmental and subsegmental pulmonary embolism . Polymerase chain reaction testing for SARS-CoV2 was negative. The patient was admitted to the intensive care unit, and intravenous heparin infusion 18 U/kg/h was initiated and up titrated till 28 U/kg/h to achieve APTT of 80 ms. She subsequently stabilized. However, 2 days later, she suddenly developed hypotension with blood pressure of 70/40 mm Hg.
+Transthoracic Echocardiography (TTE) revealed a dilated right-side, significant tricuspid regurgitation, pulmonary artery systolic pressure was 56 mmHg with normal aortic valve morphology and flow. Electrocardiography showed ST-segment elevation in the inferolateral leads . Laboratory studies showed a high-sensitive cardiac troponin-T values that increased from 5000 ng/mL to 21 957 ng/mL (reference range: 0–18 ng/mL). The patient was immediately moved to the catheterization laboratory for coronary angiography, which revealed total occlusion of the posterior descending artery. Multiple attempts for aspiration and balloon inflation to restore the flow failed. The patient then was relocated to the ICU.
+Two days later, the patient suddenly developed complete heart block, which required temporary pacemaker insertion. In addition, she became feverish with a temperature of 38.9° C, and pus oozing from the haemodialysis catheter site was observed. Line sepsis was diagnosed, and the catheter was removed with a large amount of pus. Subsequent blood culture and catheter tip culture revealed Methicillin-resistant Staphylococcus aureus.
+Transesophageal echocardiography (TOE) was performed and revealed aortic valve vegetations with acute severe aortic regurgitation, right atrial appendage mass, and patent foramen ovale. A multidisciplinary team meeting was urgently done, and the decisions were immediate initiation of antibiotics and urgent preparation for surgery. Intravenous vancomycin 30 mg/kg/d in three doses was initiated.
+After 90 min, the patient developed a disturbed level of consciousness and resistant shock. She was mechanically ventilated, intravenous inotropes were increased to the maximum dose and extracorporeal membrane oxygenation system was inserted. The patient continued to rapidly deteriorate, and then died.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2976_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2976_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3c20f1f2ec4c704cb5039df2299a47c815e930bf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2976_en.txt
@@ -0,0 +1,3 @@
+A 62-year-old male with hypertension and hyperlipidaemia presented to an urgent care clinic with 7 days of dizziness, fatigue, nausea, and vomiting. He was transported to the emergency department, evaluated, and discharged home. Approximately 4 days later, emergency medical services were called after the patient experienced syncope. Electrocardiogram (ECG) obtained en route reported anterior ST-segment elevations. Before arrival at the hospital he developed ventricular fibrillation. Cardiac defibrillation was successful and endotracheal intubation was performed. Upon arrival at the emergency department, ventricular fibrillation recurred, and resuscitative efforts restored sinus rhythm and spontaneous circulation. Following return of spontaneous circulation, exam was notable for heart rate of 77 b.p.m., a regular rhythm, and hypotension (86 mmHg/48 mmHg). There were no appreciable murmurs. There was no lower extremity oedema. The extremities were cool to touch. On pulmonary exam, he required mechanical ventilation with a rate of 28, tidal volume 500 mL, FiO2 100%, and positive end-expiratory pressure of 8 cmH2O. Breath sounds were present bilaterally. The subsequent ECG showed wide complex rhythm consistent with slow ventricular tachycardia with right bundle branch block morphology and left axis deviation. .
+Given the report of ST elevations prior to ventricular fibrillation, along with the ECG at presentation, there was high suspicion for acute coronary syndrome. He received aspirin, ticagrelor, and heparin for a presumed ST-segment elevation myocardial infarction. Epinephrine infusion was started due to bradycardia with hypotension. He was emergently taken to the catheterization lab, but coronary angiography did not reveal coronary stenosis. Right heart catheterization revealed elevated right-sided filling pressures with a right atrial pressure of 22 mmHg, pulmonary artery pressure 61/28 (39) mmHg, pulmonary capillary wedge pressure 15 mmHg, and Fick cardiac index 2.6 L/min/m2. Due to the unclear nature of his presentation, point-of-care echocardiogram was performed, and demonstrated a dilated right ventricle with severely reduced function. Based on point-of-care echocardiogram findings, there was concern for pulmonary embolism. Immediate pulmonary angiography was performed and revealed large, bilateral pulmonary emboli (, Video ). EkoSonic™ endovascular thrombolysis catheters were advanced into both main pulmonary arteries and 5 mg of tissue plasminogen activator was delivered through each catheter, followed by 2 mg/catheter/h for 2 h, then 1 mg/catheter/h for 16 h. Infusion was guided by fibrinogen monitoring as per institutional protocol.
+Upper and lower extremity Doppler ultrasounds were obtained but showed no evidence of venous thrombosis. Formal transthoracic echocardiogram confirmed depressed right ventricular function (, Video ). Computed tomography (CT) of the chest showed bilateral peripheral ground-glass opacities with wedge-shaped opacities in the right lung . These were thought to represent pulmonary infarctions, but, given refractory hypotension requiring vasopressors, he was started on broad-spectrum antibiotics for pneumonia. A viral respiratory panel was negative, but tracheal aspirate culture was positive for methicillin-resistant Staphylococcus aureus. Following completion of catheter-directed thrombolysis, repeat ECG showed sinus rhythm with first-degree atrioventricular (AV) block, left axis deviation, incomplete right bundle branch block, and prolonged QTc interval (498 ms) . Over the following 4 days, he developed anaemia, and CT of the chest, abdomen, and pelvis showed a mediastinal haematoma and persistent ground-glass opacities . Given his radiographic findings, and growing prevalence of COVID-19, he was tested for SARS-CoV-2 and found to be positive. He was transferred to a COVID-19-dedicated intensive care unit where he was placed under enhanced contact precautions and received supportive care. He was extubated 4 days later. Following extubation, he did well. He was admitted to an inpatient rehabilitation facility and discharged home on lifelong apixaban 5 mg twice daily. At 1 month follow-up, he described mild exertional dyspnoea that was improving. Transthoracic echocardiogram at that visit noted improvement of right ventricular dilation and systolic function (, Video ).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3005_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3005_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c3bfdf9e1d91a2a55f20982097f4277813cea78
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3005_en.txt
@@ -0,0 +1 @@
+23-year-old woman (gestation 2, 1 delivery) who consulted our institution in the 36.5th week of gestation for dry cough and progressive dyspnoea of three days' evolution, associated with myalgia and headaches. She was admitted tachycardic (120 beats per minute), afebrile and oxygen saturation of 96% in ambient air. In the context of a pandemic, a PCR was performed for SARS-CoV2 with a positive result. The chest radiograph was interpreted as normal. The patient began with contractions of labour, showing an unfavourable Bishop's score. In view of the lack of progression of labour, the pregnancy was terminated by caesarean section. Initial laboratory tests (pre-caesarean section) were requested, showing mild anaemia (Hb: 10.8 g%), mild platelet deficiency (123,000/mm3), altered hepatic profile: total bilirubin: 3.5 mg%, direct bilirubin: 3.3 mg%, glutamic-pyruvic transaminase (GPT): 564 IU/l, glutamic-oxaloacetic transaminase (GPT): 692 IU/l, alkaline phosphatase (AP): 337 IU/l and elevated LDH: 814 IU/l. Caesarean section was performed without complications, resulting in a healthy newborn, Apgar 8/9, Capurro 37 weeks, of adequate weight for the gestational age. Bupivacaine was used as a spinal anaesthetic. During the procedure, systolic blood pressure remained between 100 and 120 mmHg and diastolic blood pressure between 60 and 80 mmHg, with oxygen saturation of 98%. After the caesarean section, the patient was transferred to intensive care for adequate monitoring. Blood gases were measured (oxygen fraction inspired 21%), with the following results: pH: 7.17, pCO2: 23 mmHg, pO2: 115 mmHg - Bicarbonate: 8.1 mEq/l, excess base: -19 mEq/l - oxygen saturation: 96% and lactic acid: 11.4 mmoles/l. She received supportive treatment and a large amount of Ringer lactate with progressive improvement of the laboratory parameters. The parameters normalised after 72 hours. Respiratory compromise was mild, allowing discharge a few days later. The newborn did not present complications.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3029_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3029_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ae27be0ac083379806986edd5a17992c27a79787
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3029_en.txt
@@ -0,0 +1,25 @@
+Patient: Female, 61-year-old
+
+Final Diagnosis: Dilated cardiomyopathy
+
+Symptoms: Dyspnea on exertion
+
+Medication:—
+
+Clinical Procedure: Medications and CRT
+
+A 61-year-old woman with no medical history was admitted to our hospital in September 2008 for 2 months of progressive dyspnea. She was documented to have decompensated HF with New York Heart Association (NYHA) II functional limitations. She had no history of tobacco smoking, alcohol consumption, or substance abuse. Results of the physical examination were: height, 150 cm; weight, 42 kg; body mass index (BMI), 18.7 kg/m2; blood pressure, 120/66 mmHg; heart rate, 73 beats/min; and oxygen saturation, 94% (room air). Her dyspnea on exertion was class II based on the NYHA classification. On auscultation, a third heart sound (S3) and an apical systolic murmur were detected.
+
+Chest radiography revealed cardiomegaly and bilateral pleural effusions. ECG showed a sinus rhythm with LBBB and a QRS complex duration of 140 ms. Echocardiography revealed severe LV enlargement with impaired systolic function and an LVEF of 18% (normal range, 55–65%). LV diastolic to systolic dimension (LVDd/LVDs) was 56/48 mm (normal range, 40–55/30–45 mm), and moderate MR was observed. Based on these findings, the patient was admitted with a diagnosis of HF.
+
+Secondary cardiomyopathy associated with autoimmune disease, metabolic disease, and inflammatory disease may show echocardiographic findings similar to DCM. Blood tests results were normal and ruled out these diseases. Coronary angiography was also performed to exclude ischemic cardiomyopathy, and it did not demonstrate significant coronary artery disease. Cardiac magnetic resonance imaging demonstrated LV dilation with an LVEF of 16% and no evidence of abnormal gadolinium enhancement. Thus, no findings were suggestive of secondary cardiomyopathy after these examinations. Along with these results, and based on the 2006 American Heart Association Classification of “Contemporary definitions and classification of the cardiomyopathies,” we reached a final diagnosis of DCM.
+
+Diuretic treatment was initiated (furosemide: 40 mg/day, initially administered via intravenous injection and then orally) in combination with an angiotensin II receptor blocker (candesartan: 4 mg/day) and a β-blocker (carvedilol) for secondary prevention of HF. As the prognostic improvement associated with β-blockers is dose-dependent, the guidelines recommended increasing the dosage in accordance with the tolerance level of the patient. In our case, the carvedilol dosage was increased to 10 mg/day. The use of mineralocorticoid/aldosterone receptor antagonists and a further increase in the carvedilol dosage were not possible because of hypotension. The patient’s HF improved, and she was subsequently discharged.
+
+In October 2009, the patient was readmitted because of HF re-exacerbation, despite ongoing pharmaceutical treatment. Echocardiography revealed an LVEF of 30% and an LVDd/LVDs of 67/54 mm, and ECG indicated a QRS width of 144 ms. We determined that CRT was required; however, the patient refused because of fear of surgery. Hence, pharmaceutical treatment alone was continued. In June 2011, the patient’s HF worsened, and she was readmitted with significant widening of the QRS complex (160 ms), decreased LVEF (27%), and rapidly increased LVDd/LVDs (79/69 mm). In July 2011, she consented to CRT, and a pacemaker (AllureTM, St Jude Medical, MN, USA) was implanted. The placement of the LV leads resulted in a high LV pacing threshold; however, no other positions were feasible because there was no other coronary vein branch wherein the LV lead could be inserted with a good threshold. Immediately after implantation, the LVEF increased and QRS width decreased.
+
+Echocardiography performed in August 2011 revealed significant improvements in both the LVEF (46%) and LV enlargement (LVDd/Ds of 56/43 mm), the QRS width was 124 ms, and we were able to increase the carvedilol dosage to 20 mg/day. Follow-up echocardiography performed in June 2012 confirmed the improvement in the LVEF (65%) and LVDd/LVDs (47/30 mm), revealed QRS width of 136 ms, and showed mild MR.
+
+At this point, due to the high threshold of the LV pacing lead, the remaining battery power was estimated to last less than 1 year; thus, we decided to discontinue biventricular pacing. Although the LBBB persisted, follow-up ECG and echocardiography indicated that the QRS width had not increased (136 ms) and there was no deterioration in MR or LVEF. Therefore, with the patient’s consent, CRT was discontinued in October 2012 to preserve the battery. We changed the mode from DDD to AAI as there was a mild bradycardia, possibly due to the increased β-blocker dose. It was clearly communicated to the patient that CRT would be promptly restarted if there was any sign of HF re-exacerbation; she was carefully monitored for the following 4 years, during which there was no deterioration of cardiac function. Echocardiography and ECG revealed an LVEF of 69%, LVDd/LVDs of 44/27 mm, and a QRS width of 130 ms during follow-up in August 2014, and an LVEF of 60%, LVDd/LVDs of 42/30 mm, and a QRS width of 126 ms in June 2016. The latest follow-up in November 2018 revealed an LVEF of 64%, LVDd/LVDs of 44/30 mm, and a QRS width of 132 ms.
+
+In anticipation of probable cardiac remodeling that could re-exacerbate the HF, and thus require prompt resumption of CRT, a generator exchange surgery was performed in June 2016. At the most recent follow-up in 2020, CRT had not been resumed and the patient’s status remained stable without signs of re-exacerbation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3035_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3035_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b9aa4733d03a112fa233a80ed3487fdabaa25aa0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3035_en.txt
@@ -0,0 +1,9 @@
+A 29-year-old African American male individual presented to the emergency department (ED) for right upper quadrant abdominal pain and early satiety. Physical examination was unrevealing except for abdominal tenderness. His past medical history included 5 years of daily alcohol use and occasional marijuana use. A computed tomography (CT) scan revealed hepatomegaly with a large mass centered in the left lobe measuring 14 cm. Laboratory values showed mildly elevated transaminases, with an alanine transaminase (ALT) of 51, aspartate aminotransferase (AST) of 74, and an alkaline phosphatase of 93 units/L. The patient was then discharged with a planned outpatient hepatology follow-up.
+
+A total of 1 month later, the patient presented again to the ED with the same symptoms; magnetic resonance imaging (MRI) revealed a 19 cm enhancing left hepatic mass. Laboratory tests demonstrated a mild elevation in transaminases, a negative hepatitis viral panel, and unremarkable tumor marker levels, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), and carbohydrate antigen 19-9 (CA19.9). After appropriate pain control, the patient was discharged again with plans for outpatient follow-up.
+
+The patient was lost to follow-up owing to insurance concerns, until he presented to a different ED the following month for abdominal pain, vomiting, early satiety, and unintentional 10 lb weight loss. Abdominal CT angiography with contrast showed a 21 cm hepatic mass centered in the left hepatic lobe, and given the concern for hepatocellular carcinoma, the patient was admitted for biopsy and staging imaging. Laboratory tests revealed alkaline phosphatase elevation (451 IU/L) and mildly elevated transaminases, with an AST level of 93 units/L and an ALT of 45 units/L. His tumor marker laboratory results were within normal ranges (CA 19.9 < 14.0; AFP: 1.97; and CEA: 5.28). A chest CT revealed innumerable bilateral pulmonary nodules measuring up to 8 mm, favoring metastases. Initial histopathological examination of the liver biopsy specimens revealed a well-differentiated carcinoma characterized by a distinctive myxoid stroma with tubular and cribriform structures, consistent with metastatic adenoid cystic carcinoma. The patient underwent transcatheter arterial chemoembolization (TACE) and was discharged with a hematology–oncology follow-up.
+
+He was readmitted 2 weeks later for a planned repeat TACE procedure, as well as a repeat liver biopsy for further testing. Initial laboratory values on admission were an AST of 44 units/L, ALT of 24 units/L, and alkaline phosphatase of 282 units/L. During this admission, a computed tomography (CT) scan of the neck soft tissue with contrast revealed a complex bilobed mass in the right parotid gland measuring approximately 6.5 cm. Its progression into the parapharyngeal space caused notable deformity of the oropharynx, raising further concerns about potential malignancy. A biopsy was taken with immunohistochemistry findings suggestive of ACC; however, BCAC could not be completely excluded without examination of a completely removed salivary gland tumor. Therefore, a presumptive diagnosis of stage IV adenoid cystic carcinoma with metastases to the liver and lung was made. Given the tremendous tumor burden and poor prognosis, the treatment goals were palliative, and the patient was started on a chemotherapeutic regimen with cisplatin and vinorelbine.
+
+A total of 5 months later, the patient presented to the emergency department with neurological symptoms, including lightheadedness and left-sided weakness. A CT scan revealed new right frontal hyperdensities, consistent with brain metastasis. During this admission, he received one dose of radiotherapy with a plan to finish five doses. He was then discharged with a planned outpatient follow-up.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3040_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3040_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0eaf7a4e13b88f811bcda17621af6b40fa8090d1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3040_en.txt
@@ -0,0 +1,3 @@
+A 61-year-old woman with PD for 17 months because of end-stage kidney disease caused by immunoglobin A nephropathy visited our hospital regularly with no major issues. The abrupt elevation of transaminase levels in blood test results was observed during a routine outpatient session. That day was designated as day 0. The patient was awake, with a blood pressure of 158/88 mmHg and a body temperature of 36.8 degrees Celsius. She showed no signs of fatigue, nausea, abdominal pain, diarrhea, or jaundice. The effluent of PD was not cloudy and ultrafiltration was not impaired. Blood test results revealed elevations of liver enzymes such as aspartate aminotransferase and alanine aminotransferase. On a computer tomography examination, we found a slightly enlarged liver suspected of liver injury. We did not perform a liver biopsy or ultrasound imaging. Since day −49, the patient has been receiving tolvaptan 7.5 mg/day for volume control as the only new medication. Although her liver function was normal as of day −49 and the next session on day −28, we suspected tolvaptan-induced liver injury. We immediately discontinued tolvaptan administration and consulted the Gastroenterology Department of our hospital. To further investigate the cause of liver injury, the blood screening test was positive for HEV-IgA, and the patient was diagnosed with HEV infection; other blood test results suggesting hepatic failure caused by viral and autoimmune hepatitis were negative.
+
+Patient comorbidities included hypertension, renal and iron deficiency anemia, insomnia, and restless legs syndrome. The patient had no experience with blood transfusion, and the patient’s family did not have any history of liver injury. She did not consume any apparent contaminated water or raw meat such as swine, deer, and wild boar. The patient had not visited any countries with a known risk of developing HEV infection. In terms of medications, the patient was taking tolvaptan 7.5 mg/day, furosemide 160 mg/day, trichlormethiazide 4 mg/day, pramipexole 0.25 mg/day, amlodipine 7.5 mg/day, telmisartan 80 mg/day, zolpidem 5 mg/day, lansoprazole 15 mg/day, epinastine 20 mg/day, lanthanum carbonate hydrate 1500 mg/day, evocalcet 2 mg/day, sodium ferrous citrate 50 mg/day, and Clostridium butyricum MIYAIRI. We did not treat her HEV infection because lowering transaminase levels were already observed when we diagnosed the HEV infection with positive HEV-IgA on day 14, with no new symptoms. Additionally, we did not resume the usage of tolvaptan after the development of HEV infection as tolvaptan did not increase the urinary volume. The patient’s hepatic failure has not relapsed as of day 91.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3046_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3046_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec18a4e093bc7eacab6ab843fe9d74915b3952ce
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3046_en.txt
@@ -0,0 +1,23 @@
+A 74-year-old male patient with chronic kidney disease stage III, essential hypertension, coronary artery disease with 30% stenosis of the RCA, atrial fibrillation on chronic anticoagulation, rhythm control with amiodarone, rate control with diltiazem, and implantable defibrillator, who had a history of self-resolved upper respiratory infection a week prior to admission, when he started experiencing shortness of breath (SOB).
+
+Shortness of breath was evident during exertion and at rest, presenting with orthopnea and paroxysmal nocturnal dyspnea. His symptoms were accompanied by intermittent chest discomfort and pressure lasting around 15 minutes, worse when laying supine, attenuated by sitting up, non-radiating, and not accompanied by diaphoresis, and self-resolving. He did not take any medications to alleviate discomfort. He mentioned experiencing chills, diaphoresis, nasal congestion, sore throat, arthralgia, unexpected weight loss, and occasional dizziness and imbalance while walking. The day before admission, he could walk his dog for 1 block; on admission day, he could not walk due to persistent SOB. He denied having any fever, cough, hemoptysis, palpitations, edema, muscle, or joint discomfort.
+
+On physical examination his vital signs demonstrated heart rate 74 beats per minute, blood pressure 159/69 mmHg, respiratory rate 20, O2 sat above 94% on room air.
+
+He was in respiratory distress and his cardiovascular assessment revealed distant heart sounds, absence of JVD, abdominal tenderness in the right upper quadrant and epigastric area, as well as malleolar pitting edema.
+
+Electrocardiogram demonstrated sinus rhythm, 70 bpm, prolonged PR, low voltage in precordial leads, and prolonged QTc.
+
+Findings such as muffled heart sounds, low voltage ECG, and cardiomegaly lead to the decision of performing POCUS at bedside. It demonstrated a large pericardial effusion.
+
+Chest x-ray demonstrated cardiomegaly, with no evidence of infiltrates or vascular cephalization.
+
+2D-echocardiogram STAT was performed, and cardiology was consulted due to high suspicion of tamponade after POCUS, despite the patient’s adequate vital signs.
+
+He was admitted due to dyspnea secondary to pericardial effusion, ruling out cardiac tamponade and transaminitis of unclear source. A couple of hours after admission, the patient became hemodynamically unstable secondary to cardiogenic shock.
+
+Emergent pericardiocentesis was performed in the ICU by cardiologist with removal of 800 mL of dark purple bloody pericardial fluid. Pericardial window was performed, draining the remaining pericardial effusion (700 mL of bloody, nonclotting fluid); the pericardium and epicardium were extremely inflamed. No isolated source of bleeding; however, some areas of oozing.
+
+Initial 2D-echo demonstrated right atrial invagination and 0.39% inspiratory to expiratory respiratory variation in mitral inflow velocities, consistent with tamponade.
+
+Pathology report of pericardial tissue—benign fibrovascular adipose tissue with reactive fibro-cellular changes, patchy chronic-acute inflammation, and focal fat necrosis. No evidence of malignancy.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3048_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3048_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea7bd1db7cbeb93460d296149b763495e70042a9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3048_en.txt
@@ -0,0 +1,22 @@
+Patient information
+
+A 36-year-old female presented with dyspnea and chest constriction that had persisted for 20 days without any preceding predisposing factors. Progressive exacerbation of dyspnea and chest constriction was accompanied by nocturnal bouts of dyspnea and limb weakness lasting for 20 days. The patient denied experiencing fever or palpitations. The patient had no history of hypertension or cardiac ailments. No relevant treatment was undertaken before admission, and there was no record of prior surgeries or medications. The patient lacked pertinent personal or familial medical history. The patient exhibited acutely distressed countenance, lip cyanosis, marked lower extremity edema, blood pressure of 122/68 mm Hg, respiratory rate of 34 breaths/minutes, scattered moist rales in the bilateral lower lung fields, tachycardia at 188 beats/min, irregular rhythm, and discernible gallop rhythm upon cardiac auscultation.
+
+Outpatient laboratory examinations: erythrocyte 5.12*1012/L (normal range 3.8–5.112/L). Liver function: total bilirubin 43.6 µmol/L (normal range 3.4–20.5 µmol/L), direct bilirubin 20.5 µmol/L (normal range 0.5–8.6 µmol/L), indirect bilirubin 23.1 µmol/L (normal range 1.7–17 µmol/L). N-terminal pro-b-type natriuretic peptide (NT-proBNP) was 4021 pg/mL (normal range 0–450 pg/mL). Cardiac enzyme and troponin levels were within normal ranges, ruling out acute myocarditis and acute myocardial infarction. Outpatient electrocardiography revealed a rapid atrial fibrillation rhythm with type A preexcitation syndrome. Outpatient echocardiography. The left ventricular end-systolic volume was 113 mL, end-diastolic volume was 176 mL, the right ventricular anterior–posterior diameter was 31 mm, left atrial index was (LAVI) 19.9 mL/m2, left ventricular ejection fraction (LVEF) was 36%. M: Diffuse hypokinesia of ventricular wall motion and mitral regurgitation over an area of 12 cm2. This suggests an enlargement of the entire heart. Severe mitral valve regurgitation and impairment of left ventricular systolic function impairment outpatient chest CT showed calcified spots in the upper lobe of the right lung and an enlarged heart. Thyroid ultrasound revealed thyroid parenchyma with uneven echogenicity and increased blood flow.
+
+
+Initial diagnosis and treatment
+
+The patient experienced an abrupt escalation in dyspnea severity during an outpatient consultation and was initially diagnosed with dilated cardiomyopathy (DCM), atrial fibrillation with preexcitation syndrome, and acute heart failure, as ascertained through an electrocardiogram, cardiac ultrasound, and an anomalous NT-proBNP finding.
+
+Immediate resuscitation measures were initiated in the emergency department. Multifunctional monitoring indicated that the patient’s blood pressure fluctuated at approximately 134/60 mm Hg, respiratory rate was 38 breaths/minute, oxygen saturation was maintained at 93%, and heart rate was 190 beats/minute. Numerous dry and wet rales were auscultated in both lung fields, and a furosemide injection 40 mg IV was administered immediately to improve the pulmonary edema. Oxygen support was provided because the patient had rapid atrial fibrillation with preexcitation syndrome, and digitalis glycoside drugs were not administered to prevent possible ventricular fibrillation. After the administration of esmolol hydrochloride, the patient’s heart rate did not decrease significantly, and the patient rapidly developed acute heart failure decompensation. The patient presented in a forced sitting position with severe dyspnea, oxygen level of 88%, respiratory rate of 40 breaths/minute, heart rate of 156 beats/minute, and blood pressure of 126/69 mm Hg. Following confirmation of the absence of a history of bronchial asthma, 5 mg morphine was intramuscularly administered and 5 mg dexamethasone sodium phosphate was intravenously administered. Administered intravenous dihydroxypropyltheophylline 0.5 g of solution was administered intravenously to the patient to relieve airway spasms, and subsequently, recombinant human brain natriuretic peptide was injected to ameliorate heart failure. Following a loading dose of 1.5 µg/kg administered over 5 minutes, continuous infusion at a rate of 0.01 µg/kg/minute was initiated. After 30 minutes of resuscitation therapy, the patient’s heart rate remained above 140 beats/minute and rapid atrial fibrillation with preexcitation syndrome persisted. Consequently, amiodarone hydrochloride injection was initiated. Initially, 150 mg was administered intravenously for 10 minutes, followed by a subsequent infusion of 360 mg at a rate of 1 mg/minute. Following approximately 2-hours of resuscitation therapy, the patient acute heart failure was successfully corrected. Monitoring revealed an oxygen saturation of 96%, respiratory rate of 25 breaths/minute, heart rate of 126 beats/minute, and blood pressure of 132/74 mm Hg. The patient electrocardiographic rhythm persisted with atrial fibrillation; however, there were no signs of preexcitation syndrome. An improvement in dyspnea was noted, and low-molecular-weight heparin was administered to prevent thrombus formation. Calcium injections (5000 IU) were administered subcutaneously twice daily. Concurrently, alterations in the coagulation function were observed. Subsequently, propranolol hydrochloride was administered orally at a dose of 20 mg 3 times daily, accompanied by a minimal dosage of furosemide tablets (20 mg) and daily oral intake of spironolactone (20 mg). The patient received 20 mg methimazole tablets orally twice daily. Following a 2-week course of treatment, the patient exhibited robust recovery, marked by substantial amelioration of symptoms associated with heart failure, notably dyspnea. The patient was discharged with a prescription for oral medication.
+
+
+Final diagnosis
+
+Laboratory examinations on the second day: thyroid-stimulating hormone < 0.005 µIU/mL (normal range 0.27–4.2 µIU/mL), serum free T3 30.02 pmol/L (normal range 3.1–6.8 pmol/L), serum free T4 96.22 pmol/L (normal range 12–22 pmol/L), and antithyroid peroxidase antibody 270.90 IU/mL (normal range 0–34 IU/mL), NT-proBNP 3381 pg/mL (normal range 0–450 pg/mL). Coronary angiography did not reveal any stenosis of the coronary lumen, ruling out coronary artery disease. Upon evaluating the patient’s symptoms, conducting a thorough physical examination, considering the lack of previous medical history, and analyzing laboratory and imaging results such as thyroid function, the conclusive diagnosis is reached through a process of elimination encompassing the following conditions: thyrotoxic cardiomyopathy, acute heart failure, and atrial fibrillation with preexcitation syndrome.
+
+
+Outcome and follow-up
+
+During the 1-month post-discharge follow-up period, the patient had no symptoms of heart failure or dyspnea. Physical examination revealed an absence of overt positive signs. Electrocardiography indicated the restoration of normal sinus rhythm with effective heart rate control. A review of the thyroid function revealed a return to normal levels. The NT-proBNP was 321 pg/mL (reference range 0–450 pg/mL); and notable alterations in the patient indices were evident compared with the initial admission. Evaluation of the echocardiograms revealed significant changes compared with the initial visit. The left ventricular end-systolic volume was 78 mL, end-diastolic volume was 141 mL, the right ventricular anterior–posterior diameter was 27 mm, and the left atrial index (LAVI) was 14.2 mL/m2, LVEF was 45%. The mitral regurgitation area had contracted to 1.7 cm2. Subsequent thyroid ultrasound revealed heterogeneous parenchymal echogenicity in the thyroid gland, and the blood flow signal had decreased compared to the prior examination.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3059_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3059_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e0dea24eb05a43beb6453836e32afe1d44271228
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3059_en.txt
@@ -0,0 +1,34 @@
+A 51-year-old Caucasian female with a history of heart failure with mid-range ejection fraction (41%) due to EM, cerebrovascular accident, residual right-sided lower extremity weakness, asthma, recurrent bronchitis, ventricular tachycardia, right ventricular thrombus, and peripheral eosinophilia with concern for HES was referred for advanced therapies. Her complaints centered around fatigue and dyspnea with minimal exertion, confusion, poor appetite, and orthopnea and paroxysmal nocturnal dyspnea – all consistent with NYHA class 3b functional status. At presentation, her temperature was 35.8°C, with a blood pressure of 94/67 (76) mmHg, a heart rate of 61 bpm, with SpO2 of 94% on room air. Physical examination was notable for a distended abdomen with hepatomegaly (liver edge palpable 2 cm below costal margin) and cool extremities to touch, consistent with Stevenson profile C. We attempted to optimize the patient’s guideline-directed medical therapy, salt, and fluid balance, as an outpatient. However, she was intolerant. Her refractoriness resulted in progressive hypotension and confusion. One month after her initial visit, she was admitted to managing and treating acute decompensated heart failure.
+
+During her admission, laboratory workup demonstrated a peripheral eosinophil count of 1.77(NR 0.01 - 0.08 cells/uL), total eosinophils of 15.4% (NR 1.0-3.0%), absolute eosinophil count of 4.18 (0.03 to 0.48 cells/ul) and NT-Pro B-type natriuretic peptide (NT-Pro BNP) of 1723 pg/mL (NR <144 pg/mL). There was no significant troponin elevation (<.01). Electrocardiogram (EKG) showed sinus rhythm with 1st-degree A-V block, right atrial enlargement, nonspecific T wave abnormality, and prolonged QT and PR intervals, unchanged from outside hospital records.
+
+Transthoracic echocardiography (TTE) demonstrated left ventricular wall motion abnormalities with an ejection fraction of 41%, moderately enlarged right ventricular chamber size with reduced systolic function, severe tricuspid valve regurgitation, and biventricular apical thrombi.
+
+Given her intolerance to medical therapy, a peripherally inserted central catheter (PICC) was utilized to obtain a central mixed venous saturation (ScVO2) of 42%, yielding a Fick cardiac output of 1.80 L/min and an index of 1.01 L/min/m2. Given the evidence of NYHA 3b, AHA D, Stevenson profile C cardiogenic shock, she was started on dobutamine 2.5 mcg/kg/min and Bumex IV 2.5 mg BID.
+
+Cardiac MRI (CMR) with and without contrast showed diffuse mid to apical left ventricular subendocardial abnormal late gadolinium enhancement, patchy mid-wall enhancement, and areas of focal enhancement of the mid-anterior and inferior/inferolateral walls consistent with fibrosis.
+
+A bone marrow biopsy was performed, which showed hypocellular marrow (~25%) with trilineage hematopoiesis and hypereosinophilia with 50% increase of eosinophils with no evidence of dysplasia. Fluorescence in situ hybridization (FISH) analysis was negative for BCR-ABL, F GFR 1. FISH analysis also produced negative results for abnormalities related to PDGFRA, PDGFRB, FGFR1, and t (9:22). Peripheral blood flow cytometry also returned negative findings, ruling out leukemia/lymphoma. Autoimmune serology was negative. Viral research, stool test for strongyloides and parasites were negative too.
+
+Immunohistochemical stains for CD34 and CD117 showed no increase in blasts. MPO highlighted granulopoiesis. CD3 demonstrated a normal complement of T-cells, while PAX-5 showed a normal complement of B-cells. The reticulin stain was focally borderline. Flow cytometry detected no increase in blasts, no monotypic B-cell populations, and no phenotypically aberrant T-cell populations.
+
+The evaluation of blasts revealed no increase in their numbers. Analysis of B-cells showed no presence of monotypic populations and exhibited a normal expression pattern of CD19, CD10, surface kappa, and lambda. T-cells/NK-cells did not display any aberrant phenotype based on CD3 and CD16 markers. The bone marrow biopsy indicated normocellular morphology, with a 50% increase in eosinophils. Importantly, no signs of lymphoma or mass disease were observed. Flow cytometry results were consistently negative, indicating no increase in plasma cells. Further testing through FISH analysis produced negative results for abnormalities related to PDGFRA, PDGFRB, FGFR1, and t(9:22). Peripheral blood flow cytometry also returned negative findings, ruling out leukemia/lymphoma.
+
+The patient was started on Solu-Medrol 1000 mg IV daily x 3 days to treat HES and heparin infusion for ventricular thrombi. Subsequently, her condition improved, and the patient was weaned from dobutamine based on daily ScVO2 and Fick calculations and successfully transitioned to oral therapies.
+
+EMB was initially not performed because of elevated risk of complications. Given the long- term complications and risk of death with EM the patient was started on steroids as an outpatient after clinical suspicion was noted, and biopsy was scheduled to be done thereafter. She had a cardiac MRI which demonstrated findings consistent with eosinophilic myocarditis and did have peripheral eosinophilia.
+
+An endomyocardial biopsy was performed after steroids were given and was negative for lymphocytic or eosinophilic infiltration or granuloma formation. Congo red stain was negative for amyloid. The iron stain was negative for abnormal iron accumulation, and the trichrome stain was negative for significant interstitial fibrosis.
+
+Clinical history, in combination with imaging data from echocardiography and CMR, was highly suggestive of eosinophilic myocarditis. Her autoimmune serology, including the ANA test, has previously showed negative results. Testing for hepatitis B, hepatitis C, and HIV has also been negative in the past. Additionally, stool tests for strongyloides and ova and parasites were negative. Therefore, our case was diagnosed as Idiopathic Hypereosinophilia, indicating elevated eosinophil levels without a known cause associated with end-organ damage.
+
+The best clinical treatment of HES depends on disease etiology and subtypes. However, even in the absence of a known cause, HES must be promptly treated in order to reduce potential morbidity that can result from organ damage.
+
+This patient was treated with pulse steroids and heparin infusion for ventricular thrombi. Clinical condition improved and discharged with therapy with steroid, bumetanide and apixaban.
+
+The patient was discharged on oral prednisone taper, Bumex orally 2mg daily, and Eliquis 5mg twice daily. She started on Mepolizumab (Nucala, GlaxoSmithKline LLC) 300 mg subcutaneously every four weeks. Since discharge, unfortunately, the patient had refractory heart failure off Dobutamine and required readmission. She was urgently listed for heart transplantation. The donor was identified as an increased risk for transmitting blood-borne illnesses. Serologies indicated that the donor was positive for CMV and EBV, matching the recipient’s positive status for both. The ischemic time for the transplant was 3 hours and 34 minutes. Intraoperatively, the patient received 1 unit of PRBC, 1 unit of FFP, 1 unit via Cell Saver, IV Solu-Medrol and IV CellCept.
+
+Post- transplant care
+The patient was extubated by postoperative day 1. The postoperative course was uncomplicated. Upon discharge, the patient’s immunosuppressive regimen included: Prednisone taper at 20 mg daily, oral CellCept (Mycophenolate Mofetil) at a dose of 1000 mg twice a day. Tacrolimus (Prograf) was initiated on day 2, with a target level of 9-12. At discharge, the patient’s Tacrolimus level was 6.9, and she was discharged on Prograf 5 mg twice a day.
+
+On a 12-week follow-up she remains stable with no evidence of rejection on EMB and had no recent hospitalizations with an LVEF of 60%. Hematology felt that steroids and immunotherapy would control bone marrow eosinophilia and continue to follow her.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3063_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3063_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b1a6b0f977684024eaf98d7d14e046877ce5c927
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3063_en.txt
@@ -0,0 +1,25 @@
+50-year-old man, congenital single-sided deafness with adequate renal function, consults for a 18-month history that begins with general condition compromise and a feeling of proximal muscular weakness. Initial evaluation shows M5 strength in all muscle groups, associated with a study with normal electromyography and elevation of erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP). The need for further study is raised, but the patient misses the controls.
+
+Twelve months later, he developed decreased visual acuity associated with epiphora and exophthalmos, palpebral skin lesions, and persistence of elevated VHS and PCR, which is why he was hospitalized for study. A brain and orbital magnetic resonance imaging (MRI) was performed, which showed a non-specific retro-orbital mass, and a positron emission tomography (PET-CT) was performed, which showed a non-specific retroperitoneal mass with pancreatic and periaortic involvement, cardiac involvement, mild splenomegaly and hypermetabolic bone involvement of appendicular predominance of metaphyseal and diaphyseal origin.
+
+IgG4-associated disease versus lymphoma is a diagnostic hypothesis, so the study is expanded:
+
+Bone marrow biopsy: overall cellularity preserved in all 3 series with signs of adequate maturation.
+
+Retroperitoneal mass biopsy (percutaneous puncture by interventional radiology): retroperitoneal-type adipose tissue with inflammatory lympho-histiocytic foci, accumulations of foamy histiocytes and areas with marked fibrosis. Immunohistochemistry confirmed polyclonal/reactive nature of plasma cell component (CD138+) that expressed kappa and lambda chains in similar proportions. The study of the biopsy tissue was complemented with antibodies against immunoglobulins IgG and IgG4, demonstrating a low presence of these cells, so it was concluded that IgG4-associated disease is unlikely.
+
+Protein electrophoresis: hypoproteinemia and hypoalbuminemia, without paraproteina.
+
+ANA (-), ANCA (-), anti-Trab (-), anti-thyroglobulin (-), complement C3 182.9 and C4 41.8 mg/dl (normal).
+
+IgA 280.4, IgG 1320 and IgM 52.5 mg/dl, IgG subclasses with IgG4 count in normal range.
+
+Human immunodeficiency virus serology, hepatitis B surface antigen and hepatitis C virus serology negative.
+
+Given the imaging findings, which showed multi-organ involvement, with initial immunohistochemical evidence of plasma cells, Erdheim-Chester disease was considered a differential diagnosis. Corticosteroid therapy with prednisone 1 mg/kg/day was initiated empirically, and the study was expanded with a new computed tomography (CT) scan and a new biopsy of retroperitoneal tissue, omentum and Gerota's capsule.
+
+In TC, multifocal soft tissue involvement persists at the perirenal level, left excretory system, adrenal glands, periaortic tissue and appendicular skeleton, suggesting ECD as a first diagnostic possibility.
+
+The new biopsy shows fibroadipose tissue with proliferation of foamy histiocytes, with small central nucleus, in irregular pattern, associated with foci of hemorrhage and scarce lymphoplasmocitary inflammatory infiltrate, with fragments of necrosis, without multinucleated giant cells or peripheral cellularity. Immunohistochemistry reports presence of histiocytes positive for CD68 and negative for CD1a, compatible with an atypical histiocytosis of Erdheim Chester. It is complemented with search for truncated BRAF protein, showing mild-moderate positivity in histiocytes, in addition to genetic study by polymerase chain reaction (PCR) that confirms V600E mutation.
+
+With this study, the diagnosis of systemic ECD disease, positive for BRAFV600 mutation, is confirmed, so treatment with Vemurafenib (B-raf serine/threonine kinase enzyme inhibitor), 960 mg every 12 hours, is initiated. It evolves with good clinical response, with evidence of regression of involvement described in control images after 6 months of treatment, with reduction of up to 90% of the size of the masses described.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3064_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3064_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f0198e98bcc57931d36d243db0d95ac7a84cb06a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3064_en.txt
@@ -0,0 +1 @@
+A 13-year-old patient with significant neurological impairment, weight loss of 14 kg, and severe and recurrent gastroesophageal reflux disease (GERD) who had undergone three prior surgeries to address GERD, including a laparoscopic Nissen fundoplication with a gastrostomy, a laparoscopic Collis-Nissen procedure, and a Nissen procedure performed openly. The patient underwent surgery to address a chronic esophageal stricture secondary to GERD that had failed to respond to dilation. The surgery involved a replacement of the esophagus with the right colon via a retrograde approach, closure of the prior gastrostomy, and creation of a new gastrostomy. Sutures and anastomoses were performed manually. On the ninth day postoperatively, the patient developed a surgical site infection in the laparotomy incision. Four days later, a skin fistula developed through the prior gastrostomy that drained gastric and purulent contents. A contrast-enhanced CT scan showed a gastric leak and confirmed the diagnosis of FGC. Initially, management was conservative with absolute diet, parenteral nutrition, broad spectrum antibiotics, and a skin ostomy bag placed over the skin defect. A skin fistula developed through the skin defect and drained gastric and purulent contents. A contrast-enhanced CT scan was performed three days later. A 5.9 mm gastroscope was inserted through the new gastrostomy and a guide wire was placed through the FGC and externalized through the skin defect. Two 4 Fr-24 cm and 3 Fr-12 cm CUDJs were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0.64 mm-260 cm guide wire was placed through the FGC and externalized through the skin defect. Two CUDJs (4 Fr-24 cm and 3 Fr-12 cm) were placed over the guide wire from the skin, with the inner end of the guide wire in the gastric lumen and the outer end in the skin defect. The outer end of the catheters was not fully folded due to the small size and morphology of the space. A skin ostomy bag was placed over the skin defect. A gastrojejunal tube was placed through the new gastrostomy. A 0
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3070_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3070_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..56303a0f980d6e04cd66befc08bd86257785f0d9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3070_en.txt
@@ -0,0 +1,15 @@
+15-year-old overweight female adolescent (BMI/E z-score + 1.3 SD), with no other medical or family history, presented to the emergency department with a two-week history of non-quantified fever, anorexia, and diffuse abdominal pain. Initial laboratory tests included a lipid profile with TG levels of 17,580 mg/dL, total cholesterol (TC) 1,633 mg/dL, high-density lipoprotein cholesterol (HDL-C) 1.8 mg/dL, low-density lipoprotein cholesterol (LDL-C) 1,573 mg/dL, blood glucose 200 mg/dL, lipase 723 U/L, and unprocessed amylase per lipemic sample.
+
+An abdominal computed tomography (CT) scan showed an enlarged and edematous pancreas without peri-pancreatic collections. The patient was hospitalized with a diagnosis of severe PA and HTG and was started on continuous intravenous infusion of insulin. On the third day, a new abdominal CT scan showed signs of necrohemorrhagic pancreatitis.
+
+He was transferred to the Paediatric Intensive Care Unit of the UC-Christus Health Network Hospital to continue his management, where he arrived in good general condition, haemodynamically stable, afebrile and with mild abdominal pain. The physical examination did not reveal xanthomas, xanthelasma, acanthosis nigricans or hepatomegaly. Control laboratory tests were performed: TG 3,222 mg/dL, CT 887 mg/dL, C-HDL 12 mg/dL, C-LDL 231 mg/dL, glycaemia 150 mg/dL, amylase 161 U/L and lipase 643 U/L.
+
+Given the persistence of TGs above 1000 mg/dL (> 11.2 mmol/L), it was decided to maintain the continuous intravenous infusion of insulin at 0.05 U/kg/hour, with a glucose load of 2.27 mg/kg/min and gemfibrozil was initiated at a dose of 900 mg/day. On day 6, the TGs dropped to 500 mg/dL (5.6 mmol/L), so the continuous intravenous infusion of insulin was discontinued. However, the patient developed persistent metabolic acidosis, a fasting blood glucose of 206 mg/dL and a capillary blood glucose of 326 mg/dL. Because of suspicion of DM and in search of the classic triad of this disease, the patient's medical history was investigated, highlighting a history of polydipsia, polyuria and unobjectified weight loss during the last 3 months. A glycated hemoglobin A1c (HbA1c) was requested, which resulted in 14.7% (ref value < 5.7%), along with anti-TPO antibodies < 1, which determined a DM of pre-PA onset. Treatment with insulin (Lantus®) was initiated
+
+11 IU/day.
+
+On day 10, an abdominal MRI and cholangiography were performed, which showed images consistent with PA with a right anterior parrenal acute hemorrhagic necrosis collection and another in the transverse mesocolon, without signs of pancreatic necrosis or gallstones.
+
+Subsequently, insulin therapy was adjusted with improvement of metabolic parameters, stabilisation of glycaemia and reduction of TG. After 15 days of favourable clinical evolution, without fever or abdominal pain and with good oral tolerance, control laboratory tests were performed that showed TG 244 mg/dL, glycaemia 175 mg/dL, lipase 73 U/L and amylase 26 U/L. Given the improvement of the clinical, laboratory and imaging picture, hospital discharge was decided.
+
+One month after discharge, outpatient examinations showed normal levels of TG and CT, along with good metabolic control as a result of insulin treatment. Gemfibrozil was discontinued and continued on controls for DM1. A control CT of the abdomen and pelvis showed a decrease in the size of the anterior pararenal collection and resolution of the collection in the transverse mesocolon. Two months after discharge, a follow-up MRI showed findings similar to the CT, with a decrease in the size of the anterior right pararenal collection. Abdominal ultrasound performed one year after discharge showed a complete anatomical resolution of the pancreatic anomalies.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3083_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3083_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f609cf7ce3c15efa14132c4d16bc665010ff46d8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3083_en.txt
@@ -0,0 +1,9 @@
+2 years 11 months old male pre-schooler admitted to hospital with a 2-month history of abdominal distension and increased abdominal temperature accompanied by pallor. He sought medical attention at the onset of the condition and was prescribed anti-parasitics and ferrous sulphate, which he has been taking since then, without improvement.
+
+A week after admission, a bulge was observed in the left flank region when he sought medical attention again. He underwent abdominal ultrasound, which showed an enlarged left kidney with a globular appearance, with a suggestive image of a coraliform stone inside.
+
+He was referred to tertiary care, where he presented a regular general condition, hypocratic, tachycardic, with a globose and painful abdomen, with a palpable mass in the left flank and an increase in temperature to the touch in the whole abdominal region. Laboratory tests demonstrated leukocytosis (21,420 leukocytes/mm3), important microcytic anaemia (haemoglobin of 6.3 g/dL and haematocrit of 22.3%), iron deficiency (13.6 mcg/dL), thrombocytosis (757,000 platelets/mm3), an increase in C-reactive protein (16.2 mg/dL) and leukocyturia (28,000 leukocytes/mL). The urine culture showed growth of Proteus mirabilis. The contrast computed tomography of the abdomen showed the presence of a 1.6 cm coraliform renal calculus, marked calicinal dilation and paradoxical renal pelvic contraction, as well as diffuse hypodensity and hyperechoic renal parenchyma, which gave the image a "bear's paw" pattern.
+
+Patient underwent left nephrectomy by median laparotomy, under the assumption of xantogranulomatous pyelonephritis. Macroscopically, the left kidney appeared enlarged, with a look of pyelopelvic fat, adhered to the peritoneum, with a highly dilated pyelocalyceal system filled with pus. The anatomopathological study showed a kidney with intense pyelocalyceal dilation and hardened renal parenchyma, with yellowish areas. The microscopic examination revealed extensive chronic inflammation with xantogranulomatous areas coincident with the destruction of the renal parenchyma, with fibrosis and sclerosis of the remaining glomeruli. The conclusion was of xantogranulomatous pyelonephritis associated with pyelopelvic and urolithiasis with coraliform calculus.
+
+He received 14 days of antibiotic therapy with metronidazole and ceftriaxone and recovered with complete clinical improvement and was discharged in good condition, with no report of recurrence of the condition or change in function in the contralateral kidney in the following year.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3120_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3120_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f3f6f90a50a94ce76ef04263a094e8f74bfcf6fd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3120_en.txt
@@ -0,0 +1,3 @@
+36-year-old man with no medical history who was admitted to the intensive care unit with a presumptive diagnosis of malaria on 7/12/2021. His medical history included a stay in Nigeria from January to October 2021; he did not receive malaria prophylaxis. He arrived in the country on 28/11/21 from Germany. He began with continuous fever, sweating, chills and myo-artralgia of 1 week evolution, oligoanuria, copuria and abdominal pain were added. He was admitted to the intensive care unit lucid, tachycardic and tachypneic, with skin and mucous jaundice and a decrease in diuretic rhythm. He evolved with arterial hypertension and a requirement for nitroglycerine. A thick drop of peripheral blood was performed that evidenced PF, with parasitemia greater than 20%. A transfusion of blood was performed (volume 3.4 liters) and intravenous artesunate 400 mg on the 1st day, then 200 mg per day, for 7 days. In clinical analyses, an acute renal lesion and hyperbilirubinemia with platelopenia were detected. He evolved oligoanuric and confused, with a Glasgow score of 14/15 points. The initiation of veno-venous continuous haemodiafiltration (HDFVVC) was decided. After 24 hours, due to a sudden increase in bilirubinemia and a deepening of his encephalopathy, plasma filtration was performed coupled with adsorption (CPFA). Subsequently, high-exchange plasmaferesis was performed to control the liver failure. An improvement in the neurological state and a significant decrease in the serum bilirubin and analyte levels were detected.
+
+Lucid, but with persistently high uremia and creatinine levels, he continued with continuous renal replacement techniques until the eighth day of admission. The evolution was favorable with improvement of the organ failures and on the 20th day of admission he was discharged. The case described presented MG according to WHO definition. No adverse events related to the procedures were detected.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_313_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_313_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b7f0e7e4c4f4556c666719bf1dd007d89212a773
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_313_en.txt
@@ -0,0 +1,4 @@
+A 66-year-old man presented with 1-month history of bloody stool and anal pain. His history included hypertension, hyperlipidemia, hyperuricemia, traffic trauma, and postoperative right inguinal hernia. He had no history of smoking. The histopathologic evaluation of the biopsy specimen obtained with colonoscopy led to the diagnosis of moderately differentiated tubular adenocarcinoma of the anal canal. The diagnosis was Stage IVa with lymph node and liver metastases (T3, N3 [#263L], M1a [H1]) based on evaluation with computed tomography and magnetic resonance imaging . RAS and BRAF gene status were wild type. MSI test was performed postrecurrence and was negative.
+After six cycles of systemic chemotherapy with 5-fluorouracil, leucovorin, oxaliplatin, and irinotecan (FOLFOXIRI) plus bevacizumab, clinical CR and clinical near-CR were detected in the liver metastatic lesion and the primary tumor, respectively, and surgery was planned . Robot-assisted laparoscopic perineal rectal amputation and left-sided lymph node dissection were performed with no postoperative complications. Pathological diagnosis was ypT0, N0, M0 ypStage0. Postoperative adjuvant chemotherapy was not administered, and the patient was evaluated every 3 months in the outpatient clinic.
+Computed tomography performed during 1-year postoperative follow-up revealed thickening of the left bladder wall , requiring cystoscopy, which revealed no significant findings. Repeat cystoscopy was performed 6 months later because of the worsening of the left bladder wall thickening detected by computed tomography . The deformity in the left bladder wall, which was biopsied by transurethral resection, was diagnosed as metastasis of anal cancer. The histopathologic examination of the resected tissue revealed that the tumor cells had invaded the lymphatic vessels of the bladder. The tumor cells did not invade venous vessels, and histology of this tumor was similar to rectal cancer, which is a moderately differentiated tubular adenocarcinoma . After two cycles of systemic chemotherapy with FOLFOXIRI plus bevacizumab, partial resection of the small intestine was performed because of the difficulty in resolving obstruction of the small intestine with conservative therapy . The evaluation of the resected small intestine revealed lymphogenous invasion of the muscularis mucosa and subserosa of all sections, although tumor formation in intestinal mucosa were not observed .
+After excluding oxaliplatin, which had to be discontinued due to allergic reaction, the chemotherapy regimen was continued for approximately 10 months. However, ten months after the first surgery for small bowel obstruction, skin nodules extending from the lower abdomen to the thighs were observed ; the nodules gradually worsened over few months. The histopathologic evaluation of the biopsy specimens of the nodules collected at the time of the second surgery for bowel obstruction led to the diagnosis of skin metastasis of anal cancer . Following the administration of panitumumab after surgery, the skin nodules appeared to get smaller . However, four months after the diagnosis of skin metastasis, the patient developed lymphangitis carcinomatosa, discontinued chemotherapy, and died three months later.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3145_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3145_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..84a42611683b93cd0452a7936391bb9dcafbe244
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3145_en.txt
@@ -0,0 +1,15 @@
+A 38-year-old man was referred to the International Hospital of Colombia (Bucaramanga) for treatment-resistant focal epilepsy associated with cognitive deficits.
+
+The patient was the only child of the third pregnancy, born by uncomplicated vaginal delivery, with normal neurodevelopment until the age of 10 years and no history of neuroinfections, major surgeries or haematological disorders. He reported a head injury at the age of 10 years, after which he developed apparent cognitive impairment with poor school performance. One year after the injury, he had his first seizure. The seizures consisted of clonic movements in the left hemicorper, with more involvement of the upper limb and sometimes accompanied by headaches. On the EEG, interictal and ictal activity was observed in the right fronto-central region.
+
+Laboratory studies to exclude infectious and metabolic disorders were performed and were negative. A simple computed tomography of the skull was performed and showed agenesis of the pellucidum and dysgenesis of the corpus callosum.
+
+Subsequently, a brain MRI was performed with the protocol for epilepsy, which showed several clinically relevant findings, including confirmation of agenesis of the pellucidum, and suggestive of polymicrogyria, such as abnormal thickening and irregularity in several areas of the cerebral cortex, particularly in the frontal lobes and in both perisylvian regions. In addition, heterotopic gray matter was identified in the frontal lobes, most notably in the right, where two bands of abnormal, thickened gray matter were identified extending from the cortex to the lateral ventricle wall.
+
+Another band of heterotopic grey matter was identified in the left fronto-insular region, parallel to the lateral ventricle. There was also a supratentorial ventriculomegaly and, although the corpus callosum was present, its apex or rostrum had an atypical appearance. The chiasm and optic nerves were hypoplastic.
+
+It should be noted that the EEG findings correlated with areas of polymyocryria and cortical heterotopia in the right cerebral hemisphere.
+
+Although there was a history of head trauma, in the absence of findings such as areas of gliosis or bleeding, this trauma was considered to be mild, with no structural sequelae evident in the two studies obtained. Therefore, this history was most likely not directly related to the patient's clinical manifestations.
+
+Once the diagnosis was confirmed, in the initial control of the symptoms, and given the presence of bilateral lesions that compromised some critical areas, it was decided to provide medical treatment with a new anticonvulsive medication scheme and to carry out periodic monitoring in the institution.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3148_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3148_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..840eed2b2c742331d31b17a5b2e4e3d143ff5f7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3148_en.txt
@@ -0,0 +1,11 @@
+This was a 53-year-old patient with no particular medical history or knowledge of herbal medicine, who had been followed for 3 years for a Biermer's disease with vitamin B12 who was admitted urgently for diffuse abdominal pain with postprandial vomiting, evening fever and intense physical asthenia, with an acute evolution. No diarrhea or delayed stool was reported. Physical examination revealed a slightly swollen abdomen with painful hepatomegaly to the touch and epigastric tenderness with guarding, jaundice and a World Health Organization performance index of grade 3, all in a context of fever at 38.6 - 39 °C with a good haemodynamic state. No other obvious clinical point of call was identified. An abdominal-pelvic tomodensitometry (AP TDM) performed urgently revealed multifocal hepatic abscesses (88 × 76 × 72 mm for segments II and IVa; 22 to 27 mm for segments I and III), with a dominant lesion straddling segments II and IVa.
+
+Initial treatment consisted of a scan-guided drainage of the abscesses and empirical intravenous antibiotic therapy with ceftriaxone 2 g daily, gentamicin 3 mg/kg (180 mg for 60 kg of weight) once daily for 3 days and metronidazole 500 mg every 8 hours, associated with adjuvant measures.
+
+Microbiological analysis of the pus taken during drainage showed many neutrophils and the presence of rare Gram negative bacilli with some Gram positive cocci and the absence of fungal elements in Gram staining. A first culture performed was non-contributory, a second analysis performed 72 hours later was sterile. Two haemocultures performed were negative. The evolution was marked by the persistence of the clinical picture with worsening of diffuse abdominal pains, more marked in the epigastrium and the right hypochondrium.
+
+This led to a second thoraco-abdomino-pelvic scan. This showed a persistence of a hepatic collection of 64.8 × 53 mm, multi-walled to the left hepatic lobe and a residual collection in the right lobe of 43 mm. On re-examination of the scan images, a foreign body was identified between the antrum-pyloric wall and the segment I of the liver. In addition, a peri-hepatic effusion of the right iliac fossa and Douglas with infiltration of the peritoneal fat (with integrity of the other full viscera) was also observed. There was no apparent vascular lesion.
+
+A median xypho-pelvic laparotomy was performed with evacuation of approximately 200 cm3 of cloudy peritoneal fluid. The preoperative exploration allowed the objective of a gastric perforation in the pre-pyloric area of approximately 0.5 cm in diameter with the presence of a foreign body, a "fish bone" type, nearly 5 cm long. This was followed by extraction of the fish bone, a gastric suture with epiplooplasty, a peritoneal wash and a drainage.
+
+The evolution on the 7th day post-operatively was marked by a simple postoperative course and a clear clinical-biological improvement. The antibiotic therapy was continued for a total duration of 2 weeks after the surgery without recurrence of the abscesses. The patient was seen in outpatient consultation 15 days after returning home without any clinical-biological particularity. The control imaging at 3 months showed a complete resorption of the hepatic abscesses.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3154_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3154_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0354207c9f8c8f345c44a818f38b03c9358afea6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3154_en.txt
@@ -0,0 +1 @@
+A 59-year-old man presented to the emergency department with acute diffuse lower limb pain of recent onset with no history of trauma. His medical history included obesity, hypertension, type 2 diabetes, myocardial infarction, stroke, obesity, and long-term smoking. His treatment included bisoprolol 5 mg daily, furosemide 20 mg daily, metformin 1000 mg twice daily, sitagliptin 50 mg daily, atorvastatin 20 mg at night, and aspirin 75 mg daily. No relevant family history was noted. He had been smoking 10 cigarettes/day for 15 years. No allergies or history of alcohol abuse or illicit drug use. On clinical examination, the heart rate was 89 beats per minute, blood pressure 161/79 mmHg, temperature 36.9 C, and oxygen saturation 99%. The lower left limb was cold, peripheral pulses were not palpable with no edema. Cardiopulmonary and abdominal examinations were normal.  The blood work showed a hemoglobin of 18 g/dL, leukocytosis (15 700/mm3), and C-reactive protein of 6 mg/L. Liver, thyroid, renal, and coagulation tests were normal. A lower limb angioscopy was performed that confirmed an occlusion of the left common femoral artery extending to the superficial femoral artery, as well as an occlusion of the left popliteal artery to the tripod. A right tibio-fibular trunk occlusion and moderate mixed atheromatous changes in the infrarenal aorta and iliac arteries were also described. The patient was then hospitalized and a thrombectomy of the left femoral artery was performed to revascularize the left lower limb. As part of the etiologic study, a cardiac ultrasound was performed that showed no abnormality and subsequently a thoracic angiotomography that described the presence of a floating thrombus in the distal third of the aortic arch downstream of the supra-aortic trunks. In the face of these findings, a positron emission tomography (PET) scan was performed to look for occult neoplastic disease, but this investigation did not show the presence of significant hypermetabolism in the segments examined.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3165_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3165_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c6b8299e77e06816932fe008e8214fc5d3d5cde
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3165_en.txt
@@ -0,0 +1,9 @@
+A female infant, 2 months of age, previously healthy, was admitted to the pediatric emergency department. The mother reported weight loss, colic, alternating hunger cries with lethargy, mild diarrhea and worsening vomiting, with onset 5 days ago. She also reported previous symptoms of nasal congestion, sporadic cough, conjunctivitis, small skin vesicles on the chest and absence of fever. The nasopharyngeal reverse transcription-polymerase chain reaction (RT-PCR) test result for SARS-CoV-2 was positive. The mother had become infected with SARS-CoV-2 10 days before the infant. On physical examination, the infant was very irritable, alternating with lethargy, with a face of abdominal colic pain associated with multiple feeding interruptions, moderate dehydration and hypothermia (<36°C). The weight was 4.8kg; the skin had a lattice appearance, with prolonged capillary filling and decreased urine flow. The pulse was 125 beats/minute, respiratory rate 54 breaths/minute, and pulse oximetry oxygen saturation was 97% in room air. The patient was transferred to the pediatric intensive care unit (PICU) after volume resuscitation.
+
+The patient was a full term newborn with no pre-existing illness or antibiotic use, who was fed breast milk and infant formula supplement from the second week of life.
+
+Data from biochemistry, urine, faeces, coagulation function tests and infection biomarkers, performed after confirmation of SARS-CoV-2 infection at admission and follow-up. Serology for SARS-CoV-2 was positive for IgM (2.11AU/mL, with normal range <0.90) and negative for IgG. PCR for SARS-CoV-2 PCR remained positive in faeces for more than 27 days, despite the respiratory tract examination already being negative. Additional viral panel tests, urine and faeces culture were negative, and only the nucleic acid amplification test (NAAT or PCR) was positive for C. difficile .
+
+Multislice helical computed tomography (CT) of the chest, echocardiography and abdominal ultrasound were normal.
+
+During 4 days of admission to the NICU, the patient persisted with abdominal cramps and required additional amounts of intravenous fluids due to poor acceptance of breast milk and infant formula. The proton pump inhibitor initially prescribed was discontinued. No antiviral, glucocorticoid or antimicrobial was prescribed to the patient.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3172_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3172_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e311f22ad5d2cfb11a414b287bfe6df30e537ee8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3172_en.txt
@@ -0,0 +1,14 @@
+Medical History
+V.R. was a 2-year-old boy when he was referred to our Hospital Pediatric Emergency Room for a suspected allergic reaction. He was born at term via vaginal delivery, with birth weight adequate for gestational age. He had been exclusively breastfed for 6 months; thereafter, complementary feeding, including regular intake of fish, eggs, and cow’s milk, was introduced without clinical problems. His familial history was negative for allergies. At 12 months of age, he was diagnosed with atopic dermatitis and treated with skin moisturizers.
+
+Clinical Presentation
+At 2 years of age, due to the occurrence of generalized urticaria, angioedema, wheezing, sneezing, and two vomiting episodes, V.R. was referred to our Hospital Pediatric Emergency Room, after being assisted at home by the territorial Emergency Service Team (EST). On EST first clinical evaluation, he presented with fair general conditions; generalized urticaria, rhinitis, and lips and eyelid angioedema were still present, and his vital signs were as follows: 96% peripheral oxygen saturation rate on ambient air; blood pressure 95/55 mmHg (50° pc 101/63 mmHg); heart rate 150 beats per minute (bpm) (normal range 80–120 bpm), respiratory rate 32 breaths/min (normal range 25 ± 4 breaths/min), and a Glasgow Coma Scale score of 15. The symptoms had occurred 15 min after a meal of smoked salmon, anchovies, mayonnaise, butter, salmon roe, and lumpfish roe. V.R. had previously eaten smoked salmon and mayonnaise without any symptoms. No intake of other foods/juices, alcohol, or medications was reported. During the ambulance trip to the hospital, intramuscular adrenaline (0.01 mg/kg), methylprednisolone (1 mg/kg), and oral cetirizine (0.25 mg/kg) was administered by the EST. The child was admitted to our Pediatric Emergency Department in fair general condition with lips and eyelid angioedema; vital sign parameters were stable compared to the previous evaluation. The results of routine laboratory analysis on admission were within the normal range.
+
+Clinical Course
+After 12 and 24 h, due to worsening eyelid angioedema with reappearance of urticaria, a further administration of intravenous chlorpheniramine (0.25 mg/kg) was necessary. Tryptase (a protease released from mast cells during an acute allergic reaction) serum level in the acute phase (peak) was 5.39 μg/L, whereas the baseline level, detected 24 h after the allergic reaction, was 2.34 μg/L. In the pediatric population, the peak total serum tryptase should be at least 120% of the baseline tryptase level plus 2 μg/L (≥1.2 × baseline tryptase + 2 μg/L) to diagnose acute mast cell activation in anaphylaxis [11]. Indeed, in our patient, the peak tryptase level met this criterion, exceeding the diagnostic cutoff level (4.81 μg/L = 120% + 2 µg/L of the baseline level). After 36 h of hospitalization, V.R. was discharged in fair clinical condition, though the result of the specific food IgE test was not yet available. An adrenaline auto injection kit (0.15 mg) was prescribed, after instructing the patient of its proper use.
+
+
+Follow Up and Specific Allergy Tests
+One week later, the patient returned to our outpatient office for a routine visit and was in good clinical condition. Food-specific serum IgE (by Immuno-CAP, Thermo Fisher Scientific, Uppsala, Sweden), meantime assessed, tested as follows: egg white (0.67 kUA/L), milk (1.12 kUA/L), beta-lactoglobulin (0.13 kUA/L), caseine (0.18 kUA/L), alfa-lactalbumin (0.48 kUA/L), peanut (<0.35 kUA/L), cod (<0.35 kUA/L), wheat (<0.35 kUA/L), shrimp (<0.35 kUA/L), salmon (<0.35 kUA/L), parvalbumin (<0.35 kUA/L), LTP Pru p3 (<0.35 kUA/L), and Betv2 (<0.35 kUA/L). Level ≥ 0.35 kUA/L was considered positive. Unfortunately, we could not perform the serum food-specific IgE test for fish roe (salmon and lumpfish roe), because it was not yet available in Italy.
+
+Based on a food-specific serum IgE test, only an allergic sensitization to cow’s milk and egg proteins was evident; indeed, these foods had previously been eaten without any symptoms. Prick-by-prick tests for smoked salmon, anchovies, mayonnaise, salmon roe (red caviar), and lumpfish roe were also performed. All these foods had been eaten a few minutes before the occurrence of the allergic reaction. The prick by-prick test was positive for salmon roe (red caviar 11 mm × 10 mm) and lumpfish roe (4 mm × 4 mm), but negative for all the other foods tested. Positive (histamine) and negative (saline solution) controls were included.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_318_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_318_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cba35a7e7a4bb1a3c526c86f86d7dce5b86a4436
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_318_en.txt
@@ -0,0 +1,9 @@
+A 21-year-old female patient with abdominal pain, irregular menstrual cycles, hyperestrogenemia, and recurrence of an ovarian mass was transferred to our hospital in July 2020.
+Four months prior, the patient was referred to another hospital because of abdominal pain and irregular menstrual cycles. Ultrasonography revealed a large multilocular cystic mass in the abdominal cavity. As the abdominal pain increased, the patient underwent single-port laparoscopic removal of the bilateral ovarian cysts. During surgery, the bilateral ovaries were enlarged in a multilocular mass with yellow fluid inside, and histopathology revealed multiple luteinized follicular cysts of the ovary.
+After one month of clinical treatment, the patient experienced abdominal pain again. Pelvic ultrasound indicated recurrence of enlarged ovaries with multiple large cysts, and its upper edge reached 20 mm above the umbilicus; both sides reached the midclavicular line, while the thickness of the endometrium was 17.4 mm. Biochemical evaluation demonstrated normal serum levels of LH, FSH, progesterone (PROG), cortisol, Free T4 (FT4), thyroid-stimulating hormone (TSH), parathyroid hormone (PTH), calcium, phosphate, and growth hormone (GH), and elevated levels of plasma CA125, estradiol, and prolactin (PRL). Brain magnetic resonance imaging (MRI) revealed the presence of a pituitary macroadenoma (17 mm × 27 mm × 19 mm), and visual field examination after brain MRI revealed bitemporal hemianopsia. Ultrasound showed a 48 mm × 30 mm × 23 mm mass in the right breast, and histopathology revealed breast fibroadenoma. Ultrasound imaging revealed no abnormalities in the thyroid, adrenal, or parathyroid glands. The female patient was then treated with oral bromocriptine (2.5 mg) three times a day.
+The patient had no significant history of illness, medical history, drug allergy, transfusion, injury, pregnancy, or other complications.
+The patient had smoking history for over four years and had no remarkable personal or family history.
+The patient had menarche at age 12 years, and she had a regular menstrual cycle. In the past year, the menstrual cycle of the patient had extended to 2–3 months, accompanied by progressively increased dysmenorrhea.
+The patient was 167 cm tall, weighed 68 kg, and had a body mass index of 24.38 kg/m2. temperature was 36.7 °C, heart rate was 96 beats/min, respiratory rate was 20 breaths/min, and blood pressure was 98/68 mmHg.
+Biochemical evaluation showed that plasma estradiol and CA125 levels were elevated, while PRL, LH, FSH, PROG, cortisol, FT4, TSH, PTH, and GH levels were maintained at normal levels.
+An ultrasonographic study of the pelvis revealed multicystic ovaries, similar to the typical signs of spontaneous ovarian hyperstimulation syndrome (OHSS). Computed tomography confirmed a large cystic mass in the abdominopelvic cavity , with a range of 19.4 cm × 7.9 cm × 15.9 cm. A homogeneously enhancing 21 mm × 16 mm× 28 mm sellar mass imaged by Brain MRI was presented .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3206_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3206_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ced9c0304ae9774aff7a8d3b3b109a0278b97dc7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3206_en.txt
@@ -0,0 +1 @@
+Female, 32 years old, caucasian, obstetric history of three pregnancies (three caesareans), the last complicated by preeclampsia superimposed on chronic hypertension, with subsequent diagnosis of CKD (focal segmental glomerulosclerosis in renal biopsy). Undergoing immunosuppressive treatment with cyclophosphamide and corticosteroid therapy, showing good initial response but early relapse. She abandoned the consultation, without therapeutic guidance, between 2011 and November 2013, when she turned to the emergency department of the area of residence for hypertensive crisis, with subsequent need to initiate dialysis.  In March 2014, due to complaints of abdominal distension, she performed abdominal ultrasound that revealed a bicoronic/biamniotic twin pregnancy of 19 weeks. The dialysis strategy was optimised for four five-hour sessions per week and was referred to the Obstetrics/Nephrology service. At the first evaluation, at 21 weeks, both foetuses presented normal morphology, biometries in the 25th - 50th and 50th - 75th percentile, respectively, and normal amniotic fluid indices. She had ultrasound assessments every three weeks until 27 weeks, when it was decided to initiate more stringent monitoring and adjust the haemodialysis programme to six sessions per week, which was difficult to reconcile with the distance to the area of residence. This treatment was well tolerated clinically and haemodynamically, with blood pressure controlled with 30 mg daily nifedipine and stable analytical results. Following the routine second trimester examinations (PTGO 61/156/175 mg/dL), gestational diabetes was diagnosed, which was controlled with insulin therapy. She received corticosteroid therapy for foetal pulmonary maturation at 28 weeks and initiated supportive therapy with erythropoietin (1 x/week), calcium carbonate, ferrous sulphate and enoxaparin. Both foetuses presented growth in the 50th percentile, LA and umbilical artery flowmetry was normal. At 34 weeks and six days, due to the onset of labour, she underwent caesarean section. Two boys were born with 2220 g and 2260 g and Apgar scores of 8/9/10. In the postpartum period, she remained stable, with adjustment of the haemodialysis sessions to three times per week.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3210_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3210_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..df5d633d3816ce09503584baca1cb4825e367f78
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3210_en.txt
@@ -0,0 +1,15 @@
+A 27-year-old man from Bogotá, a car parts salesman, was diagnosed with high-risk CD20+ common-type B-cell precursor acute lymphoblastic leukemia. He received two cycles of HyperCVAD and consulted the National Cancer Institute for a relapse and five-day polyarthralgia, for which he was initiated into the protocol established in 2003 by the Adult Acute Lymphoblastic Leukemia Research Group (GRAALL-2003).
+
+The patient subsequently developed febrile neutropenia, cellulitis of the left hand without abscess, and methicillin-sensitive Staphylococcus aureus bacteremia. Cefapime and oxacillin were administered and the bacteremia resolved.
+
+On day 21 of hospitalization, the patient presented lesions on the back of the left hand, of the type erythematoedematosa plaque, with mild and fine desquamation on the surface and central blood crust, as well as lesions in the right scapular and infra-scapular region with presence of 3 mm non-follicular papules, grouped, some erythematous and others erythemoparous, without epidermal change. The lesions were assessed by the Dermatology Service and given the characteristics of those on the back of the hand, a skin biopsy was taken for histopathological study. The results were inconclusive for the diagnosis of mycosis and no culture was done for fungi of the biopsy.
+
+Due to the persistence of the febrile neutropenia and the appearance of the skin lesions, an invasive fungal infection was suspected, and caspofungin was initiated. The chest and sinus computed tomography (CT) scans as well as the serum galactomannan detection were negative for invasive aspergillosis.
+
+However, despite antimicrobial and antifungal treatment, the patient did not show significant improvement, as he persisted with a fever of up to 40 °C, without other localized symptoms. The patient continued in a regular general state, sleepy, with mild mucocutaneous pallor and with 1 cm nodules, soft, depressible, painless and in the previous sites of venipuncture, without other important findings.
+
+It was decided to take new samples for blood culture and another biopsy of the skin lesions was requested. The blood count showed a profound neutropenia (20 white blood cells per µl) and persistent lymphopenia; the C reactive protein was 6.15 mg/dl, the albumin was 1.94 g/dl and the creatinine and transaminases were normal. The control CT scan of the paranasal sinuses showed incipient chronic inflammatory changes in the right maxillary sinus; the chest CT scan was normal, but the abdomen scan documented hepatosplenomegaly.
+
+The three blood cultures and the urine culture from day 28 of hospitalization showed yeast-like structures that were not identified in the automated panel Yeast ID (BD Phoenix™ 100). Arthroconidia were observed by microscopy and colonies compatible with Geotrichum spp. were documented, a diagnosis confirmed by matrix-assisted laser desorption ionization time-of-flight (MALDI-TOF) mass spectrometry.
+
+Treatment with amphotericin B deoxycholate was given at a daily dose of 1 mg/kg for 14 days and 400 mg/day of voriconazole for four weeks. Clinical symptoms resolved and the patient recovered from neutropenia on day 24 of the combined antifungal treatment. The patient was discharged on day 101 of hospitalisation due to clinical improvement.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3254_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3254_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e5f025dd18bd42b7274cd8bdf15ed65f6d03abe
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3254_en.txt
@@ -0,0 +1,19 @@
+A 31-year-old male presented to the emergency department (ED) with an acute onset of left-sided weakness including upper and lower extremities, which began approximately one hour prior, following a fall while seated. The patient reported a frontal headache and slurred speech, along with non-radiating, burning epigastric pain.
+
+The patient had an unremarkable medical history, aside from recurrent episodes of left flank pain previously treated as renal colic at a urology clinic. For this, he had been prescribed a non-steroidal anti-inflammatory drug, his only medication. The patient also reported a smoking history of 18 pack-years but denied any alcohol or substance abuse.
+
+The patient was conscious, alert, and oriented to time, place, and person, with hemodynamically stable and an oxygen saturation of 98% on room air. Neurologic examination showed non-fluent speech with intact comprehension and repetition. Sensation was preserved bilaterally; however, there was a marked reduction in power on the left side, with both upper and lower limbs scoring 1/5, and a muted Babinski sign on the left compared to the normal response on the right. Cranial nerve function was intact.
+
+Initial laboratory results in the ED revealed elevated cardiac enzymes and normocytic anemia, with a hemoglobin level of 7 g/dl, a high reticulocyte count, and a low platelet count. Coagulation studies showed an elevated activated partial thromboplastin time (aPTT) with normal prothrombin time (PT) and international normalized ratio (INR). Evidence of intrarenal injury was noted, with a blood urea nitrogen (BUN) to creatinine ratio of 17:1. Additional findings included indirect hyperbilirubinemia, elevated inflammatory markers (C-reactive protein and erythrocyte sedimentation rate), normal serum electrolytes, and normal haptoglobin. The patient’s baseline creatinine was 0.7 mg/dl. Urinalysis showed + 2 proteinuria and + 3 hematuria.
+
+Diagnostic investigations included an electrocardiogram (ECG) that showed sinus rhythm with prolonged PR interval and diffuse ST-segment elevation, suggestive of myopericarditis. The echocardiogram revealed a Left ventricular ejection fraction of 60% and bi-atrial dilation. Cardiac catheterization showed non-obstructive coronary artery disease, indicating microvascular thrombosis. A CT scan showed a large acute nonhemorrhagic infarction in the right fronto-parietal–temporal lobes, along with multiple lacunar infarctions, confirmed by magnetic resonance imaging (MRI). Magnetic resonance angiography (MRA) revealed total occlusion of the middle cerebral artery.
+
+The patient was admitted to the intensive care unit (ICU), where additional laboratory investigations revealed schistocytes on blood smear, positive direct and indirect Coomb’s test, increased ferritin, and a negative rheumatoid factor. Complement component C3 was decreased, and LAC was positive (ratio: 1.74). aCL was positive (26 IU/ml), while IgA and IgM β2GP1 antibodies were negative. Anti-nuclear antibodies (titer: 1:86) and anti-dsDNA antibodies (95.4 IU/ml) were also positive.
+
+The patient received three units of packed red blood cells; two units were administered after the patient remained anemic following the first unit. The patient’s condition dramatically improved after initiating treatment with Methylprednisolone, Hydroxychloroquine, Colchicine, and Rituximab.
+
+Over the following 10 days, the patient exhibited further improvement with significant progress observed in both physical exam and laboratory results. An ECG demonstrated regular sinus rhythm with no ST-segment elevation, but T wave inversion was noted in lead aVL. On the 12th day, the patient was discharged in stable condition with residual left-side weakness (1/5 in the upper limbs and 3/5 in the lower limbs) and normal strength on the right side. An ECG showed regular sinus rhythm with negative T waves in the anterior and inferior leads. An echocardiogram revealed normal findings, including a left atrial size of 20 mm (within the normal range of 20–40 mm).
+
+At his last follow-up visit, 10 weeks after discharge, the patient remained stable and showed improvements in the strength of his left upper lower limb, which were 4/5 and 3/5, respectively. He continued to use crutches to assist with mobility while undergoing physiotherapy.
+
+Thirteen weeks after discharge, the patient visited the rheumatology clinic, where the diagnosis of APS was confirmed through repeat laboratory tests. The results showed positive LAC (ratio: 1.85), as well as positive IgG aCL (46 IU/ml), IgM aCL (22 IU/ml), IgG aβ2GP1 (46 U/ml), IgA aβ2GP1 (39 U/ml), and IgM aβ2GP1 (35 U/ml) antibodies.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3255_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3255_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fca265c9ca6fd9fcb9ae43cbd8be35f8378064e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3255_en.txt
@@ -0,0 +1 @@
+45-year-old woman with a medical history of hypertension and a surgical history of a video-laparoscopic cholecystectomy 6 years ago. She was admitted to our department due to a 3-month evolution of a condition characterised by digestive intolerance associated with a 10 kg weight loss. The laboratory presented a leukocytosis (GB: 25170/uL) as the only relevant data. A tumour marker assay (CEA and CA19-9) was performed, which was normal. A tomography of the chest, abdomen and pelvis was performed with intravenous contrast, where a relevant finding was observed at the gastrointestinal level, gastric distension with thickening of the mucosa with a sclerosing appearance at the level of the pyloric region. It was completed with a high-definition upper gastrointestinal endoscopy, which detected a mucous lesion that was raised, totally obstructive, friable, and indurated, from which multiple biopsies were taken. The result of the pathological anatomy reported a mucous duodenal infiltrated by carcinoma with a squamous differentiation. Techniques of immunohistochemistry (IHC) were performed, which interpreted the diagnosis as a poorly differentiated pavement carcinoma, and it was not possible to define the primary site of origin, since all pavement carcinomas have a similar immunophenotype, regardless of their anatomical origin. As a complementary method, a positron emission tomography (PET-CT) was requested, which reported a solid hypermetabolic lesion in the topography of the second portion of the duodenum, in close relationship, without a cleavage plane, with the head of the pancreas, 31 x 32 mm in diameter, and presented a SUVmax of 17.7. The lesion caused a supra-stenotic dilation of the digestive tract.  The patient was evaluated by specialists in gynaecology, head and neck surgery and thoracic surgery, seeking, in the first instance, to ensure that the pancreatic tumour was not a metastasis of another origin. Based on the findings, a surgical procedure was defined and a duodenopancreatectomy was performed. The pathological anatomy reported a poorly differentiated, infiltrating carcinoma of pancreatic origin that compromised the duodenum, with a maximum tumour size of 4 cm. A neoplastic proliferation with dyskeratic areas and central necrosis was observed in the pancreatic stroma, data compatible with neoplastic squamous cells. To confirm the cell line, an IHC of the surgical piece was requested, which reported the presence of AE1/AE3, cytokeratin 5 and P 63 positive, compatible with a primary pancreatic squamous carcinoma. The patient evolved without complications from her surgery. She was presented to an interdisciplinary oncological committee, where the performance of adjuvant treatment with CAPOX (capecitabine and oxaliplatin) was defined. Currently, 24 months after the postoperative, she is free of disease with periodic checks. The patient signed the corresponding informed consent and the ethics committee was informed for the publication of the case.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3269_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3269_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e96350392f8604d64765c6949259a647623d7656
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3269_en.txt
@@ -0,0 +1,5 @@
+29-year-old female patient with chronic renal disease due to primary focal and segmental glomerulosclerosis, who received a renal transplant in 2017 and was taking tacrolimus, everolimus and prednisone 5 mg daily, was non-diabetic. After a year of progressive deterioration of renal function, diagnosed by gradual increase in serum creatinine and without associated symptoms, a biopsy of the renal graft was performed, which showed findings consistent with pauciimmune vasculitis, so it was decided to hospitalize her to intensify the immunosuppression with methylprednisolone and cyclophosphamide.
+
+The patient was admitted in a stable condition, afebrile and without urinary symptoms. The examination revealed low inflammatory parameters (C-reactive protein: 17.9 mg/L, white blood cell count: 7,600 cells/uL, absolute neutrophil count: 6,000 cells/uL), but with a urine sediment of 5 leukocytes per field and few bacteria. The urine culture was negative, so 7 urine bacilloscopies were performed, with 3 positive results, reporting 4 to 9 acid-fast bacilli per 100 fields. 6 urine mycobacteria cultures were performed, all negative, as well as a urine sample polymerase chain reaction (PCR) against M. tuberculosis (GeneXpert®) also negative. The study was complemented with a Mycobacterium tuberculosis interferon-gamma release assay (Quantiferon TB-Gold-Plus®) that was negative and a non-contrast computed tomography of the abdomen that did not show structural alterations suggestive of mycobacterial infection.
+
+Due to the context of the patient with an immunosuppression plan, it was decided to postpone the start of immunosuppressive therapy and request the identification of the species of mycobacteria from a urine sample using panmicrobacterial PCR with sequencing of the amplified product. The sequence obtained was compared with the GenBank® database and was compatible with Lawsonella clevelandensis. Following the result, amoxicillin with clavulanic acid 500/125 mg was indicated every 12 h for 3 to 6 months. The patient progressed 4 months later with a severe COVID-19 case, requiring mechanical ventilation and renal replacement therapy, so the antibiotic therapy was extended for 7 months, and the immunosuppressive therapy was restarted after hospital discharge and clinical stabilisation.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3277_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3277_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b7200fcabf020918ffc3a0622f8eb08e1a61512f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3277_en.txt
@@ -0,0 +1,7 @@
+A woman in her 50s was kicked in the right upper quadrant of her abdomen by a horse that weighed approximately 600 kg. The patient was initially transported to a local hospital. Pancreatic injury was suspected due to the nature of the injury, physical examinations, and contrast-enhanced computed tomography (CT), and the patient was referred to our hospital 3.5h after the accident. Upon arrival, the patient was alert with a blood pressure of 165/92 mmHg, heart rate of 82 bpm, SpO2 of 92% under room air, and body temperature of 37.4°C. Her abdomen had a bruise in the upper right quadrant with tenderness in the same area; however, no signs of peritoneal irritation were observed. Blood test findings were as follows: white blood cell count, 8160/μL; hemoglobin, 11.7g/dL; platelets, 25.8×104/μL; aspartate aminotransferase, 265 IU/L; alanine aminotransferase, 213IU/L; amylase, 247 IU/L; lipase, 408 IU/L; creatine phosphokinase, 180IU/L; and C-reactive protein, 0.03mg/dL. Repeat contrast-enhanced CT was performed after admission, which revealed pneumoperitoneum and hematoma near the duodenum, discontinuity of the duodenal wall, and a poorly contrasted area in the pancreas head. Because duodenal laceration was suspected, the patient underwent emergent laparotomy 6h after the accident without additional examinations, such as magnetic resonance cholangiopancreatography (MRCP), to evaluate pancreatic duct injury, for the purpose of time-saving.
+
+The operative findings were as follows: the first portion of the duodenum was completely lacerated (American Association for the Surgery of Trauma Organ Injury Severity Scoring System [AAST-OIS] Grade III). An extended Kocher maneuver was performed, and the presence of any other organ injuries including the pancreatic head, was investigated. No contamination around the pancreatic head, saponification of fat tissue, or other injuries to major vessels and other organs were observed. We planned to evaluate the patient with intraoperative endoscopic retrograde cholangiopancreatography (ERCP) if any surgical findings suggested biliary or main pancreatic duct injury; however, no obvious injury to the pancreatic head was observed on intraoperative findings; therefore, intraoperative ERCP was omitted. Because the patient’s vital signs were stable and the condition of the damaged tissue was favorable, primary anastomosis was performed for repair.
+
+The ruptured duodenum and pyloric portion of the stomach were trimmed and repaired by hand-sewn end-to-end anastomosis between the gastric remnant and duodenum using 4-0 Polydioxanone. Then, an antegrade decompression tube for gastric and duodenal juice drainage and a feeding jejunostomy tube were placed. Considering the possibility of bile congestion secondary to edema of the ampulla of Vater, delayed biliary injury, and anastomotic leakage, cholecystectomy was performed to place a C-tube (cystic duct tube) for biliary drainage as an adjunctive procedure. Two drains were placed around the pancreas.
+
+The patient’s postoperative course was favorable. The serum amylase and lipase levels were normalized on postoperative day (POD) 2. An oral contrast study on POD 8 revealed no leakage from the injury site and normal passage of contrast into the jejunum. A bile duct contrast study on POD 16 revealed normal passage of contrast into the duodenum. The decompression and feeding tubes were removed on POD 15, followed by the C-tube on POD 16. The patient was discharged on POD 20 in stable condition. At an outpatient visit 3 months postoperatively, the patient reported no abdominal pain or stenosis symptoms.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3279_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3279_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da6adfbad2c73b39dd43a34eb7c5dbdecc38004d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3279_en.txt
@@ -0,0 +1 @@
+45-year-old Chilean woman evaluated for asymptomatic hypercalcemia repeated 11.6-12.0 mg/dL (normal: 8.5-10.5) and PTH 59 pg/mL (normal 10-65), calciuria not available. No history of fractures, nephrolithiasis or previous drugs. MIBI parathyroid scintigram suggestive of hyperfunctioning right parathyroid. Exploratory cervicotomy without intraoperative PTH normalization (basal 85/95, nadir 65 pg/mL) after lower right parathyroidectomy, with PTH normalization after resection of lower left parathyroid (PTH 19pg/mL). Biopsy compatible with hyperplasia of 2 parathyroid glands. However, in post-operative she developed persistent hypercalcemia, so she was referred to our Endocrine-Osteology polyclinic. The study demonstrated persistence of PTH-dependent hypercalcemia in the first year post-surgery, with normal creatinine and 25OHD in blood and 24 h urine calcium/creatinine clearance (RCCC) 0.004-0.006. She reported a history of a first cousin with asymptomatic hypercalcemia up to 11.5 mg/dL and RCCC was 0.006. Screening of available relatives showed chronic asymptomatic hypercalcemia up to 11.5 mg/dL in mother and another first cousin, compatible with HHF. INVITAE (R) genetic study in the index case, compatible with CaSR gene variant of uncertain significance c.1637G>A (p. Cys546Tyr).
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3284_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3284_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..70cda819d16aa389b368d5dd3909255b1b4823b2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3284_en.txt
@@ -0,0 +1,13 @@
+A 14-year-old male patient was admitted for extraction of the third molars in January 2022. During the clinical evaluation, a non-painful restriction of oral opening was observed, which made it difficult to eat solid food and to carry out adequate oral hygiene. There was also an interincisal separation of 15 mm at the maximum oral opening, anterior overbite, mandibular deviation to the right side and restriction of lateral movements. During the examination, the patient stated that the restriction had been gradually and slowly developing for approximately 3 years, with a sensation of “scraping” under the zygomatic arch when opening the mouth.
+
+In the initial panoramic radiograph, the image of both coronoid processes was observed to be superior to their respective zygomatic arches, so a computed tomography (CT) was requested. In the volumetric reconstructions of the patient with the mouth closed in maximum intercuspidation, an increase in volume of the AC was observed, of homogeneous density, with an attenuation coefficient ranging from 633.7 UH to 208.9 UH. In axial images, towards the inner face of the zygomatic bone on both sides, a hyperdense image suggestive of exostosis was observed, of greater size in the zygomatic arch of the right side, closely related to the enlargement of the coronoid processes. In the closed mouth, the position of the AC was posterior to the exostosis, while on the left side it was in an anterior position in relation to the ipsilateral exostosis.
+
+A bilateral coronoidectomy was performed via intraoral approach through the anterior border of the mandibular branch and subperiosteal dissection to expose the coronoid processes. At this time, mouth opening movements were performed and the premature contact of the processes with the posterior face of the zygomatic bone was observed. The disinsertion of the temporal muscle and an ostectomy at the base of the processes were performed and the processes were removed. The specimens were sent for histopathological analysis, which revealed normal morphology of trabecular and cortical bone tissue with abundant adipose tissue.
+
+In the immediate post-surgical control, performed by means of clinical evaluation, the increase in millimetres of the oral opening was observed, 30 mm and, through the orthopantomography, the sharp and precise cut of both coronoidectomies was verified.
+
+The patient came for evaluation at 12 months with a 30 mm oral opening, which was not painful. He had orthodontic appliances as a surgical preparation for the correction of dento-skeletal deformity class II. A CT was indicated, and a recurrence of bilateral hyperplasia of coronoid apophysis was observed. The pre-surgical images were compared.
+
+In the comparative study of the exostoses observed in axial image, towards the inner face of both zygomatic arches, a significant reduction of the same was observed, with greater evidence on the right side.
+
+Conservative management was decided upon, with physiotherapy and clinical monitoring by measuring the mouth opening with a vernier caliper every three months for the duration of the orthodontic treatment.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3291_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3291_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e42f2cfcf7afede4c46ce0d513d2c07eb6c1ff90
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3291_en.txt
@@ -0,0 +1,17 @@
+Premature newborn from a second pregnancy, from non-consanguineous parents, 27-year-old mother with no significant morbid history, 3 prenatal checks, with diagnosis of omphalocele, but without subsequent follow-up. Personal, pathological and toxic allergic history is unknown, peripartum STORCH examinations negative.
+
+A newborn with undetermined sex was born at a gestational age (GA) estimated to be 33 weeks based on the Ballard test; with a weight of 2,300 g, a length of 43 cm, a head circumference of 32 cm, an anthropometric assessment of length/GA: -0.21 standard deviations (SD), weight/GA: +1.17 SD and head circumference/GA: + 1.11 SD; classified as adequate weight and length for the gestational age according to Intergrowth-21.
+
+The initial physical examination highlighted a low anterior hairline, hypoplastic uvula, prominent lobes, broad nasal dorsum, anteverted nares, asymmetry with left hemifacial microsomia, absence of abdominal wall, giant omphalocele associated with vesicoureteral extrophy, epispadias, no palpable gonads, imperforate anus, a soft mass on the dorsum covered by skin at the lumbosacral level, bilateral club foot, hypoplastic nails, digitalized thumbs and halluxes.
+
+The primary management was surgical correction of the omphalocele and ileostomy through an exploratory laparotomy. A defect of the anterior wall of the abdomen of a giant omphalocele of approximately 12 cm, centrally located, with an intact amnion containing the whole liver and some loops, associated with a vesical extrophia with exposed urethral orifices, a uterus didelphus (each hemi-uterus with its respective tube and ovary), a prolapse of approximately 15 cm of intestine through the cloaca, a small intestine ending in the cecum and the cecum in the cloaca, without evidence of the rest of the colon, and a diastasis of the pubis, were described at that time.
+
+In the face of these malformations, an echocardiographic study was completed that reported a patent ductus arteriosus of 1 mm without haemodynamic repercussion, severe pulmonary hypertension of 65 mm hg. Radiological studies showed lower lumbar hemiverterbrae of the sacrum, butterfly vertebrae in the vertebral body of T9 and T12, hypoplastic iliac, without visualizing the coccyx.
+
+Computed tomography of the abdomen showed a left diaphragmatic hernia (Bochdalek), with hypertrophy of the left hepatic lobe displacing the liver anteriorly and inferiorly, causing an abnormal position of the intestinal loops posteriorly and caudally, as well as an ectopic gallbladder, a rejected bladder to the right with diffuse thickening of the walls, extrusion of the soft tissue of the pelvis with bone malformations and myelomeningocele. Magnetic resonance imaging of the brain showed myelocystocele.
+
+With these findings, a high suspicion of OEIS complex with simultaneous presentation of Cantrell's pentalogia or 1p36 deletion was considered. In the genetic study, numerical and structural chromosome abnormalities were ruled out with a karyotype of 25 metaphase, G banding with a result of 46, XX.
+
+As a management, the group of pediatric surgery and urology performed a colostomy, cloaca closure and midline vesical plaque, with adequate postoperative evolution, given respiratory stability during hospitalization, surgical correction of diaphragmatic hernia was deferred at that time and was planned to be performed later depending on clinical evolution.
+
+The hospital stay was prolonged, however, she was discharged with indication of multidisciplinary outpatient control, but the patient died of intercurrent acute respiratory pathology shortly after.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3317_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3317_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..01804cdebf4b4f608b924e1fdf300394f250bb7b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3317_en.txt
@@ -0,0 +1,19 @@
+We describe the case of a 63-year-old man, Caucasian, affected by non-ischemic dilated cardiomyopathy who did not drink alcohol, did not smoke tobacco, and did not have diabetes. He had an implantable cardioverter defibrillator implanted, in New York Heart Association (NYHA) IV class, and left bundle branch block (LBBB; QRS duration of 145 ms). He was referred for CRT-D upgrade, awaiting cardiac transplantation, despite optimal medical therapy: b-Blockade, loop-diuretic, angiotensin-converting enzyme (ACE) inhibitor, K-sparing agent, and ivabradine. Standard clinical imaging protocol revealed a dilated left ventricle with an end-systolic volume (ESV) of 380 ml, an ejection fraction (EF) of 4.8% as measured by the modified Simpson’s method, and severe FMR, assessed by qualitative estimation with two-dimensional color flow Doppler approach, showing a very large central jet and reaching the posterior wall of the left atrium.
+
+He underwent the implant of a CRT-D device with a quadripolar left ventricular (LV) lead placed in the posterolateral branch of the coronary sinus. After recording the right ventricle (RV)-to-LV electrical delay at each of the four LV rings, we chose the A1 unipolar vector for LV pacing (greatest electrical delay 80 ms).
+
+At 13-day post-implant follow-up, he showed worsening heart failure (HF) symptoms and only A2 unipolar LV vector configuration, with interventricular (VV) interval of 0 ms, was suitable for simultaneous biventricular activation.
+
+Echo-PIV was then used, during the acute study with contrast agent bubbles, to evaluate the orientation and relative magnitude of blood-induced intraventricular forces in correspondence of different pacing settings.
+
+Without pacing stimulation (CRT OFF) the intraventricular flow was dominated by rotation without evident inflow–outflow dynamics. As a result the intraventricular forces were predominantly transverse and not aligned along the LV axis as quantified by the large value of their mean angle φ (φ = 55.6°, this angle ranges from 0°, when forces are aligned with the LV axis, to 90°). A first setting option (CRT ON, VV delay 0 ms) changed the orientation of intraventricular forces reducing the angle (φ = 45°), and increasing the delay (CRT ON, VV delay − 30 ms) improved the alignment reducing the angle (φ = 40.3°). Eventually, the sequential biventricular activation with delay − 50 ms provided the best alignment of intraventricular forces (φ = 38.8°).
+
+No reduction of FMR by three-dimensional FVCD, during the same acute study with shutdown versus reactivation of device.
+
+The data acquisition time, by three-chamber apical view, for each three-dimensional color Doppler data set was approximately 5 seconds, and it took less than 3 minutes to analyze the average regurgitation volume, with automated anatomy detection of the LV endocardial border, mitral annulus (MA), LV outflow (LVOT), and placement of three-dimensional hemispheric flow sampling planes in the MA and LVOT. The software of three-dimensional FVCD computed the flow volumes as the area under the curve of both the MA and LVOT flow in three cardiac cycles, and FMR volume was calculated by subtracting LVOT stroke volume from MA stroke volume.
+
+Results at 6-month follow-up
+
+Our patient showed an improvement of NYHA class (III versus IV) and LV EF (26.6% versus 4.8%). Significant reduction of ESV (288 ml versus 380 ml) and persistent improvement of diastolic function were obtained. The regularized function is noticeable. At follow-up, a significant reduction of FMR (mean value regurgitant volume, 42.2 ml versus 65.3 ml) was estimated.
+
+The intraventricular forces estimated by echo-PIV were still partially dominated by the longitudinal path of pressure gradient with φ = 43.1°.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3320_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3320_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9239fc1419dea92c370058b97a3e5db7370585ad
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3320_en.txt
@@ -0,0 +1,5 @@
+A 29-year-old preeclamptic postpartum patient was referred to the ophthalmology outpatient clinic with the complaint of sudden vision loss in both eyes. She applied to the obstetrics and gynecology clinic with headache and cloudy vision the day before. In her first examination, systemic BP was 165/105 mmHg, and there was bilateral (++) pretibial edema. It was unclear when her BP began to rise, as the patient had no regular pregnancy follow-up. She was not at high-risk for either PE or SRD and did not have clinical high-risk predictors such as pre-existing chronic hypertension or chronic kidney disease. In her obstetric ultrasonography findings, there was anhydramnios, and the fetus was compatible with 39 weeks of gestation. While thrombocyte count was 232x103/mm3; hemoglobin was 10.2 g/dL, ALT was 142 IU/L, and AST was 142 IU/L. There was (+++) proteinuria with the dipstick. Renal function and coagulation tests were normal. She was diagnosed as PE, hospitalized and had a vaginal delivery. Antihypertensive (nifedipine) and anticonvulsant therapy for eclampsia prophylaxis (MgSO4) was started following hospitalization.
+
+On the first postnatal day, the visual acuity of the patient was finger counting at one meter for the right eye, while it was two meters for the left eye. She did not have any abnormalities in her anterior segment examination for both eyes and had normal intraocular pressure. In the slit-lamp fundus examination, there was bullous SRD involving the retina’s superior aspect and extending to the optic disk in the right eye. In the examination of the left eye, there was a similar SRD including the temporal aspect of the retina and it was enlarging into the macula. Unfortunately, we did not have the opportunity to do a retinography or optical coherence tomography (OCT) screening in our department, thus we confirmed the SRD in both eyes via B-scan ophthalmic ultrasonography in accordance with fundus examination. Both before and after the resolution of the detachment, the patient was asked to undergo an OCT examination at another hospital. We informed the patient that this disorder had a self-resolving manner and had a good prognosis.
+
+We were able to get the patients’s OCT imaging in the second week of follow-up, her visual acuity improved to 8/10 for the right eye, while it was 4/10 for the left eye. Except for a minimal subretinal fluid in both eyes and a localized retinal pigment epithelium disruption in the left eye, OCT was considered normal. While the patient’s right eye vision had fully recovered, her left eye vision improved to 8/10, after 1-month follow-up. She did not provide us with a second OCT imaging after her vision completely recovered.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3331_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3331_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..54249f4e583727833641dd86c59167e595b765b3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3331_en.txt
@@ -0,0 +1 @@
+67-year-old female patient who consulted the emergency department for palpitations. As a clinical history, she presented mitral prolapse and loss of vision in the right eye secondary to an ophthalmic artery embolism. She began 7 days earlier with sporadic palpitations, not associated with the functional class, which subsided spontaneously, and which persisted permanently for 2 hours on the day of the consultation. The patient reported progressive dyspnoea up to functional class III of 6 months of evolution. On admission, she presented the following vital signs: arterial tension of 110/60 mmHg, heart rate of 140 beats per minute, oxygen saturation of 95% of ambient air, respiratory rate of 20 beats per minute, jugular engorgement, oedema 3/6 and hepatalgia. On the admission electrocardiogram, a rhythm of atrial fibrillation was observed at 140 beats per minute, axis at 60°, qrs 0.14 with an image of incomplete left branch block, without alterations of the ST-T segment. Laboratory: haematocrit of 42, no leukocytosis, creatinine 0.92, sodium of 136, potassium of 4.3, magnesium of 1.9, NT proBnp of 12 000 pg/dL, and troponins of 1900 ng/dL. It was interpreted as heart failure in a patient with atrial fibrillation with high ventricular response. During the admission, the etiological diagnosis was deepened. An echocardiogram was performed, where increased left ventricular diameters with severe impairment of function, severe left atrial enlargement, redundant mitral valve with bivalve prolapse were observed, with a predominance of p, with mild reflux and mild tricuspid insufficiency with pulmonary systolic pressure of 28 mmHg. Due to severe impairment of function not known and positive troponins, a cinecoronaryography was performed, which did not evidence angiographically significant lesions. Differential diagnoses were proposed: myocarditis and tachycardiomyopathy. They were ruled out, given that the patient did not present echocardiographic characteristics of myocarditis and in the rhythm without sinus there was no recovery of function, which also did not correspond with a syndrome of tachycardiomyopathy. It was interpreted as severe impairment of ventricular function in a patient with Barlow's disease. An electrocardiogram of the rhythm without sinus was performed, and a transesophageal cardioversion was performed successfully. In the transesophageal electrocardiogram, the mitral valve was reevaluated again and the patient presented mild insufficiency with a prolapse similar to that observed in the transtoracic electrocardiogram. Electrocardioversion was performed successfully. In the subsequent electrocardiograms of the rhythm without sinus, the severe impairment of ventricular function persisted. At 24 hours of admission, the patient intercurred with an episode of cardiorespiratory arrest, secondary to polymorphic ventricular tachycardia. She repeated two similar events at 48 and 72 hours, all of which were reversed with advanced cardiopulmonary resuscitation. For this reason, the placement of an implantable cardiodesfibrilator (CDI) was decided as secondary prevention. The patient was discharged.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3340_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3340_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e4f09bc12142e22d8f2c6f0a31110c5765674b6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3340_en.txt
@@ -0,0 +1,3 @@
+In this case report, prepared in adherence to the SCARE 2023 guidelines for surgical case reporting. A 35-year-old female presented to our urology clinic on [02-27-2023] with a 2-week history of left lumbar pain. Computed tomography urography (CTU) performed on [02-28-2023] identified Y-shaped double renal pelvis malformations in the left kidney. Preoperative renal function was normal (creatinine: 0.60 mg/dL). Urine analysis indicated elevated white blood cells and red blood cells in the urine, and no obvious abnormalities were found in the other test results. Urinary CTU suggested double renal pelvis malformations of the left kidney, the ureters fused at the lower edge of L3, multiple upper ureteral calculi on the left side with dilation of the upper renal pelvis. The upper calculus was slightly smaller, with a long diameter of about 25 mm and an average CT value of 850 hu. The lower calculus was larger and strip-shaped, with a long diameter of about 38 mm and an average CT value of 1101 hu.
+
+The patient was placed in the right lateral position for surgical treatment. The surgical method selected was retroperitoneal laparoscopic ureterolithotomy. During the operation, it was observed that there was a double ureteral malformation in the upper left segment, in a Y shape, with severe adhesion to the surrounding tissues. After carefully separating the ureter, an incision was made at the calculus site of the upper ureter, and the incision was extended by about 3 cm. The calculus at the lower part was removed. The texture was slightly hard and was about 4 cm in length and elongated. The ureter was examined again up to the near renal hilum. No calculi were seen under laparoscopy. Considering that the calculus had moved upward to the upper left renal pelvis, a flexible ureteroscope was inserted from the first incision. With the assistance of laparoscopy, the flexible ureteroscope was placed along the ureteral incision into the renal pelvis. A calculus was seen in the left renal pelvis, about 3 cm in size. An attempt to insert a stone-catching basket to remove the calculus failed. Then, percutaneous nephrolithotomy under direct laparoscopy was changed, and a Fr18 channel was established. A ureteroscope was inserted, and the calculus could be seen. Then, a holmium laser was inserted to crush and remove the calculus. The angle of the ureteroscope was adjusted, and the junction of the left renal pelvis and ureter was found. An integrated double J stent was inserted. Under direct laparoscopy, it was seen that the double J stent passed through the ureteral incision. The operation time was approximately 3 h, and the intraoperative blood loss was about 50 mL. Postoperative review CT examination showed no obvious calculus shadow. The double J stent in the body was removed 1.5 months later. After half a year, the review of urinary CTU was normal.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3346_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3346_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c642ce61cb3194fd55440fe25477934b8ec6ae1b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3346_en.txt
@@ -0,0 +1,6 @@
+A 41-year-old Inuit female complaining of blurred vision in the left eye was referred to our eye department. The patient’s past medical history included diabetes mellitus type 2, arterial hypertension and hypercholesterolemia. The patient had no past ocular history and there was no sign of diabetic retinopathy during diabetic eye screening six months prior, although a possible area of neovascularization was found in the right eye that could not be attributed to diabetes. In retrospect, this area of possible neovascularization may have been an early sign of Eales’ disease: the patient had received antibiotic treatment for TB in 2010 following a positive QuantiFERON® test. Telemedical assessment including ultra wide-field fundus imaging could neither confirm nor deny a specific diagnosis, but images were suspicious for vitritis or vitreous hemorrhage in the right eye. Eales’ disease could not be ruled out, and the patient was flown from Greenland to Denmark for further evaluation, including investigation of the cause of her suspected vitreoretinopathy. Arrangements were made for the patient to stay at the Greenland patient hotel in Copenhagen for the duration of her treatment.
+
+Results
+On examination, visual acuity was 6/12 in the right eye and 6/36 in the left eye (Snellen). Fundoscopy revealed mild vitritis in the right eye, a vitreous hemorrhage in the left eye with neovascularization of the disc in the left eye and retinal neovascularization elsewhere in both eyes. Fundus fluorescein angiography showed vessel leakage and areas of non-perfusion in the retinal mid-peripheries. There was left epiretinal membrane with retinal thickening on macular optical coherence tomography.
+
+Eales’ disease is an occlusive vasculitis involving the retinal mid-periphery that commonly presents with vitreous hemorrhage. It is further characterized by periphlebitis, vascular occlusion and subsequent retinal neovascularization. Based on the patient findings and history of TB infection in this case, a diagnosis of Eales’ disease was made. The patient’s epiretinal membrane was thought to be visually significant, leading to treatment of the left eye with pars plana vitrectomy with epiretinal membrane peeling, endodiathermy and endolaser. The right eye was treated in outpatients with sectoral laser photocoagulation. At seven weeks’ follow-up, the visual acuity had improved to 6/6 (right eye) and 6/7.5 (left eye). The patient had met with the visual acuity requirement for driving-licence vision in either eye and both eyes were deemed to be sufficiently treated.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3354_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3354_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b0d2842f216cea8490911bef1bcb50c32392520f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3354_en.txt
@@ -0,0 +1 @@
+62-year-old previously healthy female hiker and climber presented with dizziness, imbalance, and gait instability that developed rapidly within a few weeks in 2016. Subacute cerebellar ataxia was suspected and a number of studies including oncological blood tests, oncological neuronal antibodies, brain and body PET, cerebrospinal fluid examination, brain imaging, and genetic testing for ataxia were performed with no positive findings. After an initial plateau of symptoms, the patient entered a slow and progressive neurological decline with late-onset idiopathic cerebellar ataxia as the most likely diagnosis. After multiple medical consultations, she came to our center in 2022. The patient denied a family history, frequent cough, digestive problems, and autonomic disorders. The neurological examination showed unstable, wide-based gait and a positive Romberg test. She presented dysarthria, vertical descending nystagmus in primary gaze, and lateral gaze nystagmus. The slow eye tracking was fragmented and the visual suppression of the normal vestibulo-ocular reflex was observed. The head impulse test and dynamic visual acuity were abnormal. In addition, symmetrical bilateral inframalleolar hypalesthesia and presenting vestibulo-neuromuscular reflexes were observed. No autonomic weakness or muscle weakness was detected in the extremities. In summary, the patient with no relevant family history developed a late-onset idiopathic cerebellar ataxia with diverse neurological manifestations including sensory and vestibular disorders, while the studies performed did not yield a specific diagnosis. Complementary studies: To revalidate the clinical diagnosis of a mixed vestibulo-cerebellar dysfunction, a 3 Tesla magnetic resonance of the brain (MRI), a video head impulse test (VHIT) and vestibulo-myogenic evoked potentials (VEMPS) were performed along with sensory potentials of the four limbs. The MRI of the brain showed a discrete cerebellar vermiform and para-vermiform atrophy without focal structural damage. The vestibulo-myogenic evoked potentials showed a severe global vestibular hyporeflexia. Genetic studies: A clinical exome study was performed, using next-generation sequencing (NGS), to search for point and small insertion/deletion variants on a panel of 677 candidate genes according to the patient's phenotype, mainly associated with spinocerebellar ataxia, which was negative. Subsequently, a specific genetic study for intronic expansion in the RFC1 gene was performed, which was consistent with the presence of a pathogenic AAGGG motif biallelic expansion. These findings of bilateral vestibulopathy associated with cerebellar ataxia and sensory neuronopathy suggested the diagnosis of CANVAS, which was confirmed by the identification of biallelic expansion of the RFC1 gene in genetic testing.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3383_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3383_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf5ee7064479549cf1bc19bfd02c2a08c2fd9742
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3383_en.txt
@@ -0,0 +1,9 @@
+Patient information: A 64-year-old housewife with no significant medical history presented with dysphagia to solids accompanied by a foreign body sensation in the pharynx for one month, which had not improved with symptomatic treatment. She had no respiratory difficulties or dysphonia. Her general condition was stable and she had no fever.
+
+Clinical findings: On clinical examination, no abnormality or peripheral adenopathy was found. Nasofibroscopy showed a pink polypoid tumour with a smooth surface and healthy mucosa, located on the left ary-epiglottic fold and its attached pedicle in the left retro-crico-arytenoid region.
+
+Diagnostic evaluation: cervical-thoracic CT scan revealed a well-defined polyploid mass of homogeneous tissue density that was enhanced in the post-contrast phase, located at the posterior wall of the hypopharynx. It extended anteriorly to the supraglottic level and was in contact with the laryngeal aspect of the epiglottis. Direct laryngoscopy under general anesthesia with multiple biopsies revealed a pink polyploid mass at the supraglottic level. Histological analysis revealed a large lymphoid cell infiltrate with irregular nuclear outlines and multiple prominent nucleoli. Immunohistochemical analysis of the tumor cells showed a positive expression of CD20, but not CD5, CD7, CD23, CD10, cyclin D1, LEF1, and Bcl6. Scattered plasma cells were identified, which retained CD138, but were present in a limited number. Proliferation index, evaluated with Ki67 marker, was 25%. Based on these findings, a diagnosis of a low-grade B lymphoma, consistent with a marginal zone lymphoma, was made. The laboratory findings were normal, including a complete blood count, inflammatory markers, and LDH. Extensive examinations, including a thoraco-abdomino-pelvic CT scan and a bone marrow biopsy, revealed no abnormalities, which allowed the disease stage to be determined as IEBa according to the Ann Arbor classification.
+
+Therapeutic intervention: The patient received four courses of R-CEOP chemotherapy, which consists of a mixture of rituximab and various products, including cyclophosphamide, etoposide, vincristine and prednisone. After each course, appropriate intervals were observed, followed by radiotherapy. Radiotherapy was administered over a period of four weeks, with a total dose of 40 Gy. It was divided into five sessions of 2 Gy per week, targeting the tumour site as well as the adjacent lymph nodes, including the upper mediastinum.
+
+Follow-up and results: the side effects of the treatment were minimal. After three months of treatment, the dysphagia had completely disappeared. The endoscopic and tomodensitometric control examinations performed six months later revealed normal results. The evolution was favorable, without any sign of local recurrence. The follow-up period extends over two years.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3385_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3385_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..91b4abd14587c521f272bf7010dbdede5312751e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3385_en.txt
@@ -0,0 +1,9 @@
+The patient was an 18-year-old female with Chronic Renal Disease (CRD) on haemodialysis due to probable renal dysplasia, with a history of developmental delay due to hydrocephalus (presenting ventriculoperitoneal shunts). Preoperative and admission chest X-rays were normal. No PPD or IGRA tests were performed as they were not part of the current pre-transplant routine. The recipient did not have a medical history suggestive of tuberculosis.
+
+She received a kidney transplant from a deceased donor on 10/07/18. The donor was a standard criteria one: 17-year-old male, whose cause of death was suicide (hanging). His creatinine level was 1.55 mg/dL. He was induced with thymoglobulin (panel of antibody reactivity, 29%) and maintained with tacrolimus (0.1 mg/kg), mycophenolate sodium, and prednisone. At the time of donation, there was no report of pulmonary disease and no chest radiographs were performed. The donor did not have a history that suggested the diagnosis of prior TB.
+
+Following transplantation, the patient had immediate graft function and was discharged on the seventh postoperative day with creatinine level of 1.16 mg/dL. She was readmitted on the 37th postoperative day with fever and positive cytomegalovirus antigenemia (11 cells) and was treated with ganciclovir for 14 days, but daily fever persisted. Abdominal ultrasound and chest radiographs were normal at this time, and sequential cultures (blood and urine) were positive for Leuconostoc mesenteroides, and she was treated with ampicillin and gentamicin combination, although daily fever persisted.
+
+After 2 weeks of admission without resolution of the clinical picture, a computed tomography (CT) of the chest was performed, which revealed diffuse micronodular disease compatible with miliary TB and abdominal fluid adjacent to the middle third of the transplanted kidney; this fluid fistulized through the skin. At this time, the medical team of the contralateral renal transplant was contacted who informed that their patient presented a similar condition, being diagnosed with tuberculosis from the donor and needing to undergo a graft nephrectomy. In addition, this team identified in the donor's history a hospital admission for pneumonia complicated with pleural effusion one month before his death.
+
+Our patient tested positive for Koch's bacillus by polymerase chain reaction (PCR) in urine and positive for alcohol-acid-resistant bacillus (BAAR) in surgical wound drainage fluid. After confirming the diagnosis of TB, the team decided to keep the graft and initiated specific treatment with Coxip (rifampicin, isoniazid, pyrazinamide, and ethambutol) along with the discontinuation of immunosuppressive medication. The Coxip regimen was maintained for 12 months. Prednisone was reintroduced 12 days after the initiation of TB treatment, and the rest of the immunosuppressive medication was resumed after 8 weeks. The creatinine level after the end of TB treatment was 0.85 mg/dL. The patient is currently on outpatient follow-up with tacrolimus, sirolimus, and prednisone and has a creatinine level of 0.76 mg/dL.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_361_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_361_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e8b8f9cea8a031e4318090f900addbf08f635b41
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_361_en.txt
@@ -0,0 +1,5 @@
+In August 2015, a 26-year-old morbidly obese African American man presented to the hospital with increasingly generalized weakness for 2 months and light-headedness for 4 days. His BMI was 54 kg/M2, and he had been on a special diet for a few months with a weight loss of 50 pounds. The diet was mainly composed of vegetables but of unknown detail. He sweated profusely while working as a chef in his own kitchen for a web-based catering service. He had childhood asthma and a pulmonary embolism at age of 21 years. He was born in Hartford, Connecticut to an African American father and a Caucasian mother (a Brazilian immigrant). He moved to Fresno, CA in 2010 and started working for his own catering service in 2015. On exam, his blood pressure was 138/73 mmHg with a pulse of 91 beats/min. His mucous membranes were dry. Laboratory tests showed severe hypokalemia (serum potassium of 1.5 mEq/L) and metabolic alkalosis with prerenal azotemia . Arterial blood gas revealed a pH of 7.55, PaCO2 of 50 mmHg, PaO2 of 60 mmHg and bicarbonate of 42 mEq/L. The urine sodium (< 10 mEq/L) and potassium (13.8 mEq/L) were both very low . These findings were consistent with extrarenal losses of potassium. In addition, his 24-h urine aldosterone was normal at 5.4 mcg/d (normal 2.3–21) and free cortisol was also normal. His thyroid function was normal, as were renal ultrasound and renal Doppler ultrasound. After given intravenous normal saline and potassium, he was discharged and prescribed with potassium chloride 20 mEq two tabs bid.
+In follow-up, the patient’s potassium was tapered off. His potassium remained normal through the winter, and so he was discharged from the nephrology office (YC) in April, 2016. His hypokalemia was considered a result of his reduced oral intake while on a special weight loss diet combined with excessive sweating during a Fresno summer. In July 2016, he visited the ER and was found to have a blood pressure of 150/80 mmHg, hypokalemia and metabolic alkalosis. He was given intravenous potassium and discharged the next morning. In July 2017, he was admitted to an outside hospital for the same problems, and another nephrologist was consulted.
+In July 2018, he was again admitted for the same complaints . Nephrology consultation (YC) was involved. Oral potassium chloride was prescribed at discharge. Because of repeated summertime hypokalemia with excessive sweating, CF was suspected. Initially, the pulmonologist was reluctant to pursue a test for CF because the patient lacked evidence of CF, was morbidly obese, and was from a low incidence demographic. However, further discussion with our CF expert (DL) led to disease specific tests.
+HRCT showed clear lungs and pulmonary function test was normal. Lipase was low at 8 U/L (normal 12–53). Pilocarpine sweat test demonstrated chloride of 101 mEq/L on the left arm and 106 mEq/L on the right arm (normal < 60). Genetic testing revealed two CFTR mutations: heterozygous p.F508Del (pathogenic mutation) and heterozygous (TG)12-5 T in trans conformation, also known as c.[1210–12[5];1210-34TG[12]]. The diagnosis of CF was finally established.
+The potassium dose was tapered off over the following 3 months, and the patient’s potassium level remained normal through the winter. In March 2019, his potassium was normal. In anticipation of warmer weather, potassium chloride 20 mEq bid was prescribed. He was advised to moderately increase sodium chloride intake in the summer, but to avoid its excess due to concerns for elevated BP. The monthly lab showed his potassium was maintained at 3.6–4.0 mEeq/L throughout the summer of 2019 while he continued to work in his kitchen. Our long-term plan is to supplement him with potassium from April to October every year. However, his body weight has increased steadily, with a most recent BMI of 87 Kg/M2. He is reluctant to consider bariatric surgery because his mother’s surgery was accompanied by complications. He appreciated that we had made a diagnosis and gave informed consent for publication.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_37_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_37_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f939d22078117a71e27694da5aacaed57aeb0065
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_37_en.txt
@@ -0,0 +1,6 @@
+A 63-year-old myopic female with exfoliation glaucoma presented with a visually significant cataract in the right eye. The best corrected visual acuity (BCVA) was 20/60 and IOP was 20 mm Hg on Latanoprost. Her untreated IOP was 25 mm Hg. The right eye had a cup to a disc of 0.6, with an axial length of 26.42 mm and an AC depth of 3.43 mm. She had a grade 3 angle open to scleral spur with 3+ TM pigmentation. She elected to have cataract surgery with a femtosecond laser and wanted vision correction at all distances, so the decision was made to perform FLACS with a trifocal IOL (Panoptix, Alcon, Ft. Worth, TX, USA), Given that her angle was open and her IOP was slightly elevated, she was a candidate for angle based MIGS. The decision was made to perform trabectome (Microsurgical Technology, Redmond, WA, USA) in combination with cataract surgery. Past medical history included hypothyroidism and hyperlipidemia. She had no other medical conditions, was not on anticoagulation therapy, and did not have any coagulation disorder.
+The capsulorhexis, nuclear divisions, and an arcuate incision were performed using the Catalys Precision Laser System (Johnson and Johnson, New Brunswick, NJ, USA) and there was no bleeding. She was then brought from the femtosecond laser room to the operating room for the manual portion of the surgery. A temporal paracentesis and temporal main wound were created, followed by injection of dispersive viscoelastic. Preparation for the trabectome was made by tilting the head and microscope. Upon placing the gonioprism, the angle was noted to be open, with a heavily pigmented TM and no blood noted in the Schlemms canal . The trabectome was placed into the AC and was performed, ablating and removing 90 degrees of the TM. Upon completion of the trabectome, there was a copious amount of bleeding from the nasal angle incision. Additional dispersive viscoelastic was injected into the nasal angle to tamponade the bleeding.
+The manual portion of the cataract surgery commenced. The head was tilted back to the ortho position and the microscope was positioned. The capsulorhexis was removed and phacoemulsification was performed. During the cataract surgery, there continued to be bleeding from the angle, for which more dispersive viscoelastic was injected into the angle to try to stop the bleeding. The blood was removed with irrigation and aspiration during the phacoemulsification and cortical clean-up. The intraocular lens was implanted. After the lens was injected and viscoelastic was removed, there was still a large amount of blood emanating from the angle. AC washout was performed with irrigation and aspiration and more dispersive viscoelastic was injected to tamponade the bleeding. The bleeding continued, so the decision was made to use a needle tip cautery to achieve hemostasis. The microscope was tilted, the head was rotated and with the assistance of a surgical gonioprism, cautery was applied to the bleeding area of the angle. Additional washout was performed and more dispersive viscoelastic was injected to tamponade the bleeding. The bleeding improved and the surgery was completed. Dispersive viscoelastic was retained in the eye to continue to serve as tamponade. Head of bed elevation and no straining were advised.
+On postoperative day 1, the vision was hand motions with IOP 49 mm Hg. The AC had a 7 mm hyphema with 4+ microhyphema. B-scan ultrasound showed no vitreoretinal pathology. The paracentesis was tapped until the IOP decreased to 6 mm Hg. She was started on timolol-brimonidine and netarsudil in the right eye in addition to moxifloxacin, prednisolone, and ketorolac. The latanoprost was discontinued.
+On postoperative day 2, the vision was hand motions and the IOP was 44 mm Hg. The AC had 2 mm of layered hyphema and 4+ microhyphema. There was no area of active bleeding. The paracentesis tap was repeated until the IOP was 24 mm Hg. On postoperative day 3, the vision was hand motions and the IOP was 21 mm Hg. The AC had 1.5 mm of layered hyphema with 4+ microhyphema and a nasal blood clot . She was followed daily with improving hyphema and stable IOP. There was a rebleed on postoperative day 7 with an IOP increase to 51 mm Hg. An AC washout was considered, but the decision was made to continue with office-based management due to the possibility of continued bleeding with a surgical AC washout. A paracentesis was made, and wound tapping was repeated. The IOP stabilized on postoperative day 8 and onwards with resolving hyphema.
+On postoperative day 18, the vision improved to 20/70, IOP was 13 mm Hg, and there were no clots or layered hyphema. There was remaining 4+ microhyphema. By postoperative month 1, the microhyphema had cleared, but there was an endocapsular hematoma present . An Nd:YAG posterior capsulotomy was performed successfully. On the postsurgery month 9 visit, visual acuity was 20/25 with IOP 15 mm Hg on Brimonidine once daily.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_412_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_412_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e70eda349fd5416cf61177f3d72038ad7760977b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_412_en.txt
@@ -0,0 +1,3 @@
+This 8-year-old boy presented with complaints of progressively worsening headaches along with vomiting and intermittent fever since 20 days. There were no significant findings on general physical and neurological examination. The patient's routine laboratory investigations were normal. A magnetic resonance imaging (MRI) brain was performed which showed multiple intracranial cysts predominantly in the right frontal region with significant mass effect . The patient's chest X-ray, ultrasound abdomen, and eosinophil counts were normal. The patient was started on dexamethasone, leviteracetem, and albendazole and scheduled for surgery.
+A frontoparietal craniotomy was performed. There was significant dural tension, and a c-shaped durotomy was done which revealed a huge hydatid cyst extending toward the lateral ventricle . A soft rubber catheter was inserted between the brain parenchyma and the cyst capsule (Dowling's technique); a cleavage plane was established using warm hypertonic saline and the cyst was delivered unruptured . Numerous daughter cysts were then identified which were carefully delivered unruptured using the same technique [Figure and ]. We were able to remove all of the 19 cysts without rupturing the cyst capsule this way. An endoscope was used after removing all the cysts to make sure that none of the daughter cysts was left behind. The cavity was copiously irrigated with hypertonic saline and hydrogen peroxide. Histopathological examination confirmed hydatid cyst and no bacterial agent was isolated.
+The patient continued taking albendazole (200 mg, BID), dexamethasone, cefazolin, and levetiracetam postoperatively and had an uneventful postoperative course. The patient was seen in clinic on 3 months postoperative visit and his complaints of headache and vomiting had completely resolved. His neurological examination was completely normal and considering financial constraints a follow-up computed tomography (CT) scan was thus not performed.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_415_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_415_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..69d7fe491cf943d42611697403801cb18892035e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_415_en.txt
@@ -0,0 +1,2 @@
+A 42-year-old woman with history of SLE on hydroxychloroquine, mycophenolate and prednisone, complicated by pancytopenia, presented with severe back pain 30 min after taking oral TMP-SMX 800-160 mg for paronychia. She was found to be febrile to 39.1 °C, hypotensive at 88/63 mmHg, and tachycardic at 107 BPM. Laboratory testing revealed a white blood cell (WBC) count of 8.63 × 103/uL (97.3% neutrophils, 0.1% eosinophils, 0.2% lymphocytes, with a baseline WBC of 2 × 103/uL), lactate 2.3 mmol/L and creatinine of 1.3 mg/dL (baseline 0.7 mg/dL) . HIV ELISA was negative but the CD4+ count was low at 64 cells/uL. Computed tomography (CT) angiogram of the chest showed no evidence of pulmonary embolus or infection and urinalysis was not suggestive of infection. Physical exam was significant for diffusely erythematous and warm skin without macules, papules, or urticaria. There were no other focal findings on physical exam. The patient was initially managed with aggressive 80 mL/kg intravenous (IV) fluid resuscitation, norepinephrine, broad-spectrum antibiotics (IV vancomycin and IV piperacillin-tazobactam), and stress dose steroids (hydrocortisone 50 mg IV every 6 h). Her hypotension resolved quickly over the first 36 h of admission. Over the following 3 days blood and urine cultures remained negative and steroids, vasopressors and antibiotics were discontinued without recurrence of hypotension. Additional infectious work up, including hepatitis B, hepatitis C and toxoplasma, were negative. The patient was discharged home on hospital day four with pneumocystis jirovecii pneumonia (PJP) prophylaxis with atovaquone.
+Ten months prior, the patient had a similar presentation several hours after taking her second dose of oral TMP-SMX 800-160 mg, which was prescribed for an abscess of the mons pubis. On presentation, she was hypotensive, tachycardic and febrile. Laboratory testing revealed a WBC of 10.9 × 103/uL (95.5% neutrophils, 0.6% lymphocytes and 0.5% eosinophils), acute kidney injury (creatinine 1.1 mg/dL) and lactate of 1.2 mmol/L. She was treated similarly for presumed septic shock. Work-up for infectious etiologies including blood and urine cultures, CT imaging of head, spine and abdomen as well as an echocardiogram was unrevealing. She was weaned off vasopressor support within 24 h. Her steroids and antibiotics were discontinued within 72 h with clinical improvement and she was discharged home with the diagnosis of septic shock with unknown etiology.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_416_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_416_en.txt
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index 0000000000000000000000000000000000000000..bcf8760f5b952b49dfd2d722125db4fd9fdee547
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_416_en.txt
@@ -0,0 +1,7 @@
+A 33-year-old male patient presented to a tertiary care hospital with intermittent abdominal pain, nausea, vomiting, constipation and numbness of bilateral lower limb extremities, of 3 days duration. He was conservatively managed in a surgical unit as partial intestinal obstruction and was awaiting diagnostic laparoscopy. The patient developed confusion and found to have systemic hypertension, and, therefore, was transferred to a medical ward for further management. He is a non-diabetic and did not have a previous history of hypertension. The drug history revealed usage of over-the-counter analgesics for 6 weeks.
+The past medical and surgical history revealed similar neurovisceral attacks requiring five acute hospital admissions over 2 years, which ended up in questionable diagnoses. The sixth acute attack raised the suspicion of an acute porphyria. The first attack in January 2013 led to a diagnosis of appendicitis. Because the symptoms worsened following the surgery an emergency laparoscopic exploration was done. But the exploration revealed no cause to explain the worsening symptoms. The second attack was managed as sinus tachycardia and he was started on beta adrenergic blockers. The third attack which was associated with a fever was conservatively managed for a questionable renal colic. Forth attack was complicated with transient hyponatremia and transiently high serum creatinine levels. These complications were attributed to a questionable interstitial nephritis based on the fact that patient had used 50 mg of diclofenac sodium twice a day for 6 weeks, repeating the prescription given by a general practitioner. Another attack in 2015 was managed as partial intestinal obstruction and diagnostic laparoscopy was done. In all these presentations, findings from the ultra sound scans and diagnostic laparoscopy did not support a diagnosis of intra-abdominal pathology.
+On examination he was thin built (BMI = 20 kg/m2) and pale. Brachial blood pressure was 160/90 mmHg. There were scars of previous appendectomy and laparoscopy surgeries on the abdominal, but, otherwise, the abdominal examination was unremarkable. Muscle power was 4/5 in all four limbs (could not move against a good resistance).
+The laboratory investigations performed during this admission showed severe hyponatraemia of 115 mmol/L (136–145) with serum osmolality of 255 mOsmol/Kg (275–295) and urine osmolality of 460 mOsmol/Kg (50–1200 mOsmol/Kg). Serum creatinine concentration was 106 µmol/L (80–115) with blood urea level of 20 mg/dL (6–20). Hemoglobin concentration was 8.2 g/dL (13.5–17.5) and the red cell morphology was normochromic and normocytic. The total cholesterol level was 282 mg/dL (5th to 95th centile; 142–258) with LDL fraction of 225 mg/dL (5th to 95th centile; 78–185). Serum ferritin level was 646 ng/mL (20–250). Arterial blood gas analysis was suggestive of a metabolic acidosis. Echocardiogram showed evidence of left ventricular hypertrophy. There were no significant radiological findings in abdominal X-ray film or abdominal ultrasonography. Blood lead concentration was 3 μg/dL (< 5 μg/dL).
+A urine sample collected during the acute attack was sent to the Department of Chemical Pathology for biochemical analyses. On standing the urine sample gradually turned dark brown. The Watson and Schwartz test for urinary porphobilinogen (PBG) was positive . Spectrophotometry of urine for total porphyrins showed a “Soret band”. Urine total porphyrin level, calculated using Allen corrected absorbance of the urine sample was 5505.5 nmol/L (< 300 nmol/L). Genetic studies were carried out in an overseas laboratory. The full analysis of HMBS gene was performed by PCR amplification of extracted DNA followed by exon specific primer extension analysis of all exons, exon intron boundaries and promotor regions. The gene analysis revealed a previously reported missense mutation, c.517C>T encoding p.R173W in the HMBS gene. Targeted mutation analysis was performed by PCR amplification of extracted DNA followed by allele specific primer extension analysis, in five first-degree relatives. Among these, four were heterozygous for the same HMBS gene mutation .
+Since heme arginate is not available in Sri Lanka the patient was managed only symptomatically. Carbohydrate loading with intravenous dextrose and oral carbohydrates was the only feasible option. All the medications used for symptomatic management were checked for safety in acute porphyrias. Patient was discharged from the ward after symptoms gradually improved over 6 days to a degree that he can be managed as an out-patient. Response to treatment could not be assessed due to unavailability of quantitative tests to measure urinary aminolevulinic acid (ALA) and PBG in Sri Lanka. The patient was educated regarding precipitating factors of acute porphyria. A diagnostic card with information regarding medications to avoid was provided to the patient. Patient was followed up at the clinic with regular renal functions, hemoglobin and blood pressure monitoring. Follow up of the patient over 1 year following diagnosis revealed that patient suffered from two mild attacks which didn’t require in-patient management. Nerve conduction studies were not carried out because neurological symptoms were not observed in-between acute attacks.
+Pre-symptomatic relatives who inherited the HMBS mutation were also advised to avoid the trigger factors of acute attacks such as certain medications, fasting, alcohol and hormones. The brother of the proband was counseled regarding the risk of his children inheriting the HMBS mutation and recommended targeted mutation analyses for both children.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_42_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_42_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fa398168ca0b640ba076e88ec7baedff891c5764
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_42_en.txt
@@ -0,0 +1,3 @@
+The patient’s mother was a 31-year-old, gravida 1 para 0 woman with no significant medical history who was followed for prenatal management of mono-di twin pregnancy. Routine ultrasound at 13 weeks gestation was significant for a two-vessel umbilical cord and suspected small left ventricle and VSD in Twin A. Repeat ultrasounds at 15 and 18 weeks gestation identified several pertinent findings for Twin A, including sIUGR, missing right umbilical artery, and complex cardiac anomaly. In particular, Twin A’s heart was noted to have a conoventricular-type VSD with the overriding aorta and right ventricle larger than the left ventricle. Fetal biometry identified 28% weight discordance at week 15. However, there were no abnormal umbilical dopplers in either infant. Both fetuses presented with visible bladders, without evidence of fetal hydrops or other indicators for twin–twin transfusion syndrome. Additionally, weight discordance improved somewhat over the course of gestation. First-trimester screening showed decreased risk (1:>10,000) of trisomies 13, 18, and 21.
+With multiple anomalies in one of the twins, the family was referred for prenatal genetic counseling. The mother’s family history was significant for unilateral renal agenesis (in the mother’s mother and maternal aunt), learning disability (mother’s maternal half-brother), and bipolar disorder (mother’s maternal cousin). The father’s family history was also notable for unilateral renal agenesis (in the father’s paternal grandmother) and bipolar disorder (father’s maternal aunt). After discussion, the family opted to pursue amniocentesis for single nucleotide polymorphism (SNP) microarray testing, alpha-fetoprotein level, and carrier screening for 421 autosomal recessive and X-linked disorders (Natera Horizon). SNP microarray found an interstitial duplication of unknown significance in the long arm of chromosome 15 (arr[hg19] 15q26.3(99282850_99627413)x3, ~345 kb) in both twins . This duplication partially overlaps the IGF1R gene (OMIM*147370), from exons 3 to 21. Further testing of both parents found that the duplication was maternally inherited. Notably, the mother was negative for any history of cardiac or renal disease but had not had ultrasounds.
+Delivery was performed by the primary cesarian section at 35 weeks due to premature rupture of membranes. Delivery was otherwise uncomplicated; APGAR scores were 8 and 9 at 1 and 5 min, respectively, for both twins. At birth, Twin A weighed 2.04 kg, whereas Twin B weighed 2.69 kg. Twin A was transferred to the pediatric cardiac intensive care unit for initiation of prostaglandin treatment, whereas Twin B was transferred to the newborn nursery. A postnatal echocardiogram confirmed cardiac abnormalities for Twin A, including transverse aortic arch and isthmus hypoplasia, bicommissural stenotic aortic valve, and large posterior malalignment VSD but normal ventricular size and function. Twin B presented with no cardiac anomalies. Abdominal ultrasounds with two functional kidneys were normal in both. On examination, both infants presented with brachyclinodactyly of the fifth finger and microretrognathia, though this was more pronounced in Twin A and accompanied by a sloping forehead. Twin A additionally presented with the widened distance between the first and second toes bilaterally. Other features demonstrated typical variation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_436_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_436_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..be7675a873dc1db3f266d1c4e57c7e3dd2f43e70
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_436_en.txt
@@ -0,0 +1,8 @@
+A Chinese boy with a medical history of eczema and obesity presented with two episodes of anasarca and hypovolemic shock.
+When the patient was six years old, he had coryzal symptoms for two days and a one-day history of vomiting, diarrhoea and generalised abdominal pain. His blood pressure was 85/66 mmHg and heart rate was 144 beats per minute (bpm) upon presentation at another local hospital. This progressed to hypovolaemic shock requiring admission to the paediatric intensive care unit for fluid resuscitation. Laboratory investigation showed haemoconcentration, hypoalbuminemia and renal impairment with metabolic acidosis . Echocardiogram revealed a thickened left ventricle. Blood culture yielded coagulase-negative Staphylococci, which was deemed a skin contaminant. He was treated with fluid resuscitation and a seven-day empiric course of ceftriaxone. The patient’s renal function normalised after fluid replacement and he was discharged after one week. An echocardiogram was repeated a month later, which showed normal ventricular wall thickness, structure and function.
+The patient was well afterwards until he was eight years old. He presented with vomiting, diarrhoea, abdominal pain and a low-grade fever for one day. Again, he was admitted to another local hospital. The child became lethargic, hypotensive (76/52 mmHg), tachycardic (141 bpm), with physical signs of poor perfusion. Within 8 h of admission, a total of 3500 ml (70 mL/kg) of normal saline boluses were given but there were only transient periods of improvement and the blood pressure remained low overall. Laboratory investigation again showed haemoconcentration, hypoalbuminemia, impaired renal function and metabolic acidosis . Echocardiogram from the referring hospital showed a thickened left ventricle; the interventricular septum was 11.9 mm (Z-score + 13.34) and free wall was 14.2 mm (Z-score + 16.22).
+His blood pressure remained unstable despite additional boluses of 3500 ml (70 mL/kg) of normal saline in total over the next 12 h. Multiple inotropic medications including dopamine, dobutamine, noradrenaline and stress dose hydrocortisone were started. He was transferred to our hospital, a tertiary referral centre, for consideration of ECMO within 24 h of admission.
+During the transfer, he was given a total of 11 intravenous boluses (total 21 mL) of 0.1 mg/mL adrenaline due to persistent shock. He developed pulseless electrical activities shortly after arrival to our cardiac intensive care unit and recovered after two minutes of cardiopulmonary resuscitation. Upon return of spontaneous circulation, his blood pressure was 44/37 mmHg and his heart rate was 185 bpm. Post-resuscitation echocardiogram showed poor systolic function of both ventricles with the left ventricular internal dimension at end-diastole (LVIDd) of 18.3 mm (z-score − 8.65); the intraventricular septum at end-diastole (IVSd) was 18.3 mm (z-score + 4.61); left ventricular posterior wall at end-diastole (LVPWd) was 13.4 mm (z-score + 3.95); left ventricle fractional shortening (LVFS) was 18.3%; tricuspid annular plane systolic excursion (TAPSE) was 14.3 mm (z-score − 3.60) and the left ventricular mass index was 70 g/m2 .
+Emergency central veno-arterial ECMO was immediately initiated via cannulation of the right atrium and ascending aorta, and another 5200 ml (100 mL/kg) of fluid and blood products were given over the first 12 h after ECMO was started to maintain his intravascular volume. An optimal ECMO flow was achieved at 3 L/min with a cardiac index of 2.2 L/min/m2 afterwards. His nasopharynx aspirate was positive for parainfluenza virus type 2 and stool culture was positive for Salmonella group B. Blood culture and urine culture were negative and there was no detectable urinary protein. The patient had a mildly low immunoglobulin (Ig) G level of 687 (724–1380) mg/dL, but normal IgA and IgM. Protein electrophoresis and urine immunofixation showed no monoclonal antibody peak.
+The patient was very oedematous and developed compartment syndrome involving both lower limbs that required emergency fasciotomy. He also developed rhabdomyolysis with deranged renal function and pulmonary oedema 24 h after ECMO was initiated. Echocardiogram repeated 12 h after ECMO insertion showed reduced thickening of his left ventricular wall. The patient’s cardiac function, renal function and perfusion subsequently improved. Inotropic and ECMO support was weaned off three days after initiation. Echocardiogram four days after termination of ECMO support showed improvement of the left ventricular dimension and wall thickness and cardiac function: LVIDd was 33.4 mm (z-score − 2.63); IVSd was 6.95 mm (z-score 0.09); LVPWd was 6.62 mm (z-score 0.28); LVFS was 32.6% and the left ventricular mass was 39 g/m2 .
+As the patient’s clinical and laboratory findings were all suggestive of ISCLS after discussion with an immunologist, montelukast 5 mg daily was started as prophylactic treatment at three weeks, and he received his first monthly immunoglobulin infusion (1 g/kg) prophylaxis two months after the initial presentation. At his subsequent follow-up appointment, he still had residual peroneal neuropathy. Echocardiogram 11 weeks later showed normal left ventricular wall thickness and a full recovery of his biventricular function. He has remained asymptomatic so far for more than 12 months at his most recent clinic follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_437_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_437_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..40e5f36dddb389abc745159ca16d0c3e73c41a84
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_437_en.txt
@@ -0,0 +1,6 @@
+A 56-years-old woman with history of hypertension, decompensated diabetes mellitus, was referred to our hospital with critical limb ischemia (CLI) presenting rest pain and ulcer on the left leg and negative COVID-19. On physical examination, her blood pressure was 160/90 mmHg with 130 b/m. Auscultation of the abdomen revealed a mesogastrium systolic bruit. Electrocardiogram showed signs of ST segment depression without thoracic pain. Coronary angiography was positive for severe coronary artery disease with no indication to treatment. Duplex ultrasound (DUS) revealed widespread irregularities of the aortic wall with monophasic wave on right common femoral artery and direct flow on the left femoral axis; diffuse disease of both superficial femoral arteries (SFA) with distal occlusion in the left side.
+CT-scan showed atherosclerotic disease on infrarenal abdominal aorta with focal dissection, occlusion of right common iliac artery origin and short dissection of the left common iliac artery origin not hemodynamically significative .
+The presence of ulcers in the left leg was the indication to address the left SFA throughout an antegrade percutaneous homolateral access with drug eluting balloon (DEB) angioplasty in the proximal SFA (6.0 × 60 mm Luminor®; iVascular, Vascular S.L.U., Barcelona, Spain) and distal stenting (5.0x80mm iVolution; iVascular) . The final result was a complete lesion healing in the left foot at three weeks .
+After two months of the index procedure, the patient was readmitted due to gangrene of the right foot and asymptomatic COVID-19 infection. The control CT showed a similar vascular pattern on the right side with no significant difference with the previous CT. At this stage, the rapid and aggressive right foot lesions evolution was the indication to address vascular lesions in the right axis.
+The intervention was carried under general anesthesia with surgical exposure of both common femoral arteries employed as remote accesses for multilevel endovascular intervention. The first step consisted of aorto-iliac repair (aortic dissection and right common iliac occlusion) using an AFX aortic endograft (Endoogix Inc., Irvine, CA, USA); stenting of the right common iliac artery (balloon expandable stent - Isthmus 10 × 39; CID SpA, Saluggia, Italy).
+During the same operation, the right SFA disease was addressed with a DEB (Luminor 5 × 200 iVascular) . The multiple intervention determined the increase of the distal flow and the reappearance of dorsalis pedis pulse. After two days, the patient was asymptomatic for right foot pain and underwent to right foot minor amputation. The patient was discharged after a week with double antiplatelet therapy. CT angiography performed after two months confirmed the proper positioning of the aortic stent-graft with good patency of iliac-femoral axis and right foot ulcers healing .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_463_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_463_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..18d1a2299c02c5f126fd10c232a5e5b1800fbc84
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_463_en.txt
@@ -0,0 +1,3 @@
+On 7 March, 2018, a 73-year-old man, HIV-negative, was hospitalized to the local county hospital for 2-month chest pain, low-grade fever, asthenia, anorexia and weight loss. The patient had history of type II diabetes mellitus with regular administration of gliclazide, but efficacy was poor. Physical examination revealed body temperature 36.7 °C, pulse rate 96 beats/min, blood pressure 133/83 mmHg, respiratory rate 20/min, oxygen saturation 96% and mildly yellow skin and sclera. Respiratory system, cardiovascular system, neurological system and abdomen were normal. Laboratory examination showed anemia (hemoglobin 114 g/L), abnormal liver function (alanine aminotransferase 57 U/L, aspartate aminotransferase 48 U/L, γ-glutamyl transpeptidase 818 U/L, alkaline phosphatase 671 U/L, total bilirubin 44 μmol/L) and elevated cancer antigen 19-9 (CA19-9, 165 U/ml). The interferon-γ release assay test was negative. The skull computerized tomography (CT) showed lacunar infarction in bilateral basal ganglia. The thorax CT revealed multiple round or round-like nodules with variable sizes scattered throughout both lungs, suggestive of metastatic lung disease . Abdominal enhancement CT showed that a mass at the pancreatic head was obviously strengthened in the arterial phase, and the pancreatic duct and intrahepatic bile duct was slightly dilated . Taken together, all examination results were strongly suspected of lung metastasis, which was originated from the pancreatic head or intestinal origin. However, TB infection could not be excluded completely. The patient denied further biopsy, and chose to accept experimental anti-TB therapy with rifampin and isoniazid. After one month, chest CT showed that lung lesions were not absorbed. Laboratory test showed that CA19-9 sharply increased, up to 1167 U/ml. Sputum smear for acid-fast bacilli (AFB) was negative. The doctors in the local county hospital excluded TB infection and proposed gastrointestinal malignant tumors combined with lung metastasis. The patient family was in deep sorrow and prepared to give up.
+On 7 May, 2018, his daughter persuaded the patient to the provincial hospital for further diagnosis. Laboratory examination revealed hyperbilirubinemia (total bilirubin 70 μmol/L), CA19-9 832 U/ml, cancer antigen 125 141 U/ml, neuron-specific enolase 22.98 ng/ml, angiotensin-converting enzyme 178 U/L and serum (1,3)-β-D-glucan 235 pg/ml. 18F-fluorodeoxyglucose positron-emission tomography (18F-FDG-PET) scan showed focal high uptake in the multiple organs, including lung, liver, pancreas, spleen, gallbladder neck , which suggested benign disease (especially TB). The patient accepted the endoscopic retrograde cholangiopancreatography to relieve hyperbilirubinemia, which was caused by bile duct obstruction. Biopsy from brushed biliary cell indicated no malignant tumor. A CT scan-guided transthoracic needle biopsy of the nodule at the left upper lobe was performed and the histopathology showed coagulative necrosis combining with granulomatous inflammation. AFB staining was positive and Periodic Acid-Schiff staining was negative . In the meanwhile, qPCR for MTB DNA showed 4900 copy/ml in the sputum. Thus, the diagnosis of TB infection was definite. The patient then accepted anti-TB regimen, including isoniazid (300 mg/once a day [QD]), rifampicin (450 mg/QD), ethambutol (750 mg/QD), pyrazinamide (1500 mg/QD), levofloxacin (600 mg/QD) for three months, followed by isoniazid (300 mg/QD) and rifampicin (450 mg/QD) for another nine months.
+On 2 September, 2018, almost four months after hospitalization to our hospital, the thorax CT revealed that the lung lesions were absorbed significantly . After one year of treatment, continuous clinical and radiological improvement was observed, and the drugs were then withdrawn. The patient was asymptomatic at the follow-up of half year after withdrawal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_468_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_468_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8609ea4a90fee7754ad919d7e91d1eac1d4ac739
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_468_en.txt
@@ -0,0 +1,2 @@
+A 60-year-old woman complained of blurred vision in her left eye for one week. On presentation, the best corrected visual acuity (BCVA) was 0.6 in the right eye, and hand motion in the left eye. Slit lamp examination revealed normal anterior segment in both eyes. Direct ophthalmoscopy revealed slight macular epiretinal membrane in the right eye, and grey submacular membrane surrounded by subretinal hemorrhage in the left eye . The axial length of the right eye was 30.61 mm, and that of the left eye was 30.43 mm by IOL Master measurement. Fundus fluorescein angiography revealed early-staged submacular hyperfluorescence lesion , followed by strong fluorescein leakage and enlargement of hyperfluorescence in the later phases . Indocyanine green angiography demonstrated early-staged clustered hyperfluorescence spots , which showed evident leakage and enlargement in the later phases , confirming an active CNV in the left eye. Spectral-domain optical coherence tomography (SD-OCT) revealed type 2 CNV surrounded by serous neurosensory macuar detachment and intraretinal cysts above CNV in the left eye . Her past medical history was not remarkable. CNV secondary to degenerative myopia in the left eye was then diagnosed and uneventful intravitreal conbercept (2.5 mg/0.05 ml) injection was performed soon after the informed consent was signed.
+Three weeks after the injection, the patient came back with a complaint of central scotoma in the left eye. BCVA was counting fingers, funduscopic examination revealed a full thickness MH and surrounded retinal detachment , SD-OCT comfirmed a full thickness MH accompanied by macular detachment and intraretinal cysts in the left eye . Vitrectomy, internal limiting membrane peeling assisted by indocyanine green staining, and silicone oil tamponade were successfully performed in the left eye. Postoperative SD-OCT at one week’s follow-up revealed a reattached macular retina yet still open MH in the left eye. At three months’ follow-up, BCVA in the left eye was 0.05, MH still kept open depite successful macular reattachment and Fuchs spot formation which was characterized by a hyperreflective subretinal spot in SD-OCT.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_478_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_478_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3ed1abf8ccf98d3e88ab41397ce0801db329df7a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_478_en.txt
@@ -0,0 +1,5 @@
+We present the case of an 84 years old male presenting with dyspnea (NYHA III) and fatigue, hypotension (88/50 mmHg), tachycardia (97 bpm), and fever (38.4 °Celsius) to our emergency department fulfilling 2 of 4 criteria for SIRS . Clinical examination was significant for discrete bibasal pulmonary rales and a 2/6 systolic murmur, in agreement with a preexisting, moderate mitral valve insufficiency. Initial laboratory findings showed substantially elevated C-reactive protein (CRP) (84 mg/l) and serum creatinine (159 μmol/l).
+Recent medical history was significant for ST-elevation myocardial infarction (STEMI) 15 days prior to the current presentation with successful percutaneous coronary intervention and implantation of two drug eluting stents in the proximal right coronary artery. Other relevant comorbidities included pre-existing coronary artery disease, arterial hypertension and hypercholesterolemia. His current medication included aspirin, ticagrelor, nebivolol, olmesartan, rosuvastatin and pantoprazol, with ticagrelor initiated 15 days ago. He had no history of allergies.
+Empirical antibiotic treatment with ceftriaxone was initiated in the emergency department due to suspected severe sepsis after blood and urine culture sampling. Extensive infectious disease work-up including blood cultures, a respiratory panel for the comprehensive detection of respiratory disease-causing viruses and bacteria, HIV testing, and imaging studies (CT-scan of the chest, abdominal ultrasound, transthoracic and transoesophageal echocardiography) did not reveal an infectious cause of SIRS.
+Symptoms (dyspnea and fatigue), signs (fever), and laboratory signs (CRP) of SIRS persisted despite 6 days of intravenous antibiotic treatment . Further, Dressler-Syndrome was considered as a differential diagnosis. However, lack of a pericardial rub, leukocytosis, pericardial effusion, or clinical and laboratory response to preemptive treatment with ibuprofen rendered it very unlikely.
+After broad, unrevealing diagnostic work-up ticagrelor was suspected as the causative agent of persistent SIRS due to recent initiation and no other change in drug treatment. Accordingly, ticagrelor was discontinued at day seven and replaced by clopidogrel. No other drug was changed during the hospital stay. This was followed by a rapid improvement in symptoms as well as clinical and laboratory signs of SIRS. In clinical follow-up 2 weeks and 1 year after discharge the patient remained asymptomatic and well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_494_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_494_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..12b1a0bd4cb8c1d493fda0719566a8a43731340d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_494_en.txt
@@ -0,0 +1,4 @@
+A 45-year-old German Caucasian woman was transferred to our department of general surgery with a suspected esophageal perforation after endoscopic recovery of a pearl onion which was impacted in the middle third of the esophagus. After recovery of the pearl onion, upper gastrointestinal endoscopy revealed slightly bleeding mucosa at the site of impaction as well as an impassable stenosis. Her medical history, included relapsing periods of dysphagia since her childhood that were never examined by endoscopy or gastrografin swallow. At admission, she presented in a stable condition with normal laboratory findings. Clinical investigation revealed no abnormalities other than retrosternal pain as well as emphysema of the skin. Chest and abdominal radiography showed free intra-abdominal air as well as a pneumomediastinum. A gastrografin swallow was performed revealing leakage at the distal esophagus and pneumoperitoneum . Explorative laparotomy and direct closure with hemifundoplication were performed and the mediastinum was drained.
+Because of pathological drainage continuing on the tenth postoperative day as well as increasing white cell counts, we performed a gastrografin swallow that revealed mucosal irregularities and a double-barreled esophagus . Upper gastrointestinal endoscopy identified an esophageal intramural dissection with complete obstruction of the true lumen at 35 cm, as well as mucosal bridges .
+These findings left us without any feasible conservative management options. The presence of mediastinitis due to a suspected transmural perforation prompted us to perform a transhiatal esophagectomy with cervical esophagostoma and blind closure of the stomach.
+The pathology report showed the true esophageal lumen and a transmural perforation as well as a second lumen that was focally covered by a flat squamous epithelium with multiple ulcerations within the submucosal layer . The postoperative course was uneventful and 3 months after esophagectomy, a reconstruction with a cervical esophagogastric anastomosis was performed and the patient was discharged on the 12th postoperative day after an uneventful course.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_503_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_503_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..311bed47b8ff047886eee5de6e44aca5e7bc862c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_503_en.txt
@@ -0,0 +1,4 @@
+A 69 year old Caucasian female with a past history of ocular melanoma was found to have an incidental 1.6 × 1.6 × 0.7 cm hypodense lesion in the head of the pancreas, on surveillance computed tomographic (CT) scanning of the abdomen . In addition, there was a single enlarged porta hepatis lymph node measuring 2.8 × 1 cm. The patient was asymptomatic and without any prior episodes of pancreatitis.
+Additional imaging studies were performed to characterize the lesion. Magnetic resonance imaging (MRI) demonstrated the 1.7 × 1.3 cm lobulated lesion with effacement of the distal CBD . Endoscopic ultrasound (EUS) confirmed the 1.5 × 1.4 cm hypoechoic lesion suggestive of a cyst, which did not show communication with the pancreatic duct. EUS further demonstrated thickened cyst wall with mural nodule and presence of luminal debris . The mural nodule measured 0.8 × 0.7 cm. Vascularity of the nodule on EUS was not assessed. Fine needle aspiration of the cyst revealed turbid, viscous fluid, however the pathology evaluation was inconclusive. Post-EUS, the patient developed right upper quadrant abdominal pain, with post-prandial worsening, and was associated with dark colored urine and acholic stools. Due to concern for extrinsic compression on the CBD, the patient underwent ERCP, which identified a 7 mm single area of stenosis in the CBD that was relieved with placement of a plastic stent. Following stent placement, her blood work and symptoms normalized. She underwent repeat EUS with FNA of mural nodule. The FNA cytologic evaluation revealed atypical cells. Clinically, the cyst was considered to be an intraductal papillary mucinous neoplasm or mucinous cystic neoplasm. Considering the worrisome features of lymphadenopathy on imaging studies and atypical cells on FNA cytology of mural nodule, a decision was made to resect the lesion. Pancreas protocol CT scan performed prior to surgery showed a vague hypodense area in the pancreatic head, likely collapse of the cyst following aspiration, and a decompressed biliary tree. Pancreatic duct was not dilated, however, there was distal pancreas atrophy. A pylorus preserving pancreaticoduodenectomy was performed.
+Gross evaluation of the pancreas revealed a 1.6 × 1.1 × 1 cm uniloculated cystic lesion in the head of the pancreas. The cyst did not show communication with the main pancreatic duct. The cystic lesion was completely excised and all margins were negative. The entire lesion was submitted for histological evaluation. Microscopic evaluation showed a unilocular cyst lined by gastric type mucinous epithelium . No papillary projection or configuration was seen. Immunohistochemical stains showed the cyst wall lining to be diffusely positive for MUC5AC, and focally positive for MUC 6. The mucinous lining was negative for MUC1 and MUC2 . The histological features were consistent with a simple mucinous cyst. No dysplasia or carcinoma was seen. There was focal thickening in the cyst wall with intraluminal nodular lesion characterized by amorphous eosinophilic congophilic material consistent with amyloid, surrounded by foreign body type giant cell reaction and chronic inflammation composed of lymphocytes and polyclonal plasma cells . Upon further evaluation of congo red stain, the amyloid deposits showed characteristic apple green birefringence on polarizing microscopy, and red fluorescence on fluorescent microscopy using Texas Red filter . This focus correlated with the mural nodule seen on EUS. Laser microdissection (LMD)-liquid chromatography-tandem mass spectroscopy (LC–MS) confirmed the amyloid to be lactoferrin type. In addition, an immunostain for lactoferrin was positive in the amyloid deposits . The background pancreas showed mild chronic pancreatitis. No amyloid deposition was noted in the islets of Langerhans, interstitium or blood vessels of pancreas.
+Her post-operative course was uneventful apart from a mild wound seroma requiring only local wound care. She has since been seen multiple times in clinic following surgery and has recovered well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_528_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_528_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..97d26376f79d08ee9a9c878118b37f2af6e952b0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_528_en.txt
@@ -0,0 +1,9 @@
+A four-month-old female child presented with five day's history of non-projectile vomiting, three episodes of food contents vomitus per day, aggravated by feeding. This condition was accompanied by on and off lower grade fever and one episode of passing black tarry stool. She was prescribed ampiclox syrup 5mls po 8hrly for five days and paracetamol syrup 3mls po 8hrly for five days, at a nearby hospital as an outpatient. The child's health was reported to be in good progress for about three days. Over the course of the illness, the mother noted a protruding, self-reducing mass per anal, non-painful, not bleeding, no vomiting, and no abdominal distention associated with passing a normal soft stool, rectal prolapse diagnosis was reached, and she was referred to our center for father management.
+On physical examination; the child was alert and active, not pale, not dehydrated and afebrile.
+Vital signs; blood pressure = 95/45, pulse pate = 110bmn, respiratory rate = 45 cpm Spo2 = 98 % on room air and body temperature = 36 °C.
+Per-Abdominal Examination; not distended, soft abdomen, no tenderness, palpable mobile, free mass on the left lower quadrant which was mobile and non-tender.
+Digital Rectal Examination; an obvious circumferential protruding mass per anal on straining, which reduces spontaneously; no other lesion is seen. .
+Plane abdominal x ray done shows nothing significant.
+Abd ultrasound findings were specific to features of intussusception, including the “target sign,” with a remarkable end and suggestive features of edematous bowel.
+Electrolyte results revealed mild hyponatremia of 133.01 mmol/l, with normal chlorine and potassium levels, CBC was essentially normal paramitas, with Hb 11.3 g/dl.
+The diagnosis of intussusception was based on the history, clinical examination, laboratory, and radiological results. Plan for emergency laparotomy procedure reached, in which intraoperative finding was ilea caecum intussusception, which advanced to the anus with edematous bowel , milking was managed only up to the level of transverse colon, then it was impossible to progress up to the caecum due to oedema, hence right hemicolectomy was done and ilea transverse end-end anastomosis performed. The child was admitted to the pediatric ICU, whereby on the 2nd day, the child was doing well and transferred to a general ward, started to feed and pass stool normally. On the 4th day the patient was discharged home, and with a follow up on surgical outpatients' clinic for six weeks, with no complications were reported.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_536_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_536_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ca21bafd87aea2bd8de76740d7dd9c0187cc43ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_536_en.txt
@@ -0,0 +1,3 @@
+On October 8, 2020, a 52-year-old Chinese female was admitted to a local state hospital with cough and expectoration, and a chest CT scan revealed an oblique fissure effusion in the right lung , which was diagnosed as a pulmonary infection and treated empirically with levofloxacin at the local state hospital. After 1 week of treatment with this regimen, the patient developed shortness of breath, and the supervising physician adjusted the treatment regimen to levofloxacin combined with latamoxef sodium considering poor infection control. After another 1 week of anti-infective treatment, the patient felt that her symptoms were relieved and asked to be discharged from the hospital and stopped taking antibiotics on her own. After discharge, the patient’s shortness of breath gradually worsened, and she went to the local state hospital again on October 31, and a repeat CT scan showed a large thick-walled cavity in the right lung . Outpatient doctors suggested that the patient continue hospitalization. On November 1st, the patient suffered from sudden pain in the right chest and difficulty breathing during hospitalization, so she was transferred to our hospital in the emergency department. She used to have type 2 diabetes without a history of joint pain, heart valvular disease, lung surgery, and no family history of the tumor.
+Once admitted, the patient underwent re-examination by CT that revealed right hydropneumothorax and extensive compression atelectasis , and then was diagnosed with pyothorax. Moreover, laboratory inspection including WWBC 6.5 × 109/L, PLT 298 × 109/L, IL-6955.2 pg/mL, PCT 0.99 ng/mL, CRP > 90 mg/L, ALB33.02 g/L, indicated infection and malnutrition, and empirical treatment of moxifloxacin were given in the emergency. On November 3, she was admitted to the intensive care unit. The ultrasonic examination showed that the localized anechoic area of 13.0 cm × 10.1 cm × 6.2 cm in the right thoracic cavity and she was given moxifloxacin plus thoracic puncture and drainage. The drainage was porridge-like, with a fishy smell, and the pus was sent for biochemical examination . Dyspnea was improved after drainage of 1300 ml pleural effusion for 2 days.
+On November 6, she was transferred to the general ward and continued to be treated with broad-spectrum moxifloxacin. At the same time, fibrinolytic drugs were injected into the pleural cavity for 72 h. During the treatment, the symptoms of shortness of breath worsened again, and ultrasound re-examination showed that the localized anechoic area of 12.5c × 6.8 cm × 6.7 cm was in the right thoracic cavity. The drainage device was replaced by closed thoracic drainage and intermittent drainage of 1000 ml pleural effusion. The drainage fluid was sent to 2 groups of blood culture on different days (each group included an aerobic bottle and an anaerobic bottle). The equipment is a two-way blood culture bottle, consisting of peptone, beef paste, and other culture media, which is suitable for in vitro culture and detection of various aerobic or anaerobic bacteria in body fluids (blood, pleural fluid, etc.). The culture results showed that there were 3 strains of G.adiacens, 1 strain of Eikenella corrodens, and 1 strain of Staphylococcus aureus. G.adiacens were identified as the main pathogen due to its high detection rate, and the drug sensitivity test showed that it was sensitive to penicillin, erythromycin, vancomycin, cefotaxime, levofloxacin, and linezolid. According to the results of drug sensitivity, we continued to give moxifloxacin treatment (both moxifloxacin and levofloxacin belong to fluoroquinolone antibiotics, with similar antimicrobial spectra and stronger effect of moxifloxacin on cocci and anaerobic bacteria), and additively covered anaerobic bacteria with ornidazole. We also arranged echocardiography and electronic bronchoscopy for the patient. Echocardiography examination showed local calcification of the aortic valve without valvular insufficiency and vegetation, which ruled out endocardial infection. Bronchoscopy examination showed external compressive stenosis of the right middle bronchus . Besides, minced meat-like tissue of the lower lobe of the right lung was found in the bronchoscopy, and pathological examination revealed adenocarcinoma . On November 18, CT re-examination showed right pleural thickening, pleural effusion, multiple cord shadows in the middle and lower lobe bottom consolidation . After multidisciplinary consultation, it is suggested that surgical intervention should be carried out after the control of pulmonary infection. On November 19, the patient went home with a drainage device and was given oral moxifloxacin and ornidazole as discharge drugs. At the same time, nutritional support lasted throughout the medication period. The patient was revisited On December 7, WBCC and CRP were in the normal range, CT showed right pleural thickening, obvious absorption of multiple cords in the middle and lower lobe of the right lung, and slightly reduced consolidation range of the lower lobe . During the telephone follow-up on December 16, we learned that the patient had successfully removed the closed thoracic drainage tube and was receiving further antineoplastic therapy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_544_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_544_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cb08cb3a65a399ca211a3e3ec3070072c55d568e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_544_en.txt
@@ -0,0 +1,4 @@
+A 50-year-old Japanese woman presented to a hospital with left-sided abdominal distention. Abdominal ultrasonography revealed a cystic mass in the left-lower quadrant of the abdomen measuring approximately 10 cm in diameter. The patient had a history of iron deficiency anemia due to menorrhagia. She was referred to our hospital for surgical management. Upon admission, she complained of left-sided abdominal distention and denied abdominal pain and nausea. Physical examination revealed mild distention and a mildly tender mass in the left-lower quadrant of the abdomen. Laboratory examination findings on admission revealed elevated serum tumor marker levels: carcinoembryonic antigen (CEA) level of 21.4 ng/mL (normal range: 0–5.0) and carbohydrate antigen 19-9 (CA19-9) level of 804.0 U/mL (normal range: 0–37.0). Other laboratory results were normal except for a low hemoglobin level of 10.4 g/dL. Abdominal US revealed a tumor located in the left abdomen with a maximum diameter of about 9 cm. The cyst wall was about 4 mm thick and relatively uniform, with no septa or nodules visible within the cyst. Enhanced computed tomography (CT) and magnetic resonance imaging (MRI) of the abdomen revealed a 10.2 × 9.1 × 9.3-cm-sized unilocular cystic lesion with maximum 12-mm-sized nodules located on the left side of the abdomen . CT revealed three uniform contrast-enhanced nodules similar to the cyst wall. The boundary between the nodule and the wall was unclear for all three nodules; one of the nodules was seen as a gentle ridge. MRI revealed three nodules in the cyst, and the nodules and cyst wall showed low signal intensity on T1-weighted images and high signal intensity on T2-weighted images. The cystic mass was close to the left ureter, proximal jejunum, and descending colon, but separated from the left kidney and pancreas. The cyst wall was 3-mm thick. 18F-fluorodeoxyglucose (FDG)-PET/CT revealed mottled mild FDG uptake in the whole cyst wall and intense FDG uptake in the mural nodules with standardized uptake value (SUV)-max of 16.15, and no abnormal FDG uptake in other organs . There were no malignant tumors on endoscopic gastrointestinal examination, and no findings to suspect gynecological diseases such as ovarian tumors. Although we were not able to identify the exact origin of the cyst based on radiological findings alone, we suspected a primary malignant cystic tumor arising from the retroperitoneum.
+A midline laparotomy was performed after confirming the absence of disseminated lesions by laparoscopy and it revealed a cystic mass located in the mesentery of the descending colon . The cystic mass was rigidly attached to the descending colon, but not adhered to any other organs. The arterial supply of the tumor originated from the left colic artery; based on this, we diagnosed a mesenteric cystic tumor rather than a retroperitoneal cystic tumor. The cystic mass with the descending colon were completely removed without rupture.
+The surgical specimen measured 9.2 × 9.2 × 6.5 cm . The cyst contained a serous, cloudy, ‘café-au-lait-like’ fluid . The pathological diagnosis of the specimen was adenocarcinoma. However, it was difficult to determine the histopathological subtypes (mucinous, serous, or seromucinous) due to the atypical histologic findings. The inner surface of the cyst wall was lined predominantly by a single layer to multiple layers of columnar epithelium and partially by simple cuboidal epithelium. The nodules consisted of atypical cells that showed nuclear atypia and abundant clear or eosinophilic cytoplasm composed of an irregular glandular or sheet-like structure with stromal infiltration , and the surface was covered with papillovillous component . The mesenteric tumor slightly invaded the subserosal layer of the descending colon, but not the mucosal layer. No ovarian stroma or teratomatous elements, including ectopic endometriosis, were observed. The atypical cells were immunohistochemically reactive for cytokeratin 7 (CK7), and p53, but negative for cytokeratin 20 (CK20), estrogen receptor (ER), progesterone receptor (PgR), Wilms’ tumor gene-1, napsin A, and calretinin. Therefore, the final diagnosis was primary cystadenocarcinoma arising from the mesentery of the descending colon; the atypical cells were immunohistochemically reactive for CEA and CA19-9 .
+The postoperative course was uneventful, and the patient was discharged 11 days after the surgery. Adjuvant chemotherapy was initiated with S-1 (TS-1; tegafur, gimeracil, and oteracil potassium) at 100 mg/kg body weight per day for 8 courses (4 weeks of administration and 2 weeks of discontinuation). Approximately 1 year after the surgery, abdominal CT revealed no signs of disease recurrence, and serum CEA and CA19-9 levels had returned to normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_559_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_559_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a343fa0fa7a74867beb2a28d1ed7022b40ca46fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_559_en.txt
@@ -0,0 +1,2 @@
+A 70-year-old male patient was admitted to hospital because of lumbago accompanied by left lower extremity pain, numbness and weakness for 2 years, which aggravated for 2 months. Ten years ago, he underwent PLIF for lumbar spinal stenosis, and recovered well after the operation. Physical examination revealed tenderness and percussion pain in the L3–4 spine area, and limited lumbar extension. Decreased skin sensation in the medial calf and medial malleolus of the left lower extremity. The muscle strength of the left lower extremity was grade III, the muscle strength of the right lower limb was grade IV, and the muscle tone was normal. The straight leg raising test of the left lower extremity was positive (30 degrees), and the straight leg raising test of the right lower extremity was negative. Physiological reflexes of the lower limbs were elicited normally, but pathological reflexes were not elicited. Based on the Japanese Orthopaedic Association (JOA) scoring system, the neurological function score of the patient was 10 points. Back pain Visual Analogue Scale (VAS) score is 7 points, leg pain VAS score is 8 points. Preoperative lumbar spine Oswestry Disability Index (ODI) score was 60%.
+Magnetic resonance imaging (MRI) revealed disc herniation at the L3/4 level, along with hypertrophy of the ligamentum flavum, inward hyperplasia of the articular process, and spinal canal stenosis . A diagnosis of ASD after lumbar fusion was made. The treatment plan for ASD after lumbar fusion involved bilateral microdecompression through a unilateral percutaneous microchannel approach.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_609_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_609_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d51eedc872314f469dcb9574af8a9a04a56fcd01
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_609_en.txt
@@ -0,0 +1 @@
+A 26-year-old female patient, presented with pain in the lower right mandibular anterior area on the lateral incisor. No caries was noted via clinical examination or evidence of periodontal disease and pulpal inflammation (pulpitis) was suspected. The patient reported no prior history of inflammatory symptoms and several months prior endodontic treatment had been performed on the right mandibular lateral incisor. A panoramic radiograph was taken to evaluate the tooth and surrounding area and a large periapical area was noted on the tooth . A periapical radiograph was taken to further evaluate the tooth with confirmation of a large lesion with a mixed area within the cyst and slight over extension of the obturation beyond the apex was noted with no notable external apical resorption of the root . The lesion appeared like a radicular cyst. In addition, on CBCT scan was performed to evaluate the area three dimensionally. The coronal view noted that the lesion has an expanding character to it . A cross-sectional view through the tooth, noted the lesion had a irregular shape with a mixed appearance and a radio-opaque area at its center . A reconstructed view of the facial on the CBCT, noted a relatively intact facial plate overlying the lesion . Moreover, a small partial damages of external lamina were observed. Based on the clinical findings, the treatment recommended would consist of flap exposure of the facial aspect of the anterior mandible, bone removal to expose the underlying lesion, removal of any pathological tissue making of the lesion, endodontic microsurgery to perform an apicoectomy and retrograde fill, placement of a graft to fill the resulting osseous defect, and flap closure in one-step treatment. Treatment complied with Surgical CAse REport (SCARE) 2000 Criteria.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_632_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_632_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8256a2ce7eb08af060a07a8a52e385d452a22e55
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_632_en.txt
@@ -0,0 +1 @@
+The patient was a 62-year-old man who had undergone combined phacovitrectomy for the epiretinal membrane of the left eye performed by a local ophthalmologist 4 years previously. Postoperative refractive values did not differ between the right and left eyes. The patient was referred to our department after complaining several months prior that the power of his left eyeglasses was out of alignment. Ocular examination revealed an uncorrected distance visual acuity of 20/100 in the right eye and 20/200 in the left eye. The corrected distance visual acuity was 20/20 in both eyes, and the subjective refraction was −4.50 diopters sphere (DS)/−2.00 diopters cylinder (DC) × 90° in the right eye and −7.00 DS/−0.50 DC × 80° in the left eye. No abnormalities were observed in the corneas of either eye; the fundus of the right eye was normal, with only a mild cataract. The left eye was vitrectomized and showed no recurrence of epiretinal membrane; however, a slightly protruding milky white opacity in the shape of a convex lens was observed between the IOL and posterior capsule (shown in a). After the ocular examination, when the Nd-YAG laser treatment was performed, a milky white fluid drained into the vitreous cavity, resulting in the disappearance of the milky white contents (shown in b). The IOL depth in the left eye was measured using a swept-source AS-OCT device (CASIA2; Tomey, Nagoya, Japan). The IOL depth in the left eye was 4.553 mm in horizontal sections and 4.530 mm in vertical sections before, and 4.607 mm and 4.559 mm after, the Nd-YAG laser posterior capsulotomy, respectively (shown in a–d). Objective refraction of the left eye before and after the Nd-YAG laser treatment changed from −7.23 DS/−0.88 DC × 81° to −5.92 DS/−1.18 DC × 71° in normal pupil condition. Two weeks after the Nd-YAG laser treatment was administered, the left corrected distance visual acuity was 25/20 and the subjective refraction was −5.50 DS/−1.00 DC × 70°, indicating that the myopia improved.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_635_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_635_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..069dee8d5046b1997249f53cf2a7fb1dded6be30
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_635_en.txt
@@ -0,0 +1,2 @@
+A 43-year-old male with a history of a C2 fracture sustained 28 years ago, now presented with the 10-day duration of the onset of a severe spastic quadriparesis with sphincter dysfunction. His motor examination was 2/5 in all distributions, accompanied by hyperreflexia and a C2 sensory level.
+The CT scan of the cervical spine demonstrated a chronic pseudarthrosis of a C2 Type II odontoid fracture. This was accompanied by anterior subluxation and a significant ventral osteophyte, all of which narrowed the spinal canal. The C2 odontoid fracture warranted a two-stage circumferential procedure. The first part included an anterior transoral decompression of the odontoid fragment (e.g., with resection of the ventral osteophyte to achieve anterior spinal cord decompression). The second part performed posteriorly warranted a C1 laminectomy, subaxial decompression, and C1-C2 fusion. Following this extensive circumferential approach, the postoperative course was unremarkable, and the patient was discharged with Philadelphia collar.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_647_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_647_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..71b1c35abdd20903b96cf1aeea296529fd1d6bb3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_647_en.txt
@@ -0,0 +1,2 @@
+A 57-year-old Caucasian man with a smoking habit who had a history of hypertension and dyslipidemia as well as a family history of thoracic aortic dissection presented to a community hospital complaining of sudden onset of chest discomfort and dyspnea. He was diaphoretic, with blood pressure of 114/60mmHg and no pulse deficit, heart rate of 114 beats per minute and respiratory rate of 20 breaths per minute. In addition, he required oxygen by nasal cannula to maintain oxygen saturation above 90%. He had a large-volume central pulse, no extra heart sounds and soft systolic and early diastolic murmurs over the aortic valve. His jugular venous pressure was 4cm above the sternal angle, and he had crackles at both lung bases. There were no features suggestive of Marfan syndrome or connective tissue diseases. The initial emergency work-up included an electrocardiogram (EKG), which showed left ventricular hypertrophy with repolarization abnormalities; a chest X-ray with increased interstitial markings suggesting acute pulmonary edema; a troponin I level of 0.41μg/L; and a brain natriuretic peptide level of 487ng/L.
+On the basis of the patient’s abrupt onset of symptoms, family history of aortic dissection and findings consistent with acute aortic insufficiency (large-volume pulse, early diastolic murmur and heart failure), an emergent contrast-enhanced CT scan was obtained . This scan showed a 5cm aortic root aneurysm but no aortic dissection. The patient was treated medically for acute coronary syndrome and heart failure, including dual anti-platelet therapy and anti-coagulation. He was subsequently transferred to a tertiary care hospital. Because of the high clinical suspicion of an acute aortic dissection based on his family history, sudden onset chest discomfort and findings of acute aortic insufficiency and heart failure , a transesophageal echocardiogram was taken, even in light of the negative CT scan . This test demonstrated an aortic dissection flap confined to the aortic root, superior to the aortic valve and associated with severe aortic insufficiency. The patient underwent successful repair of his Stanford type A aortic dissection with a 27mm mechanical valved conduit 21 hours after his initial presentation to the community hospital. The pathology report showed a structurally normal trileaflet native valve and cystic medial necrosis of the wall of the aortic root. Specialist cardiovascular radiologists who reviewed the initial CT scan post hoc reprocessed the raw data and correctly identified the dissection above the aortic valve . The dissection flap had initially been misinterpreted as a combination of normal aortic valve apparatus and motion artefact.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_653_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_653_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a173d576084d8b76455c59f3c3f95251f62f73e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_653_en.txt
@@ -0,0 +1,6 @@
+A 3-year-and-3-month-old boy presented with abnormal renal function, frontal bossing, low-set ears, dolichocephaly, sparse hair, and short limbs. He was the seventh child of his unrelated parents and was delivered naturally at full term with a birth weight of 3.8 kg. He could walk at the age of 1 year and 3 months and has language retardation. On admission, a physical examination showed that the patient was developmentally delayed, with longer skull diameter, macrocephaly, sparse and delicate hair, narrow eye cleft, hypertelorism, low bridge of the nose, sparse teeth with dysplasia, short and curved fingers/toes, and the testes were not touched in the bilateral scrotum.
+Computed tomography (CT) examination of the head revealed that the bilateral frontocephalic space had widened, the anteroposterior diameter of the skull had increased, and the sagittal suture was partially closed. Frontal chest radiographs showed increased heart volume, decreased bone density, and enlarged trabeculae. Electrocardiogram and color echocardiography were normal. The abdominal color ultrasound examination revealed that the liver volume was increased, the parenchymal echo was dense and enhanced, the intrahepatic hypoechoic mass was enlarged, and the intrahepatic bile duct was widened. Dysplasia of both kidneys enhanced parenchymal echo, unclear demarcation of the cortex and medulla, hydronephrosis of the right kidney and ureter, and dilatation of the left calyces. The spleen is enlarged with open sinuses. In particular, the child had an abnormal testicle position, with the right testicle located in the iliac fossa and the left testicle situated in the groin, and a hydrocele existed on both sides . These were not found in the previously reported CED patients.
+The biochemical indicators of the patient showed that the urea value was 28.3 mmol/L (reference range: 1.7–7.1 mmol/L), the creatinine value was 432.1 umol/L (reference range: 18–80 umol/L), and the uric acid value was 393.8 umol/L (reference range: 134–415 umol/L). The 24-hour (h) urine volume was only 350 ml (reference range: 300-1500ml), and the 24 h urine protein quantity was 0.416 g (reference range: 0.03–0.15 g/24 h). Urine-specific gravity is 1.010 (reference range: 1.015–1.025), and pH is 7.0 (reference range: 5.5–6.5). The urinary protein and creatinine ratio was 4.32 mg/mmol (reference range: ≤0.2 mg/mmol), urinary microalbumin was 595.0 mg/L (reference range: 0–20 mg/L), α1-microglobulin was 39.56 mg/L (reference range: 0–12 mg/L), urinary transferrin was 2.52 mg/L (reference range:<1 mg/L), and urinary β2- microglobulin was 422.70 ug/L (reference range: 0-300 ug/L). His parathyroid hormone level was 739.400 pg/mL (reference range: 15–65 pg/mL). These data indicate that the child’s renal function is significantly abnormal. Moreover, routine blood tests showed that the value of erythrocytes was 2.28 × 1012/L (reference range: 3.5–5.5 × 1012/L) and the hemoglobin value was 65 g/L (reference range: 120–170 g/L), suggesting moderate anemia.
+The patient had no family history and no genetic disease or nephropathy among his family members. He has three healthy sisters, and his mother has experienced three miscarriages . Because the child has a unique appearance and multi-system and multi-organ abnormalities of the body, we suspect he has a genetic disease. With the informed consent of the boy and his parents, we performed a trio-whole exome sequencing (trio-WES) for them and verified the results by Sanger sequencing. It was found that the patient carried a c.2590 C > T (p.Gln864*) nonsense variant and a c.2408_2416del (p.Asn803_Ala805del) in-frame variant of the WDR35 gene (NM_001006657), which were derived from his father and mother, respectively .
+To our knowledge, this is the first CED patient caused by WDR35 variants in the Chinese population. Moreover, the child presented with a novel phenotype of ectopic testis except for showing typical CED characteristics. The patient carries a novel compound heterozygous variant that includes a c.2590 C > T nonsense variant and a c.2408_2416del in-frame variant derived from his father and mother, respectively. According to the American College of Medical Genetics and Genomics (ACMG) guidelines, these two variants were classified as “pathogenic” and “uncertain” variants. A comparison of the amino acid sequences of WDR35 proteins from different species showed that p.Gln864 and p.Asn803_Ala805 are highly conserved across species , suggesting that amino acid sequences at these sites play a vital role in the function of this protein. The p.Gln864* variant can lead to a truncation of 318 amino acids at C-terminal, and the p.Asn803_Ala805 deletion causes the loss of three amino acids and generates an in-frame mutant protein . Using the same bioinformatic tools reported previously , we analyzed the crystal structures of the mutant WDR35 protein by a SWISS-MODEL database with homology modeling using yeast β’-COP (3mkq.1.A) . The results showed that the crystal structure is truncated due to the p.Gln864* variant, which resulted in the disorder of the 3-dimensional system . This generates a loss of function of the protein. Alanine consistently stabilizes the helical conformation because it buries a more apolar area upon folding and because its backbone entropy is lower , thus its loss might cause the altered conformation of the protein. Asparagine-linked (N-linked) glycosylation is one of the most complex enzyme-catalyzed protein modification reactions. The modification can influence early events in protein folding, mediating significant effects locally, on the adjacent polypeptide sequence, and at remote sites distant from the modified asparagine residue . Therefore, we speculate that the compound heterozygous variants in WDR35 may lead to the loss of function of the protein, which is pathogenic for the patient.
+The child was given iron succinate and erythropoietin to improve anemia after a routine blood examination after admission. He had repeated metabolic acidosis and hyperkalemia and was given acid correction, diuretic, and potassium-lowering treatments. However, the parents refused further treatment using renal replacement therapy for the child and were discharged voluntarily. The patient died when followed up six months later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_671_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_671_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5300a49ec6d80363e97e5433e642f52cc28cb099
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_671_en.txt
@@ -0,0 +1,4 @@
+The patient was a 46-year-old man, 169 cm in height, and weighing 60 kg. He was diagnosed with myotonic dystrophy type 1 5 years previously, with weakness in the distal muscles and electrophysiological tests. The patient complained of vision disability due to cataracts, and phacoemulsification and intraocular lens implantation for both eyes were scheduled under general anesthesia.
+Serum creatine phosphokinase level was 2921 U/L (normal range, 43–272 U/L). There were no further abnormal findings on preoperative tests, including an electrocardiogram and transthoracic echocardiogram. Although the relationship between myotonic dystrophy and malignant hyperthermia is controversial, we planned to use total intravenous anesthesia in this case.
+The use of propofol, which is a commonly used intravenous anesthetic, might cause prolonged recovery after anesthesia in patients with myotonic dystrophy . Therefore, we planned to use remimazolam to achieve fast recovery in this case.
+No premedication was administered. We administered 6 mg/kg/h of remimazolam intravenously for 1 min. The patient lost the response to the verbal command after the infusion of remimazolam . Continuous infusion of remifentanil (0.2 μg/kg/min) and remimazolam (0.5 mg/kg/h) was started. Neuromuscular monitoring of the left ulnar nerve was commenced using a train-of-four (TOF) stimulus (TOF watch, MSD). Three minutes after administration of 40 mg rocuronium, all four twitch responses disappeared, and tracheal intubation was performed. During surgery, the remimazolam dose was planned to maintain a bispectral index (BIS) value between 40 and 50 with continuous remifentanil infusion (0.1 μg/kg/min). However, the BIS value remained below 40 at a continuous infusion rate of 0.25 mg/kg/h, a 1/4 dose of the standard infusion rate. At this dose, the electroencephalogram showed continuous alpha wave spindles and delta waves . Therefore, we judged that an appropriate anesthesia level was achieved. An additional 5 mg rocuronium was administered 60 min after the first dose because the first twitch response was observed. The surgery time was 46 min, and the infusion of all anesthetics was stopped. At the end of the procedure, TOF showed the first twitch response, and then 180 mg(3 mg/kg) of sugammadex was administered. Three minutes after administering sugammadex, the TOF recovered to 100%. Six minutes after remimazolam discontinuation, the patient opened his eyes on verbal command with sufficient spontaneous respiration. Next, the tracheal tube was removed. Finally, flumazenil (0.2 mg) was administered to boost the recovery, and the postanesthetic course was uneventful. A post-operative interview with the patient was performed on the day and the next day. He had no memory during the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_685_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_685_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0bcb62c6aeec919b0fc746e0d7166ede7596b384
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_685_en.txt
@@ -0,0 +1,3 @@
+The patient is a 59-year-old male who had struggled with oxalate nephrolithiasis since the age of 13, without formal workup. He previously underwent multiple lithotripsies, as well as a partial nephrectomy and remained relatively controlled with a baseline creatinine of 1.2-1.3 mg/dL (reference range: 0.70–1.30 mg/dL). Unfortunately, in September 2016, the patient progressed to chronic kidney disease, after an episode of dehydration. He was seen in our institution in November 2016 after presenting with an episode of acute on chronic renal failure. He had no renal reserve and was initiated on hemodialysis. Further history revealed a daughter with oxalate stones disease as well, raising concern for hereditary oxalosis; other serological studies were negative, and biopsy confirmed acute tubular necrosis (ATN) with oxalate nephropathy. Genetic testing was pursued, and the results showed an AGXT mutation consistent with a type 1 primary hyperoxaluria. All preoperative liver testing results were within the normal limits. Given this diagnosis, the patient was evaluated by the transplant committee, and a combined liver-kidney transplant was recommended [, ]. The patient underwent a combined orthotopic liver (OLT)-kidney transplant in July 2017. A donor cholecystectomy was done as per the standard protocol. Pathologic examination revealed Cystoisospora belli organisms. The patient was treated with trimethoprim/sulfamethoxazole (TMP/SMX) DS 800–160 mg every 6 hours for ten days followed twice daily for three weeks. There is currently no evidence of C. belli reactivation.
+The donor was a 20-year-old Caucasian male who suffered an anoxic brain injury. He had no history of biliary disease/symptoms and had no evidence of acute or chronic cholecystitis, biliary disease, or other biliary disease at the time of donation. There was no reported history of acute or chronic diarrhea, and he was otherwise immunocompetent. He had no medical comorbidities, no prior surgeries, no history IV drug use, or other risky behaviors. He had no history of recent travel outside of the United States. Notable pretransplantation labs included bilirubin of 0.5, AST 62, ALT 76, and alkaline phosphatase of 49.
+The donor gallbladder specimen measured 5.6 × 2.1 × 0.6 cm. It had a tan-gray and smooth serosa, with a limited amount of attached adipose tissue. There were no pericystic lymph nodes, and the cystic duct was not obstructed. The lumen had no calculi and no erosion, and mucosa was tan-brown, with an average wall thickness of 0.3 cm. This was consistent with a grossly normal gallbladder. On H&E staining, oval-shaped intracellular structures, measuring approximately 20 µm, were identified within the cytoplasm of the biliary epithelium, consistent with C. belli. The background gallbladder was otherwise unremarkable [, , ]. The organisms were highlighted by the PAS/D special stain. . The liver histologic evaluation was otherwise unremarkable, with no significant fat, fibrosis, or inflammation. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_707_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_707_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dc7fa5bb19b9a2a6afb5184b2cdf543a6e6cfb94
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_707_en.txt
@@ -0,0 +1,5 @@
+A 30-year-old male with a known history of KTS presented with a rapidly enlarging subcutaneous central frontal mass, measuring 41 × 47 × 54 mm since its formation just 3 months earlier causing pain and an obvious cosmetic defect. The patient had no demonstrable neurological signs on examination with normal pre-operative laboratory studies, however, had previous episodes of significant hemorrhage arising from the lesion as a result of minor trauma.
+Clinically, the patient was dysmorphic, most notably severe soft tissue overgrowth, bilateral lower limb lymphoedema, and cellulitis. Despite this, he had no history of other complications arising as a result of his KTS such as malignancy or peripheral hemangioma.
+Radiological findings initially began with computed tomography angiogram, which revealed a destructive expansile arterially-enhancing lesion arising from the frontal bone. Heterogenous contrast enhancement on magnetic resonance imaging further defined the lesional dural involvement and invasion into the superior sagittal sinus sparring cerebral parenchyma.
+Gross total resection consisted of a T-shaped incision followed by bilateral frontal craniectomies . The vascular lesion was identified arising from frontal bone and within the superior saggital sinus. The lesion was resected en bloc from calvaria. A custom-made titanium implant was used for cranioplasty .
+Postoperatively, the patient had a full recovery. Histopathological hemotoxylin and eosin stains revealed the lesion extending through bone, with a small foci of extramedullary hemopoiesis, consistent with hemangioma. There has been no evidence of recurrence 6 months post resection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_717_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_717_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5e279bd42d856d689ff31aaf719649b82565db53
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_717_en.txt
@@ -0,0 +1 @@
+A 15-year-old girl was admitted to our hospital complaining of severe headaches since the eighth month of pregnancy, which had worsened in the last five hours. The following information was observed in the prenatal card: G1P0A0; gestational age: 37 weeks (estimated by date of last menstrual period); type O+ blood and negative serology. On examination our patient presented an arterial blood pressure of 180/120 mmHg, her uterine cervix was 20% effaced, with impervious external orifice and cephalic presentation. The diagnostic hypothesis was pre-eclampsia and routine investigations were requested to diagnose the HSP. After the tests, the diagnostic hypothesis changed to gestational hypertension. As our patient continued with elevated blood pressure levels, she was submitted to a cesarean section on the fourth day in hospital, delivering a male live baby with no intercurrences. After the procedure, she was referred to our infirmary, presenting a blank distant look and with no interaction with the environment. On examination she presented with dyslalia, and labial and upper and lower right limb paresis. During an examination six days after hospital admission, our patient was confused and unable to speak, but responded to painful stimuli as she conveyed abdominal pain at superficial and deep palpation. Moreover, she had a hematoma on the upper region of the surgical wound and physiological lochia. The hypothesis of post-partum psychosis was suggested and a careful neurological evaluation requested. She was administered the following drugs in hospital: nifedipine 1 mg, methyldopa 500 mg, 750 mg paracetamol, betamethasone, oxytocin, tenoxicam, promethazine, diclofenac sodium, cephalexin, and haloperidol. She was then transferred to the teaching hospital on the same day, and admitted to our intensive care unit, maintaining an impassive attitude in bed but reacting to external stimuli. She also emitted incomprehensible sounds, presented a blank look, with upward conjugated deviation of the eyes and mydriatic pupils reactive to light. She had Glasgow Coma Scale (GCS) score of nine points (2 +5 +2). Our patient was then submitted to orotracheal intubation with mechanical ventilation and central venous access through her right internal jugular vein, in addition to continuous sedation. Computed tomography (CT) of her skull and pelvis were requested. Results revealed tomography findings consistent with ischemic infarction of the territory of her left middle cerebral artery, but no pelvic alterations were observed. Our patient showed progressive worsening of the neurological symptoms, hyperthermia, tonic-extensor crisis, difficulty in breathing and scored four points in the GCS. A repeat skull CT revealed ischemic lesions in the mean cerebral system affecting her basal ganglia and parietal lobe, with proper filling of venous sinuses and no signs of meningeal inflammation. During this period, her blood pressure levels remained elevated (MAP 140-150 mmHg) and refractory to medication. In addition, our patient presented with neuropsychomotor agitation and periods of tachycardia and systemic arterial hypertension alternating with bradycardia and normotension. An urgent selective cerebral arteriography was requested; this showed bilateral occlusion of her internal carotid artery in the intracranial position, pre-bifurcation and angiodysplasia in the cervical segments of the internal carotid artery. Sixteen days after hospital admission, there was a worsening of our patient's condition and she died. Brain death as a consequence of bilateral obstruction of the internal carotid was certified as the cause of death.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_718_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_718_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0fc059d1f676c9bbc5d951699e1c5c83ddffe01d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_718_en.txt
@@ -0,0 +1,8 @@
+A 97-year-old Caucasian woman presented to the emergency department of our institution with a painful, malodorous, necrotic right submandibular mass . A solitary enlarged lymph node had been identified in this region on computed tomography two months prior. She gave no history of B-symptoms, immunodeficiency or immunosuppression.
+She lived at home alone with support from a carer who visited twice daily. She did not smoke tobacco or consume alcohol. Her comorbidities included dementia, congestive cardiac failure, paroxysmal atrial fibrillation, a previous above-knee deep vein thrombosis and early-stage breast cancer diagnosed 17 years earlier, managed surgically and considered to be in remission. Her regular medications included bisoprolol 2.5 mg daily, ramipril 1.25 mg daily, aspirin 100 mg daily, digoxin 62.5 μg daily and periciazine 2.5 mg daily.
+She was afebrile and hemodynamically normal at presentation and other than the right neck mass, her physical examination was unremarkable. Blood work showed a white cell count of 10.87 × 109/L (normal range, 4–11) with slight neutrophilia at 9.05 × 109/L (normal range, 1.8–7.5) and lymphopenia at 1.01 × 109/L (normal range, 1.5–3.5). Her hemoglobin was normal at 137 g/L, as was her platelet count of 197 × 109/L. Her potassium was measured as 3.3 mmol/L (normal range, 3.5–4.9) but all other electrolytes were within the normal range. Her creatinine measured 69 μmol/L with an estimated glomerular filtration rate of 64 ml/minute/1.73 m2. Her lactate dehydrogenase was elevated at 267 U/L (normal range, 110–230) but her liver enzymes were all within the normal range.
+Following non-diagnostic fine needle aspiration of the mass, core biopsy revealed DLBCL with a non-germinal center immunophenotype using the Han's algorithm, and Epstein Barr encoded ribonucleic acid (RNA) in situ hybridization positivity .
+Computed tomography and 18-fluorodeoxyglucose (FDG) positron emission tomography revealed this to be the only site of disease, consistent with stage 1A.
+Given her age, frailty, performance status and multiple comorbidities, she was deemed unfit for systemic therapy and palliative radiotherapy was recommended.
+She received a dose of 25 Gy delivered over five fractions on alternate days over a two-week period. Treatment was delivered using a four-beam three-dimensional conformal technique with 6-megavoltage photons and daily image guidance. The treatment incorporated the use of bolus material placed over the surface of the mass to optimize the radiation dose delivered superficially to the skin.
+The patient was followed up monthly and after four months the mass completely resolved . The overlying skin on the right neck had healed to cover the previous necrotic deficit and no mass was palpable. She was asymptomatic with no observable toxicity at the latest review at four months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_766_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_766_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8fbe6779c5fa9fba6366e72fff77529fa2b63655
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_766_en.txt
@@ -0,0 +1,6 @@
+A 19-year-old male was referred to our department after initial physical examination to a military training center as part of his compulsory enlistment for the Greek military service. During the examination, he reported having a solitary right kidney but was otherwise asymptomatic with no further relevant details. Neither a history of trauma nor previous surgeries were reported. Physical examination was unremarkable. He had no scars on the trunk and normal external genitalia. No pain provoked or masses felt during palpation. A digital rectal examination was not performed due to the patient’s preference. No sexual intercourse was reported at the time. Furthermore, no previous notable medical history for hereditary or acquired diseases was mentioned. The whole blood count and urinalysis results were within normal limits.
+Abdominopelvic computed tomography (CT) and magnetic resonance imaging (MRI) of the pelvis were performed. CT depicted only a right kidney with absence of left kidney . Additionally, CT demonstrated a large lobulated multicystic lesion of left seminal vesicle without enhancement on contrast-enhanced images . A saccular dilated ectopic ureter opening into the left cystic seminal vesicle and extending centrally up to the level of L3 vertebral body was revealed with a length of approximately 16 cm .
+MRI was performed with a Siemens Magnetom Avanto (1.5 Tesla) MRI unit (Siemens Inc., Germany) using a pelvic phased-array coil. The imaging protocol comprised T1-weighted, T2-weighted, T2-weighted with fat saturation (FS) and T1-weighted FS images on axial, sagittal and coronal planes. Finally, images on T1-weighted FS sequence after intravenous administration of contrast medium (gadolinium) were added.
+MRI demonstrated a large lobulated multicystic lesion in the anatomic region of left seminal vesicle. The lesion measured approximately 7.2 cm × 6.1 cm with low signal intensity on T2-weighted FS and high signal on T1-weighted images, corresponding to a dilated seminal vesicle cyst (SVC). The high signal intensity on T1-weighted sequences was strongly suggestive of proteinaceous or hematic content. In contrast, the normal right seminal vesicle exhibits high and intermediate signal intensity on T2-weighted FS and T1-weighted images, respectively, corresponding to fluid . An enlargement of the left ejaculatory duct communicating with the dilated SVC was well depicted on sagittal T2-weighted images . A saccular dilated ectopic left ureter with tortuous morphology, which was also filled with proteinaceous or hematic content, was revealed on all T1-weighted images, communicating with the SVC and extending centrally .
+Unfortunately, the patient declined additional investigation by means of transrectal ultrasonography (TRUS), which might have assisted in clarifying the ejaculatory duct obstruction.
+Semen analysis revealed cryptozoospermia (volume < 1 ml, pH 8.0, total sperm count 126 /ml) of obstructive origin. Nevertheless, fertility was not the patient’s primary concern. He declined further management, although he was made aware of the rarity of the syndrome and the possible future need of surgical management. Despite detailed analysis of the importance of cryopreservation and fertility maintenance, he had no intention to cryopreserve sperm or undergo microsurgical sperm retrieval at the time. Therefore, annual semen analysis was recommended for as long as he presented with altered fertility status. Although SVCs are generally benign and rarely symptomatic, cases of malignant transformation and late diagnosis due to the absence of warning symptoms have been described . Thus, we adequately informed our patient about the possibility of the carcinomatous evolution of SVCs. Finally, we advised him to undergo ultrasonographic monitoring on an annual basis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_767_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_767_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7768cc392c08c9fc3adae663ec8a7b214fba9987
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_767_en.txt
@@ -0,0 +1,3 @@
+A 6-year-old Chinese boy sustained a crush injury in a motor vehicle accident resulting in extensive damage to his right lower limb with comminuted fractures of his right femur and his right tibia-fibula. His right femur was a Gustilo type IIIC fracture with sciatic nerve and femoral artery tears associated with a 9cm bony fragment lost during the trauma . His right tibia-fibula also had severely comminuted, Gustilo type IIIC fractures . He was taken to the operation room 5 hours after injury. A right below-knee amputation was performed on the basis of the major neurovascular damage to the femoral artery, vein and sciatic nerve in his thigh along with the severe soft tissue injury and comminution of his distal tibia-fibula. The amputated specimen was prepared with normal saline irrigation. The distal tibia-fibular osteomuscular flap was then harvested to microsurgically reconstruct the femoral bony defect. Informed consent to perform this procedure and report the case was obtained from the patient and his parents. Due to segmental loss of the femoral artery and vein, the tibia-fibular osteocutaneous flap pedicle was anastomosed with a flow-through artery and vein graft. The posterior tibial artery was anastomosed to the torn femoral artery, and the posterior tibial vein was anastomosed to a superficial vein in the groin area. The femoral vein was grafted using the greater saphenous vein from the amputated specimen. The sciatic nerve was repaired directly using 9–0 nylon end-to-end perineurium repairs. Ankle joint cartilage was removed to increase the contact area for the incorporation of the distal femur-graft. A Hoffmann’s external fixation was applied to keep the same length as the opposite leg and immobilize the fracture . After meticulous debridement, the wound was sutured directly without any skin defect, because adequate skin and soft tissue were provided by the tibia-fibular composite graft. The operation took 6 hours and 40 minutes.
+Postoperatively, the patient was treated with intravenous antibiotics using cefazolin 500mg every 8 hours and gentamicin sulfate 20mg every 8 hours. No anticoagulants were used postoperatively in this patient. Subsequent wound cultures grew Escherichia coli and Streptococcus bovis. On the 7th postoperative day, bone scanning using technetium-labeled methylene diphosphonate was performed which demonstrated positive uptake on both ends of the donor tibia-fibular graft. Because the right leg was not stable enough, no specific physical therapy or temporary prosthesis was used. The wound at the medial and posterior aspect of the right thigh became erythematous and purulent discharge was noted 11 days after the initial operation. Debridement of the necrotic muscle and tissue was performed and the wound was then closed loosely. The antibiotics were changed to cefamandole 250mg every 8 hours and ampicillin 500mg every 6 hours, based on the culture data. The stump of the below-knee amputation also became necrotic and was debrided 26 days after the initial surgery. The skin and wound condition were stabilized thereafter.
+The patient was discharged 6 weeks after the operation, with the wound clear and the infection under control. Non-weight-bearing crutch walking was started 5 weeks after the surgery and partial-weight-bearing was allowed 2 months later when the patient used 50% weight-bearing with the aid of a below-knee prosthesis. Unfortunately, delayed callous formation at the distal femoral-graft junction and pin tract infection in the distal femur were noted at 4 months after surgery . At that time, a change was made from the Hoffmann’s external skeletal fixation to an internal compression plate supplemented by an autogenous iliac crest bone graft. During the operation, the pin holes of the external fixation device were curetted and the iliac bone graft was put on the distal end of the host-donor bones. The transferred epiphyseal plate of the distal tibia and fibula were removed because there was no length discrepancy of the injured femur at 4 months. The pin tract infection healed 2 weeks after the removal of the Hoffmann’s external skeletal fixation. Over the subsequent 6 months, serial radiographs revealed complete incorporation and gradual remodeling of the vascularized tibia-fibular composite graft in the femur . Walking with full weight-bearing was allowed at 8 months after the surgery. Plate removal was performed 1.5 years after the operation due to chronic irritation from the loosened plate and screws, and for fear that the plate might hinder further remodeling and hypertrophy of the femur. Hypertrophy of the tibial graft, good remodeling of the femoral shaft, and atrophy of the unloaded fibular graft were noted at the 10-year follow up . On the standing scanogram, both the hip and the knee joints were at the same level, and the femurs were of equal length . Clinically, there were symmetrical alignments of both legs. The boy did well with his prosthesis, including all his daily activities. He was able to participate in outdoor activities such as basketball while wearing his prosthesis . The range of motion of the right knee was between 5 and 95 degrees in extension–flexion and that of the right hip was between 0 to 90 degrees in extension–flexion, 40 degrees in abduction, 15 degrees in adduction, 15 degrees in external rotation, and 10 degrees in internal rotation. The repaired sciatic nerve was functioning well, in that there was full strength of hip extension and knee flexion indicating good function of the hamstring muscles and normal sensation at the stump.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_778_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_778_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fd13c746e49b5c4699db11d3d70e5bcf62dfa1dc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_778_en.txt
@@ -0,0 +1,4 @@
+A previously healthy 30-year-old Caucasian woman presented to her primary care office with complaints of COVID-19. She developed symptoms after her husband returned from international travel. She initially had symptoms of an upper respiratory tract infection, including nasal congestion and cough. She had fatigue and shortness of breath on ambulation. Ten days after her initial symptoms, she developed an urticarial rash on her abdomen, legs, and hands . The rash was transient and reappeared twice before disappearing. The rash only lasted hours on each occasion. The patient has no past medical history and takes no medications. She does not drink alcohol, smoke cigarettes, or use drugs. She is married and lives at home with her husband, works as a wedding planner, has no children, and has never been pregnant.
+She also complained of tongue swelling on the tenth day after developing COVID-19. The swelling went away after 1 hour on its own, but she then developed geographic tongue with the appearance of tongue papillae that were inflamed and some papillae that were flattened . Her tongue had a sensation of sensitivity in the areas interspersed between areas of regular mucosa, and she had some mild loss of sense of taste.
+In the office, her blood pressure was 117/71 mmHg, heart rate was 90 beats per minute, temperature was 98.4 °F, respirations were 14 per minute, and pulse oximetry was 100% on room air. On further examination, she had a geographic appearance to the tongue, with denuding of regions of tongue papillae with an irregular appearance. Her abdomen and extremities showed no signs of rash at the time of the clinical examation. Her neurological examination showed intact motor and sensory strength, normal heart sounds, and lungs that were clear to auscultation; the rest of her examation was normal. Her white blood cell count was 4100/μL (normal range 3800–11,000/μL), hemoglobin was 13.8 (normal range: 13–17) gm/dL, and platelets were 248,000/μL (normal range: 140,000-450,000/μL). Creatinine level was 0.79 (normal range: 0.5–1.1) mg/dL, aspartate transaminase level was 18 (normal range: 10–30) U/L, and alanine transaminase level was 17 (normal range: 16-29) U/L. Her vitamin B12 level was 468 [normal range: 200–1100) pg/mL, and her serum folate was 10.3 (Normal range: > 5.4) ng/mL.
+She was diagnosed as having COVID tongue and was started on a mouthwash containing diphenhydramine-lidocaine-aluminum-magnesium-simethicone-nystatin to be swished and swallowed orally at a dose of 5 mL every 6 hours. She subsequently completed 30 days of the mouthwash and achieved 90% improvement in the appearance of the geographic tongue. Over the next 6 months, she had multiple flares of tongue sensitivity and visually active tongue lesions about every 3 weeks, and she was prescribed dexamethasone 0.5mg/5mL to be swished and spit four times daily for 10 days. However, she did not achieve complete resolution of her tongue lesions. Six months after developing COVID tongue, she underwent three treatments of photobiomodulation therapy (PBMT) to her tongue with an interval of 24 hours between each session. At a follow-up 2 months after the PBMT, she had no further flares and her tongue lesions were healing . Her systemic rash never returned, and she subsequently did well.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_826_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_826_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..684d296197f2ed817bbf19ad47d564b653c9af6d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_826_en.txt
@@ -0,0 +1 @@
+A 60-year-old Thai woman presented with a 4-month history of episodic, painful, horizontal binocular diplopia. She denied any oscillopsia. She was previously treated for nasopharyngeal carcinoma with several courses of chemotherapy and external beam radiotherapy (total dose of 7000 cGy). The tumor was well controlled; her most recent radiotherapy was administered 13 years previously. General neurological examination findings were unremarkable. Neuro-ophthalmic examination revealed normal visual acuity, visual fields, pupils, and fundi. Ocular alignment showed orthotropia and orthophoria by alternate cover test. Her ocular motility was normal in all gazes, including adduction. Myasthenic eyelid signs, including orbicularis oculi weakness, fatigable ptosis, and Cogan’s lid twitch, were absent. However, following a 30-s right eccentric gaze, she developed involuntary contraction of the left medial rectus, which resulted in left esotropia while returning both eyes to the primary position. The left esotropia lasted approximately 2 min, then spontaneously resolved . Likewise, these spells occurred following a 30-s gaze in the opposite direction (left eccentric gaze), which resulted in right esotropia in the primary position . During these spells, esotropia was steady (until it waned) and not variable. Both the pupils and the eyelid positions remained normal throughout the examination. No anisocoria was detected during the episodes of esotropia. Prolonged vertical eccentric gaze did not induce any ocular misalignment. Magnetic resonance imaging revealed neither brain parenchyma/brain stem lesions nor tumor recurrence. Her symptoms were successfully treated with carbamazepine at 200 mg daily.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_838_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_838_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..edd11457cb7a8777a1e0ea64000bf5f345ac42e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_838_en.txt
@@ -0,0 +1 @@
+This is the case of a 26-year-old G3P2A1 female with a past medical history of polycystic ovarian syndrome (PCOS) status-post tubal ligation that presented with right lower quadrant pain that began 1 h prior to arrival. Stated that this had an acute onset and described it as a constant, stabbing pain that was worst when she moved. She stated that this felt like her past PCOS exacerbations and denied any other infectious symptoms or recent trauma. Her vital signs upon arrival were remarkable for a mild hypotension to 93/48 and tachycardia to 102, but she was afebrile and these both improved with administration of 1L of lactated ringers. On exam, she was found to have tenderness in her right lower quadrant with negative Rovsing and obturator signs. Her labs were grossly unremarkable with no leukocytosis and no electrolyte abnormalities. Her urine pregnancy test was also found to be negative, so the decision was made to pursue a computed tomography (CT) scan of the abdomen and pelvis with intravenous contrast instead of a pelvic ultrasound. By this point, her pain and nausea were beginning to increase so 4 mg of morphine was ordered along with 4 mg of ondansetron for her nausea. She underwent the CT scan which was remarkable for a mild, uncomplicated acute appendicitis without perforation or abscess formation. Surgery was consulted and the patient was consented for an appendectomy. At this time, the patient was requesting more pain medication as she felt that her pain was continuing to increase. After a discussion regarding risks and benefits of more opioid medication versus an erector spinae block, the patient elected to pursue an erector spinae block. The patient was consented for both a block and for research purposes and the procedure was prepared. The patient was situated in a sitting position, similar to a lumbar puncture, with her lumbar vertebrae exposed. While many patients are positioned in the prone position with the operator at the head of the bed facing caudally, our patient’s abdominal pain was exacerbated with the prone position so the decision was made to place her in a less ideal sitting position. One should note that when a patient is placed upright, this may lead to bradycardia or hypotension during the procedure. The operator was positioned behind her and the patient was prepped and draped. Using sterile technique and ultrasound guidance with a curvilinear probe (due to patient’s body habitus), the L1 vertebra was located in the parasagittal plane. The probe was then moved right approximately 2 cm lateral to the spinous process and a 21 g Pajunk single-shot 100-mm needle was inserted in a cranial-to-caudal distribution until contact was made with the posterior surface of the transverse process. Hydro-dissection with 10 mL of normal saline with direct visualization confirmed needle tip placement in the fascial plane. After negative aspiration, 20 mL of 0.2% ropivacaine (2 mg/mL) were injected in aliquots of 4–5 mL with repeat aspiration in between. The patient remained on the cardiac monitor for the duration of the block and was monitored for any signs and symptoms of local anesthetic systemic toxicity. Over the next 15 min, she was found to have a significant decrease in pain from a 6/10 to a 1/10 and did not require any more pain medication throughout her stay in the emergency department and initial stay on the floor. Surgery elected to provide an as needed pain regimen of acetaminophen with codeine (300 mg with 30 mg), ketorolac (15 mg), and methocarbamol (500 mg). The patient did not request her first dose of pain medication until 6 h after the block had been performed and required minimal repeat non-opioid doses throughout the night. She underwent an appendectomy the following morning and was discharged afterwards without any complications.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_862_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_862_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..52932204c3b19bedfcf63d4ce781a21b368bb4fb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_862_en.txt
@@ -0,0 +1,6 @@
+A 37-year-old male patient presented to the emergency department with visual impairment and photophobia. He had noticed a black line in the visual field of his left eye 3 days ago. Physical examination was otherwise unremarkable. The patient had a body mass index (BMI) of 37 and a 31 pack-year smoking history. He was previously diagnosed with arterial hypertension and started taking candesartan 8 mg b.i.d. approximately 5 years prior without attending any regular check-ups. On admission, his blood pressure was 243/149 mmHg, which was lowered immediately using amlodipine and intravenous urapidil. Other vital signs were within normal ranges, and the patient denied further neurological or cardiovascular symptoms. Examination of the heart, lungs, abdomen, and fluid status was unremarkable. Emergency fundoscopy showed a large subretinal bleeding near the left macula and bilateral Roth and cotton wool spots consistent with hypertensive retinopathy. The patient was admitted to the cardiology department for further evaluation and management of malignant hypertension.
+Resting electrocardiogram showed normal sinus rhythm with left anterior fascicular block and t-wave inversions in I, aVL, V5, and V6. There were no signs of intracranial bleeding or stroke on computed tomography scan of the brain. Laboratory testing revealed hyperlipidaemia [low-density lipoprotein 177 mg/dL (normal range <115 mg/dL)], elevated HbA1c (6.7%) (normal range <5.5%), and leucocytosis (12.9 G/L) (normal range 3.9–10.2 G/L) . Inpatient 24 h blood pressure monitoring values were still substantially increased (24 h mean 181/128 mmHg, reverse dipping profile, no side difference) . Transthoracic echocardiography showed a mildly reduced left ventricular (LV) ejection fraction without regional wall motion abnormalities and LV hypertrophy (interventricular septum thickness 20 mm, posterior LV wall thickness 23 mm) without obstruction of the LV outflow tract or systolic anterior movement phenomenon, in summary consistent with hypertensive cardiomyopathy. Contrast-enhanced cardiac magnetic resonance imaging confirmed these findings but showed no signs of myocardial oedema, infiltrative cardiomyopathy, or specific distribution of late gadolinium enhancement ( and ).
+Based on the patient’s age, severely elevated blood pressure, and presence of hypertension-mediated organ damage, evaluation of common causes of secondary hypertension was initiated according to the current European Society of Cardiology/European Society of Hypertension guidelines. Renal artery duplex sonography did not show signs of relevant renovascular disease. Regular serum creatinine, plasma metanephrine, and 24 h urinary cortisol excluded parenchymal kidney disease, phaeochromocytoma, and Cushing’s disease, respectively. Plasma aldosterone–renin ratio, plasma parathyroid hormone levels, and thyroid function were normal, as well. The patient was discharged with optimized anti-hypertensive and heart failure medication including candesartan (16 mg b.i.d.), amlodipine (5 mg b.i.d.), bisoprolol (2.5 mg b.i.d.), doxazosin (4 mg b.i.d.), and spironolactone (25 mg q.d.), as well as metformin (500 mg q.d.) and atorvastatin (40 mg q.d.) . He was advised for smoking cessation, life-style modification, and ambulatory polygraphy for evaluation of obstructive sleep apnoea.
+After 11 days, the patient’s clinical condition worsened. He reported daily episodes of fever up to 38.0°C, night sweats, and fatigue and was re-admitted. The patient denied dyspnoea, chest pain, or symptoms of infection. Inflammatory markers were elevated [C-reactive protein 8.2 mg/dL (normal range <0.5 mg/dL), erythrocyte sedimentation rate 88 mm/h (normal range <15 mm/h), and leucocytes 12.3 G/L (normal range 3.9–10.2 G/L)]. Transoesophageal echocardiography was performed, which did not show evidence of vegetation formation. Blood culture samples remained sterile. Laboratory screening showed negative anti-nuclear antibodies, anti-neutrophil cytoplasmatic antibodies, and rheumatoid factor. An 18F-fluorodeoxyglucose positron emission computed tomography (18F-FDG PET-CT) scan was performed, which identified areas of abnormal tracer uptake in both common carotid arteries [target-to-blood pool ratio (TBR): 1.3] as well as the brachiocephalic trunk (TBR: 1.3) and subclavian arteries ( and ). There was no relevant involvement of the pulmonary artery or the aorta itself other than areas adjacent to the origins of affected supra-aortic vessels ( and ). There were no signs of active coronary lesions. The diagnosis of TA was substantiated using vascular sonography, which showed typical homogenous hyperechoic wall thickening of the left carotid (2.6 mm) and left subclavian artery (2.4 mm). Furthermore, extended ophthalmological evaluation showed ocular manifestations consistent with Takayasu retinopathy. Conclusively, the patient fulfilled three major and three minor criteria according to the 1995 diagnostic algorithm by Sharma et al.
+We began treatment of active severe TA with retinal involvement using 1000 mg intravenous methylprednisolone q.d. for 3 days, following 250 mg q.d. for 4 days, and switched to oral application with 100 mg q.d. for another 14 days . The patient temporarily required additional insulin treatment for blood glucose control [max 346 mg/dL (normal range <100 mg/dL)], which was terminated after steroid dose adjustment. Dual-energy X-ray absorptiometry (DEXA) scan yielded a minimal T-value of −1.4, indicating osteopenia. We decided to start glucocorticoid-sparing therapy using adalimumab 40 mg every 14 days. This allowed for gradual reduction of prednisolone dose to 10 mg per day, followed by further tapering. The patient’s discharge medication otherwise included candesartan (16 mg b.i.d.), amlodipine (5 mg b.i.d.), bisoprolol (2.5 mg b.i.d.), doxazosin (8 mg b.i.d.), eplerenone (25 mg q.d.), pantoprazole (40 mg q.d.), metformin (1000 mg b.i.d.), cholecalciferol (1000 units q.d.), and atorvastatin (40 mg q.d.).
+Eight weeks after discharge, the patient reported feeling overall well. His blood pressure had stabilized allowing for discontinuation of doxazosin. He was cleared for ophthalmic surgery and underwent pars plana vitrectomy and pan-retinal endolaser photocoagulation of his left eye, which significantly improved his vision. The patient was scheduled for multidisciplinary follow-up appointments, including specialist consultation in rheumatology, cardiology, diabetology, angiology, and ophthalmology.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_864_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_864_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..16ed2694508fb66d13227ccf71bbc12ec7e079d5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_864_en.txt
@@ -0,0 +1,5 @@
+A 32 year old woman, gravida three para one with a history of cervical incompetence, polycystic ovarian syndrome, antiphospholipid antibody syndrome (APLS), and tubal factor infertility, conceived with frozen embryo transfer of a single blastocyst resulting from standard insemination technique; intracellular sperm injection was not performed. They did not opt for preimplantation genetic screening. The embryo was originally frozen in 2013, 2 years before the first identification of a Zika case in Haiti. Embryo transfer occurred in April of 2016. Her husband was actively traveling back and forth to Haiti for work before and during the pregnancy.
+Her history of two mid-trimester losses was managed with an abdominal cerclage placed pre-pregnancy. She was treated with prophylactic low molecular weight heparin for APLS and insulin for her type two diabetes mellitus. She received betamethasone in the early third trimester for an episode of threated preterm labor. At delivery she was euglycemic.
+Endemic Zika was identified in Haiti per the CDC early in the epidemic . When recommendations were issued regarding the possibility of sexual transmission of Zika virus in August 2016, her maternal fetal medicine provider counseled her to use condoms or refrain from intercourse with her husband, whose business travel continued through the pregnancy . She herself never left the greater Boston area prior to or during the pregnancy. She had not been to her native Haiti in over 10 years. There has never been any local transmission of Zika virus in the state of Massachusetts. Additionally, interview with the couple after delivery confirmed that neither of them ever experienced any symptoms of Zika infection. In the absence of symptoms in either partner, it was not our practice to recommend Zika serology during the pregnancy to screen for sexual exposure.
+The patient underwent extensive fetal surveillance because of her multiple morbidities. She had a level II fetal survey at 18 weeks that revealed normal intracranial anatomy and head circumference (HC), and occipitofrontal diameter (OFD) measuring only 2 days smaller than her best dates. Biometry performed at 29 and 33 weeks was normal, and neither the HC nor the OFD measured less than 5%ile for gestational age. There was never any evidence of intracranial calcifications, ventriculomegaly, or abnormal posturing on antenatal ultrasound. She delivered in the 37th week via scheduled cesarean section. Her baby boy had APGARs of 8 (− 2 for color) and 9 (− 1 for color) at 1 and 5 min. He weighed 2775 g (30%ile by Fenton curve), was 49.5 cm long (65%ile) and had a head circumference of 29.2 cm (0%ile). The placenta was sent for conventional pathologic analysis given the maternal comorbidities. In addition, in light of the small measured neonatal HC and possible Zika virus sexual exposure, samples were sent to the CDC for evaluation. The timing of the IVF cycle relative to the Zika epidemic in Haiti was discussed with the Massachusetts Department of Public Health and CDC at length and the frozen embryo was determined not to be the source of infection.
+The baby had a normal hearing screen and was discharged on day of life (DOL) 6. His workup for microcephaly included serum and urine Zika RT-PCR and IgM, both of which were ultimately negative; CMV, head ultrasound and MRI were also negative. Head ultrasound performed in the first week of life was notable for bilateral mineralizing vasculopathy but no intraparenchymal calcifications and otherwise normal anatomy. A subsequent head MRI was normal. The mother was rubella immune and had negative testing for other relevant TORCH infections. Approximately 3 months after delivery, confirmation was received from the CDC that all placental samples were positive for Zika RNA, thus supporting the diagnosis of congenital Zika syndrome. By the time the placental results from the CDC had been received, both parents were too far removed from the time of suspected infection to be able to do serology. HC at a pediatric visit shortly after receipt of the CDC report revealed an interval increase in HC, although it was still less than third percentile for his age. The child continues to meet normal pediatric milestones and receives early intervention services as well as assessment by pediatric neurodevelopment specialists. A genetics evaluation will be pursued if there is any lag in his neurodevelopment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_876_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_876_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c1d9b1d1f3e3c10bc4ee46fe7f600c2c2101f9e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_876_en.txt
@@ -0,0 +1,8 @@
+A 60- year-old Aboriginal female, presented to our emergency department following collapse at home. She was on Warfarin for paroxysmal atrial fibrillation and mitral regurgitation and her past medical history included hypertension, hypercholesterolemia, depression and cerebro vascular accident without any residual effect.
+On presentation, she was agitated; her heart rate was 96/minute and systolic blood pressure was 70 mm of mercury. Clinical examination showed a distended abdomen with generalized tenderness. Laboratory investigation revealed Haemoglobin of 48 g/L, White blood count of 19.3 × 10/L and International Normalised Ratio (INR) of 1.7. Venous blood gases showed PH of 7.3, and a lactate of 6.03.
+She was resuscitated with intravenous fluids, red blood cells and fresh frozen plasma. She had a cardiac arrest during resuscitation and Cardio Pulmonary Resuscitation was performed with good outcome. An urgent laparotomy was performed for apparent intra- abdominal bleeding.
+Laparotomy showed 3 litres of free intraperitoneal blood and a large haematoma involving the lesser curve, upper body of stomach and the gastro oesophageal junction. The haematoma was expanding with active bleeding from the left gastric artery and its branches. Local measures to control the bleeding in this unstable patient failed and a total gastrectomy had to be performed.
+Damage control principles were applied due to hemodynamic instability and reconstruction deferred with stapling of her oesophageal stump. An abdominal vacuum assisted closure (VAC™) dressing was applied and she was transferred to the Intensive care unit, where she was stabilised and her coagulopathy corrected.
+A Roux-en-Y oesophago- jejunal anastomosis with Hunt - Lawrence pouch reconstruction and a feeding jejunostomy was undertaken thirty six hours later. Five days later, a gastrograffin swallow demonstrated anastomotic integrity; she was commenced on a diet and discharged 14 days after admission.
+Histological evaluation of the gastrectomy specimen and extensive sampling of the vessels revealed the diagnostic clues. Figures A, B and show SAM in the reparative phase with significant segmental disruption of the media by pronounced fibromyxoid proliferation and marked expansion of the intima in the moderate-sized arteries, with granulation tissue filling gaps and extending over the intima of arterial wall islands. In other areas of the arteries, there is often marked attenuation of media with gap formation only prevented by retained internal elastic and intima . The lesions showed only scanty inflammation characterized by some occasional sparse lymphocytes and collection of haemosiderin containing histiocytes . Focally, there was abrupt disruption of media with recoil of the internal elastic lamina, fibromyxoid tissue herniation into the adventitia and microaneurysmal appearances . Occasional small arteries showed intimal thickening, internal elastic lamina fragmentation, and attenuation of media. There was no evident feature of fibrosis and scarring.
+Follow-up Computerised Tomography (CT) Mesenteric Angiogram scan 3 months later showed no significant vascular structure abnormality. Twelve months later, the patient remains asymptomatic.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_890_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_890_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a235fa8c9351366ea57a1e1073d9e4197d1b150e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_890_en.txt
@@ -0,0 +1,7 @@
+The patient was an 81-year-old Japanese man. He was diagnosed with a recurrence of UC with multiple lymph node metastases, originating from the left renal pelvis, 1 year after laparoscopic radical nephroureterectomy. In addition, his renal function worsened 1 month before the above diagnosis; a shunt was created surgically for hemodialysis initiation. Thus, chemotherapy was planned while the patient continued hemodialysis.
+Before the commencement of chemotherapy, the patient’s Eastern Cooperative Oncology Group performance status was 1. His height was 163.5 cm, dry weight was 51.90 kg, and body surface area (BSA) was 1.55 m2. Laboratory findings were as follows: white blood count, 3700/μL; hemoglobin, 11.0 g/dL; platelet count, 168 × 103/μL; blood urea nitrogen, 24.2 mg/dL; and creatinine, 3.38 mg/dL. The patient had residual renal function, with daily urine volume > 500 mL and a 24-h creatinine clearance of 7.3 mL/min.
+The GEM dose was reduced by 25% (750 mg/m2) and was administered by intravenous infusion for 30 min on days 1 and 8 of a 21-day cycle. CBDCA was administered by intravenous infusion for 60 min on day 1, followed by infusion of GEM. The initial CBDCA dose was calculated according to the Calvert’s formula (target AUC: 5.0 mg/ml min, GFR: 6.1 mL/min). GFR was calculated based on knowledge that 24-h creatinine clearance is generally approximately 20% higher than GFR . Therefore, the CBDCA dose was calculated as 160 mg.
+Hemodialysis commenced 2 h after the end of CBDCA infusion on day 1 and was performed for 3 h, with a blood flow rate of 200 mL/min and a continuous infusion of heparin as an anticoagulant. The dialyzer membrane was made of polymethyl methacrylate, with a surface area of 1.6 m2 (BK1.6P, TORAY Inc., Tokyo, Japan). Subsequent hemodialysis was performed on days 3 and 5.
+A pharmacokinetic study was performed to monitor the measured AUC of CBDCA. This study was approved by the ethical review board at Nagoya City University Graduate School of Medical Sciences. Informed consent was obtained from the patient. Blood samples were collected during the first 2 cycles of chemotherapy. Sampling points were as follows: immediately after CBDCA infusion, before starting and ending hemodialysis, and 20 and 48 h after CBDCA infusion on day 1 . The plasma was stored at − 80 °C until analysis. The plasma platinum level was measured by inductively coupled plasma mass spectrometry. The CBDCA level was calculated using the molar ratio of platinum: CBDCA (371.25/195.08). The measured AUC of plasma CBDCA was calculated using the trapezoidal method according to the intervals before, during, and after hemodialysis, with extrapolation to infinity.
+The measured AUC of CBDCA in the first cycle was 5.96 mg/mL min, which was 19.2% higher than the target AUC . Consequently, grade 4 neutropenia and grade 3 thrombocytopenia were observed, according to the National Cancer Institute’s Common Toxicity Criteria for Adverse Events version 4.0 . To match the target AUC more closely in the subsequent cycle, we performed a pharmacokinetic study using parameters obtained in the first cycle. Consequently, the CBDCA dose was reduced to 135 mg, and the time interval between the CBDCA infusion and hemodialysis initiation was shortened to 1 h in the second cycle. The hemodialysis duration and conditions, such as the dialyzer and blood or dialysate flow rates, were unchanged. The measured AUC of CBDCA in the second cycle was 4.97 mg/mL min . The CBDCA dose and administration procedure in the third cycle were the same as that in the second cycle. In the second and third cycles, neutropenia severities were grades 2 and 3 and thrombocytopenia severities were grades 2 and 1, respectively . In addition, no other serious adverse events, including nausea and vomiting, were observed by the supportive care. Serum creatinine levels immediately prior to starting the second and third cycles were 3.12 mg/dL and 2.84 mg/dL, respectively; the 24-h creatinine clearance was only measured prior to the first cycle. The CBDCA removal rates by hemodialysis in the first and second cycles were calculated at 56.9 and 59.3%, respectively, though the redistribution phenomenon in the post hemodialysis period could not be considered due to the small number of blood sampling points. Other pharmacokinetic parameters in the first and second cycles are shown in Table . Total clearance of CBDCA was slightly higher in the second cycle than in the first cycle. Stable disease (according to Response Evaluation Criteria in Solid Tumors) was demonstrated by computed tomography after the second and third cycles.
+The patient’s QOL before treatment and after 2 cycles of treatment was evaluated using the Medical Outcomes Study 36-Item Short Form Survey (SF-36, iHope International Inc., Kyoto, Japan), which is a questionnaire used to measure general health status . Mean norm-based score (NBS) is an international common score recalculated on the basis of the score of 8 items of the SF-36. Our patient’s NBS did not significantly decrease after 2 cycles of chemotherapy compared with his NBS before treatment .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_896_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_896_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..547e43686278c3e7c8ef1201fbf5e851b0ae456a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_896_en.txt
@@ -0,0 +1,8 @@
+A 60-year-old male with a mild factor VIII deficiency presented to the hematology clinic at our hospital with a 1-week history of asymptomatic gross hematuria. He had suffered a hemorrhagic gastric ulcer at the age of 48 and was diagnosed with mild hemophilia A (his factor VIII levels were 6 % of normal) at that time. He had suffered a cerebral hemorrhage at the age of 59. For several years beginning at the age of 50, the patient had experienced mild hematuria, and he had experienced one episode of intramuscular and subcutaneous hemorrhage; both conditions were managed with recombinant factor VIII products.
+A physical examination revealed no abnormal signs. Laboratory tests revealed that the patient’s activated partial thromboplastin time (aPTT) was prolonged to 74.6 s (normal range, 28.5–40.9 s), but his prothrombin time-international normalized ratio, platelet count, serum creatinine level, and prostate-specific antigen level were unremarkable. The patient’s urinalysis results were normal, except for the gross hematuria, and urine cytology revealed no cancer cells. The patient was treated with a third-generation recombinant factor VIII product (Advate). However, he had persistent hematuria, followed by clot retention. Thus, he was referred to the Department of Urology. Computed tomography demonstrated that his bladder was filled with a blood clot , but his prostate and upper urinary tract were apparently normal.
+He was admitted to our hospital and received the following therapy: clot evacuation by vesicoclysis, continuous bladder irrigation with normal saline, and intravesical instillation of aluminum hydroxide/magnesium hydroxide (Maalox) concurrent with the administration of Advate, which failed to resolve the hemorrhage. Consequently, the patient had repeated transfusions of packed red cells. Although the patient also underwent transurethral coagulation of the bladder mucosa under anesthesia, the bleeding presented with oozing throughout the mucosa and was not controlled. Subsequently, the patient developed pyelonephritis in his left kidney with a severe reduction (<50 mL) in his bladder capacity. Conservative management for 2 months failed to resolve the patient’s symptoms, so he was offered a cystectomy with ileal conduit and consented to it after a detailed discussion.
+The quality of intraoperative clotting seemed to be normal with the use of sufficient Advate to raise the levels of factor VIII to 100 % (3000 U, IV bolus) and the transfusion of 3 U of fresh-frozen plasma. His aPTT was 54 s during surgery. The cystectomy was performed safely without severe bleeding events. A 15-cm length of ileal segment at 15 cm from the ileocecal valve was used for the ileal conduit. The technique of side-to-side stapled anastomosis was used for the ileoileal anastomosis, and the Bricker anastomosis technique was used for ureteroileal anastomosis. The total operating time was 220 min and the estimated blood loss was 800 mL.
+The resected specimen revealed multiple erosions and ulcers in the bladder mucosa, and sclerosis of the bladder wall. Histological examinations demonstrated inflammatory cell infiltration and fibrous changes in the bladder wall without malignant figures. The cause of the hematuria was unclear.
+Postoperatively, Advate (3000 U, q12 h) was administered to maintain 100 % levels of factor VIII for 2 days with no bleeding complications. After removal of the ureteral catheters on postoperative day 13, the patient had urinary leakage from the ureteroileal anastomosis, which induced a pelvic abscess followed by septic shock and acute respiratory distress syndrome. Blood cultures were positive for Candida tropicalis. Several antibiotics and surgical drainage of the abscess were needed.
+At 4 months after the cystectomy, the patient had blood in his stool requiring a transfusion of packed red cells. No bleeding site was demonstrated in the colon by colonoscopy and 99mTechnetium-human serum albumin-diethylenetriaminepenta-acetic acid scintigraphy demonstrated that the extravasation of radioactive isotope was detected at terminal ileum, cecum, ascending and transverse colon but not at the oral side of terminal ileum . These findings were suspected to be bleeding from the ileoileal anastomosis. The patient was given Advate (2000–4000 U) three times per week for 6 months, and the blood in his stool resolved. His condition recovered gradually and he was discharged at 8 months after admission.
+After discharge, he had mild gastrointestinal bleeding and mild hematuria several times a year; however, this was controlled by Advate. The patient had been doing well, other than the bleeding tendency, until he suffered a malignant lymphoma at the age of 66 and was transferred to another clinic for treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_931_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_931_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd8b2e253ceb7a25ed7df5ecdb61c46bac4f15ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_931_en.txt
@@ -0,0 +1 @@
+We present a 60-year-old male patient with Crohns disease who came to our emergency department complaining of headache, nausea, vomiting and muscle weakness. He was diagnosed with pre-renal acute on chronic kidney failure, hyponatremia, hypomagnesemia and hypocalcemia as has been diagnosed many times in his past medical history. He was in remission for Crohn's disease but had developed short bowel syndrome because of multiple intestinal resection. Kidney function and electrolyte deficiency improved with fluid and electrolyte replacement in a short course of hospitalization. Administration of intravenous fluid and electrolyte repleacement treatment at regular intervals prevented further kidney injuries and occurrence of symptomatic electrolyte disordres.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_932_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_932_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..254f4a7ac9b7e36f9696332572af6401bce3dd03
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_932_en.txt
@@ -0,0 +1,11 @@
+A female infant was born at 27 weeks of gestation to a 33-year-old, Gravida 8, Para 5 mother. The pregnancy was complicated by subchorionic hemorrhage at 11 weeks, rupture of amniotic membranes at 24 weeks gestation, and intrauterine growth restriction with absent end-diastolic flow of the umbilical artery. Doppler scans and a poor biophysical profile (2/8) at 27 weeks highlighted the need for an urgent cesarean section.
+The patient received a complete two-dose course of betamethasone at 24 weeks and a single rescue dose before the C-section at 27 weeks. The birth weight was 680 g (13th percentile), and the head circumference was 22 cm (6th percentile). The infant received delayed cord clamping for 1 min, and her 5-min Apgar score was 8. Noninvasive intermittent positive pressure (NIPPV) was initiated in the delivery room, which was continued on admission to the NICU.
+A chest X-ray showed radiographic features of RDS . There was an increase in the oxygen and ventilatory requirements. The infant met the institutional criteria for surfactant delivery via LISA. In our institute, the surfactant is administered via the “Hobart method”, which utilizes a semirigid 16-G catheter that is placed into the trachea without the use of Magill forceps. Bovine lipid extract surfactant (BLES®, 5 ml/kg) was successfully instilled.
+The catheter was prepared by removing the introducer needle and marking the desired estimated depth. The catheter tip was slightly curved to mimic the natural airway anatomy to facilitate the insertion past the vocal cords. The infant was premedicated with atropine and fentanyl.
+The procedure was performed by a neonatal physician trainee who was certified to perform LISA. The vocal cords could easily be visualized using a laryngoscope. Despite easy visualization, an attempt to insert the catheter between the vocal cords to the desired depth failed due to unexpected resistance. Given that the angiocath tip was passed beyond the vocal cords, a decision was made to start the instillation of surfactant. However, resistance was encountered during instillation, which prevented the administration of surfactant. At this point, a second visualization with the laryngoscope was conducted that confirmed that the catheter was through the vocal cords. The angiocath was then withdrawn by 0.5 cm.
+A second attempt to deliver surfactant was performed, and this time, it was successfully instilled without any resistance. Subtle subcutaneous neck swelling was noted after the procedure, vital signs were normal, and no bleeding or clinical deterioration was observed. The orogastric tube was aspirated, and no surfactant was retrieved, thereby confirming that there was no inadvertent intragastric delivery of surfactant. The oxygen could be weaned down from 30 to 21% by 45 min after the procedure, and the ventilatory parameters were weaned.
+Three hours after the procedure, the infant became hypotensive. A pneumothorax was suspected, so chest X-ray was ordered and revealed a pneumomediastinum . The air leak was localized to the anterior mediastinum, with a linear radiolucency showing a tract to the anterior aspect of the trachea close to the level of the vocal cords, suggesting a high tracheal perforation. Air tracking up to the soft tissue in the neck region was noted, suggesting subcutaneous emphysema.
+The infant required prompt management of hypotension, which was addressed with a fluid bolus of normal saline, and needed initiation of dopamine that was ultimately weaned off 8 h later. The pneumomediastinum was conservatively managed with close monitoring of the clinical condition and switching from NIPPV to nasal continuous positive airway pressure (nCPAP) and decreasing positive end-expiratory pressure (PEEP).
+The infant remained stable from a respiratory perspective on a low level of noninvasive support. Follow-up chest X-ray revealed a gradual resolution of the pneumomediastinum, and a complete resolution of the radiographic findings was noted by day 10 of life. There was no need for a further dose of surfactant or intubation for mechanical ventilation.
+The newborn was transitioned from nCPAP to a high-flow nasal cannula at 32 weeks. Cranial ultrasound performed on day 3 showed a grade 2 germinal matrix hemorrhage on the right side and a periventricular hemorrhage on the left side.
+Subsequent cranial ultrasound examinations demonstrated the evolution of periventricular hemorrhage into cystic lesions. The infant had a brain MRI at 32 weeks that showed similar findings. The newborn also had an episode of late-onset sepsis at 20 days of life that was successfully treated with antibiotics. Enteral nutrition was gradually established. The infant was completely off respiratory support by day 50 of life at the corrected gestational age of 34 plus 1 day and therefore did not develop bronchopulmonary dysplasia. The infant was discharged home at 40 weeks’ gestation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_945_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_945_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6d3e0feb045d9f2b0f5513eb1b171f8f6de1602c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_945_en.txt
@@ -0,0 +1,7 @@
+A 54-year-old male with a remote history of Hodgkin lymphoma treated with chemotherapy and mediastinal radiation was admitted to the hospital to undergo elective surgical mitral valve (MV) replacement and tricuspid valve (TV) repair. He previously had radiation-induced aortic valve stenosis requiring surgical aortic valve replacement with bioprosthetic aortic root in 2013. He was again referred to cardiothoracic surgery in 2019 for shortness of breath, fatigue, and severe pulmonary arterial (PA) hypertension (mean PA pressure 75 mmHg on right heart catheterization) resulting from radiation-induced calcific mitral stenosis, mitral regurgitation (MR) and tricuspid regurgitation (TR). Intraoperatively, there was enormous calcification extending from the interannular fibrosa to the A1, A2, P1, and P3 regions of the mitral valve requiring extensive debridement (Video 1, Figure ). A bioprosthetic MV and TV annuloplasty ring were then successfully inserted with initial improvement in PA pressures by approximately 30% by invasive monitoring. Limited intraoperative TOE post-cardiopulmonary bypass showed preserved ventricular function, trace TR, and trace paravalvular MR in the A1 region where calcification had been heaviest, and debridement caused disruption of the anterior mitral annular structure.
+He was admitted to the intensive care unit for post-operative care and weaned off ventilator and vasopressor support. He was found to have post-surgical complete heart block requiring placement of a permanent pacemaker on post-operative Day 11.
+One week later, he developed shortness of breath, orthopnoea, and weight gain. Physical exam was notable for jugular venous distention, bibasilar pulmonary crackles, and peripheral pitting oedema. Despite escalating diuretics, the volume overload progressed with a net weight gain of 16 kg. He developed acute kidney injury, transaminitis, and hypotension requiring inotropic and vasopressor support. Laboratory investigation also revealed worsening haemolytic anaemia (haemoglobin nadir 8.1 g/dL, total bilirubin 43.8 mg/dL, lactate dehydrogenase 2993 U/L, haptoglobin <30 mg/dL, and schistocytes on peripheral smear). Additional testing ruled out adrenal insufficiency (Ante meridiem (AM) cortisol 18.8 µg/dL), hyperthyroidism (thyroid stimulating hormone (TSH) 3.59 mIU/L, free thyroxine 1.25 ng/dL), or arteriovenous fistula at the recent left heart catheterization femoral access site.
+Repeat transthoracic echocardiogram (TTE) identified increased transmitral gradient (mean 14 mmHg, peak 33 mmHg) with normal pressure half-time (81 ms), elevated peak velocity (2.8 m/s), elevated velocity Time integral (VTI) ratio (2.92), and decreased indexed effective orifice area (0.4 cm2/m2) suggestive of significant occult MR vs. patient-prosthesis mismatch; it also revealed moderate TR and an estimated right ventricular systolic pressure of 80.3 mmHg . Due to concern for paravalvular leak causing severe haemolytic anaemia and high-output heart failure, a TOE was performed. Images confirmed a moderate-to-severe medial paravalvular mitral leak and a smaller posterolateral leak without evidence of valvular MR. There was a pacemaker lead crossing through the septal portion of the tricuspid annuloplasty ring with dehiscence and associated moderate TR. Most notably, the TOE unexpectedly identified a large septal defect between the LV and the RA , making the diagnosis of acquired iatrogenic Gerbode defect.
+The Gerbode defect was adjacent to the medial aspect of the MV prosthesis and posterior to the TV apparatus. Because of the significant risk posed by surgical intervention, the decision was made to pursue transcatheter device closure.
+The patient subsequently underwent right heart catheterization, which demonstrated mean RA pressure 30 mmHg, right ventricular (RV) pressure 80/8 mmHg with end-diastolic pressure of 28 mmHg, PA pressure 80/30 (52) mmHg, and mean pulmonary capillary wedge pressure 36 mmHg. Intraoperative TOE confirmed a Gerbode defect (6.5 mm × 7.8 mm). The defect was closed via right internal jugular approach using a 12-10mm AMPLATZER Duct Occluder (Abbott, Lake Bluff, IL, USA) with immediate drop in mean RA pressure to 21 mmHg, increase in systolic blood pressure by 30 mmHg, and trace residual shunt (Video 3). Because of the hemodynamic significance of the Gerbode defect, as well as the proximity of the defect to the mitral valve prosthesis, the paravalvular mitral leak was not primarily addressed. Incidentally, there was mild improvement of the paravalvular mitral leak following Gerbode closure due to some overlap of the retention disc with this area (Video 3).
+Following defect closure, there was rapid recovery of renal function, resolution of haemolysis and increased response to diuresis . On repeat TTE 1 week later, the device remained in appropriate position with insignificant residual shunt. Despite the fact that a mild paravalvular mitral leak persisted with a prosthetic mitral valve mean gradient of 9.5 mmHg, the patient clinically improved, and the decision was made to defer any further attempts at repair. He was discharged after a prolonged hospital course asymptomatic on daily diuretics, including bumetanide, spironolactone, and metolazone. The patient completed his subsequent follow-up visits at an outside facility closer to his home, but 8 months later, he remained well with no hospitalizations following his discharge.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_989_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_989_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..014176e86e4f1391836cafcb1e549bab98df8655
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_989_en.txt
@@ -0,0 +1,4 @@
+A 65-year-old woman with a background of hypertension, stroke, and fibromyalgia was admitted to the cardiology department due to recurrent malignant syncope with no prodrome. Her resting electrocardiogram (ECG) demonstrated sinus rhythm with complete right bundle branch block and left anterior hemiblock. The medical testing included 24 h-Holter ECG, stress-echocardiography, and nuclear test which were unremarkable.
+Eventually, she underwent implantation of the new generation Biotronik ILR—BioMonitor 3—according to standard procedure protocol: the skin was pinched perpendicular to the intended tunnelling direction at the left fourth intercostal space between suprasternal notch and left nipple with a small angle. The tunnel was created in the subcutaneous fat-layer in parallel to the skin surface, and the tunnelling tool was advanced until it reached the blue stop. The knob was unlocked, the white handle was fixed and the blue part was pulled back for device release. A clean ECG signal was observed; the measured R wave was 1.98 mV . The wound was unremarkable. Just after the procedure, the patient complained of sharp local chest pain. Chest X-ray demonstrated ILR at the normal expected position, and no pneumothorax was seen. Later on, the pain was relieved and the patient was discharged home on the same day.
+During the post-procedure period, the patient felt well with no chest pain but kept touching and moving the subcutaneous device until she had stopped feeling it about 1 week later. The remote communication with the device at the standard location was lost and the patient was invited for interrogation in the pacemaker clinic. During that visit, we were able to interrogate the device from the left lower chest area . A repeat chest X-ray and computer tomography located the device in the left postero-inferior part of the pleural cavity.
+A video-assisted patient thoracoscopy was performed. A 5-mm port was placed in the left mid-axillary line in the fifth intercostal space. The ILR was found free in the pleural space . The device was retrieved with forceps and the patient had no further complications during a follow-up of 40 days.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_990_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_990_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74e8fa0dc12bd6b6b57d5fa852f6d7775be19e71
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_990_en.txt
@@ -0,0 +1,4 @@
+A 12-year-old girl presented with non-progressive congenital flexion deformities of bilateral elbows and complaints of difficulty in writing, typing, jogging, and difficulty in using the Indian toilet such that she had to sit with one leg extended for balance. She was the firstborn child of a second-degree consanguineous marriage. Her mother gave a history of delayed and decreased fetal movements during pregnancy. Her motor milestones were delayed though social adaptive and language milestones were normal. She was good at academics. She had attained menarche at the age of 12 years and has normal menstrual cycles. Family history was unremarkable. On clinical examination, she had prominence in the suprascapular region on both sides with trapezii contracture and mild-to-moderate restriction of cervical spine range of motion in rotation and lateral bending. She had 20° of internal rotation deformity bilaterally and abduction was restricted to 120° at both the shoulders. She had 22° of fixed flexion deformity at the left elbow and 20° at the right elbow. Bilateral passive forearm supination was restricted to 60° with passive wrist dorsiflexion restricted to 35° on both sides. Clinodactyly was noticed in bilateral ring fingers and her fingers were hyperextensible at the interphalangeal joints. Otherwise, there were no signs of generalized ligamentous laxity. She had hypoplastic left thenar eminence with MRC Grade III power of the thenar muscles. She had bilateral tendo Achilles contractures with no passive dorsiflexion possible from neutral though the plantar flexion was full. She had a propulsive gait with a restricted arm swing on both sides. Mirror movements were demonstrated in bilateral fingers, elbows, toes, and ankles. ( & ) Mirror movements of the toes and fingers worsened with fatigue, but at the elbows and ankles, the mirror movements became less frequent as the voluntary movements were continued. Neurological examination was otherwise normal. Her height for her age was normal. There were no craniofacial malformations, hearing impairment, or visual defects.
+X-rays and 3-D computed tomography (CT) scan revealed bilateral Rigault Grade II Sprengel deformities and mild scoliosis at the cervical spine segment, cervicothoracic junction, and thoracolumbar junction . There was no fusion at any vertebral level. MRI revealed no central nervous system (CNS) or spinal cord malformations. Ultrasonography revealed no renal or genitourinary anomalies. ECHO showed mild aortic regurgitation.
+She started on regular joint range of motion exercises, muscle stretching and strengthening physiotherapy, and retraining therapy with techniques for increasing wanted movements while focusing on restricting unwanted movements.
+Her frequency of mirror movements decreased and writing and typing co-ordination was getting better. She is compliant with therapy and on regular follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_992_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_992_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..818cc3dbfc67a9f7ede43613c80461b87c853c06
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_992_en.txt
@@ -0,0 +1,52 @@
+A 23-year-old woman was referred to the Oral and Maxillofacial Surgery Service of
+Associação Paulista de Cirurgiões-Dentistas 30 days after accidental extraction of a
+mandibular second molar during extraction of a third molar on the left side. and show the panoramic radiographs taken before and after extractions, respectively. The
+patient also reported that the surgeon had considerable difficulty during the surgical
+procedure, which imposed an extensive period of time with the mouth opened. She reported
+severe joint pain on the right side soon after surgery, accompanied by difficulty in
+mouth opening and a deviation to the opposite side of the extractions.
+Clinical examination also revealed 23-mm mouth opening , with normal eccentric movement to the ipsilateral side and
+restriction of eccentric movement to the contralateral side . The following hypotheses were considered: permanent trismus,
+mandibular fracture or ADDWoR on the right side of the TMJ. Patient denied having
+history of symptoms related to TMD before surgery. Magnetic resonance imaging (MRI)
+confirmed ADDWoR on the right side of the TMJ .
+The patient was advised to try to reduce deviation by performing lateral movements, as
+much as possible, to the contralateral side of displacement, and, from this position,
+try to reach maximum mouth opening. At that time, no increase in mandibular opening and
+laterality was observed. Thus, two attempts of manual manipulation were performed within
+the period of one week. In the first attempt, we chose to test mandibular reduction
+using extraoral anesthesia alone. Due to failure and patient's discomfort, we decided to
+wait a week before making a new attempt. At this time, we applied the same type of
+extraoral anesthesia associated with intravenous sedation, thus contributing to
+successful reduction of disc displacement.
+Extraoral anesthesia was applied by blocking the auriculotemporal nerve with 1.8 ml of
+2% lidocaine hydrochloride associated with norepinephrine 1:200,000, followed by
+anesthesia of masseteric and posterior deep temporal nerves with the same amount of
+anesthetics. With a view to providing the patient with greater comfort, an intravenous
+injection of 2 g midazolam hydrochloride was administered ten minutes before the manual
+reduction procedure . Thus, 40-mm mouth
+opening and immediate improvement of mandibular functions were achieved .
+Minagi et al's technique for mandibular
+manipulation was used. It assists patients in performing maximum lateral excursive jaw
+movements to the nonaffected side with teeth slightly occluded, and in making maximal
+jaw opening movements through lateral border movements, as follows: 1) Place the thumb
+and forefinger on the maxillary canine on the nonaffected side and the mandibular canine
+on the affected side. Hold the gonion with the forefinger and middle finger of the other
+hand. 2) Instruct the patient to make maximal lateral gliding excursive jaw movements to
+the nonaffected side with teeth slightly occluded. Support movement with fingers and
+ensure that lateral excursive position is maximal. Lateral excursion with the jaw
+protruding is not adequate for this procedure. 3) Subsequently, instruct the patient to
+make jaw opening movements through the lateral border path on the nonaffected side.
+Support this opening movement with assisting fingers. 4) Continue to support voluntary
+mouth opening up to the maximal opening position.
+The patient received a prescription of anti-inflammatory drugs (100 mg of nimesulide,
+12/12 hours, orally) during five days, and also was advised not to force mandibular
+movements after reduction. The patient was instructed to use a stabilizer plate
+immediately after correct manipulation, so as to avoid a new disc displacement and
+reduce muscle hyperactivity. There were no complications after the manipulation
+maneuver, and an immediate 40-mm mouth opening was achieved after manual manipulation
+. The patient was followed-up on a
+weekly basis in the first month and every two weeks until the third month, showing no
+episodes of TMD within this period. and show MRI sagittal slices of the right TMJ
+with closed mouth presenting disc displacement and in maximum mouth opening movement,
+evincing reduction of TMJ articular disc.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_999_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_999_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fb042354f03426257e3b36276194afbcbb552357
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_999_en.txt
@@ -0,0 +1,3 @@
+A 67-year-old White male with no past medical history presented to the gastroenterology clinic in February 2017 with a complaint of persistent intermittent mid-chest discomfort over the past year. Prior to presentation, the patient underwent a negative coronary workup for intermittent mid-chest discomfort of unclear etiology. The patient described a retrosternal chest pressure that only later became associated with food intake. He denied heartburn, regurgitation, dysphagia, nausea, vomiting, abdominal pain, bleeding, dyspepsia, fevers, dark stools, night sweats, or weight loss. The patient did not use any medications, was never a smoker, did not drink alcohol, and denied a significant familial medical history. On physical exam, the patient appeared in no acute distress and had a normal exam of his oral cavity, along with a soft, non-tender, non-distended abdomen and no apparent organomegaly or lymphadenopathy. His initial complete blood count, basic metabolic panel, and liver function tests were within normal ranges. His negative workup and persistent symptoms, which were refractory to conservative measures, warranted further evaluation. He was referred for endoscopy, which revealed an ulcerative mass and a stricture in the distal third of his esophagus—concerns for malignancy .
+Endoscopic ultrasound (EUS) examination further characterized the mass as 5 cm in length, 16–18 mm in thickness, and as a partially circumferential mass contained within the submucosal area, with evidence suggesting muscularis propria invasion . It was staged T3N0M0 as per endosonographic criteria. The mass appeared to be primarily below the diaphragmatic hiatus and its center within 0.5 cm of the gastroesophageal (GE) junction. Positron emission tomography (PET) scans demonstrated fluorodeoxyglucose (FDG) avidity involving the GE junction and extending to the lesser junction, but no signs of FDG avidity elsewhere. Biopsy obtained from EUS suggested a poorly differentiated carcinoma of suggested large cell neuroendocrine histology . As such, immunohistochemical staining followed, and it showed strong immunoreactivity for both synaptophysin and CD56, but showed negative chromogranin immunoreactivity. Serum chromogranin A was mildly elevated at 16 ng/ml (normal < 15 ng/ml), while serum serotonin at 154 ng/ml and 24-h urine 5-hydroxyindoleacetic acid (5-HIAA) at 3.1 mg were normal (normal ranges < 230 ng/ml and < 8 mg/24 h, respectively). These findings confirmed the diagnosis of a stage IIA poorly differentiated large cell neuroendocrine tumor.
+The patient was started on neoadjuvant chemoradiation in June 2017, consisting of weekly carboplatin with target area under the curve 2 (AUC2), and paclitaxel 50 mg, along with radiotherapy, ahead of surgical resection. He tolerated four cycles of chemotherapy and seven sessions of radiotherapy, which helped in shrinking his tumor size. This was followed by a successful and noncomplicated robotic-assisted, laparoscopic esophagectomy in July 2017. Surgical biopsies and lymph node dissection revealed metastatic involvement in 1 of 3 diaphragmatic lymph nodes and no tumor invasion beyond the muscularis propria, further fine-tuning staging as T2N1M0. The patient has been under active surveillance, with yearly EGD and computed tomography (CT) scans every 6 months.
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