Add files using upload-large-folder tool

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1020_en.txt

@@ -0,0 +1,6 @@
+A 45-year-old man presented to our center with gradually developing weakness of the right limbs for 3 months. He underwent brain magnetic resonance imaging (MRI) at another hospital 3 months prior to admission, which showed an acute ischemic stroke of the left parietal lobe. Twenty days before admission, MRI showed cerebral and subarachnoid hemorrhages, although he had no new symptoms or exacerbation at that time. Ten days before admission, he presented with a sudden headache in the occipital region, difficulty in finding words, and unsteady walking. The patient did not complain of abdominal or bone pain.
+At admission, his vital signs and general examination were normal. Mucocutaneous alterations were not observed. Neurologic examination revealed expressive aphasia and right-sided extremity weakness graded 4/5 on the Medical Research Council scale (total range, 0 [no movement is observed] to 5 [muscle contracts normally against full resistance]).
+His medical history was unremarkable, with no history of vascular risk factors, including diabetes, hypertension, hyperlipidemia, cardiomyopathy, and atrial fibrillation. He also denied smoking, alcohol consumption, or illicit drug use. The patient’s father died of cerebral hemorrhage.
+A computed tomography scan of the brain showed an area of infarction with hemorrhage in the left subcortical and corona radiata regions , and the European Cooperative Acute Stroke Study classification was that of parenchymal hematomas 2 (PH2). MRI revealed meningeal and peripheral enhancement but no significant enhancement in the hemorrhage area. High-resolution MRI revealed a thrombosis on the surface of the atherosclerotic plaque. Digital subtraction angiography (DSA; Fig. ) revealed an insect bite-like change in the C1 branch of the left internal carotid artery, which caused up to 50% stenosis. Cerebrovascular malformations and other carotid or intracranial arterial stenoses were excluded.
+All blood test results were unremarkable, except for a continued elevation in the platelet (501 × 109/L-601 × 109/L) and white blood cell counts , with normal coagulation function. Therefore, bone marrow biopsy and genetic testing were performed after consultation with a hematologist. Bone marrow biopsy revealed proliferative bone marrow changes, with numerous megakaryocytes and proliferative but mature granulocytes. Further genetic testing revealed a positive JAK2-V617F mutation.
+Myeloproliferative disease is a possible cause of complex cerebrovascular lesions. Therefore, the diagnosis of ET was confirmed according to the diagnostic criteria of the World Health Organization (WHO) 2016. After discussing with the hematologist, we decided to administer aspirin and hydroxyurea. After treatment, the patient remained stroke free (mRS score = 1/6, total range 0 [symptom-free] to 6 [dead]), and platelet levels were normal throughout the 1-year follow-up period.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1056_en.txt

@@ -0,0 +1,7 @@
+A 69-year-old female patient presented with a 3-cm-diameter firm mass that had gradually increased over the prior 6 years on the left thigh, with local pain.
+Lumpectomy was performed at The Second Affiliated Hospital of Chongqing Medical University. Postoperative pathology results confirmed the mass to be a spindle cell soft tissue sarcoma. Postoperative immunohistochemistry results indicated CK(-), EMA(-), Vim(+), S100(-), SMA(±), Act(-), CD34(+), BCL-2(-), CD9(±), Ki-67(+), 50% AB(+), MBP(-), NF(-), and CD68(+), confirming the diagnosis of spindle cell soft tissue sarcoma . The patient was treated with an expanded resection.
+However, after 2 years, a firmer mass with some tenderness was found at the surgical site. Therefore, the patient underwent another expanded resection, followed by radioactive particle implantation. Postoperative immunohistochemistry results indicated CK(-), EMA(±), DES(-), S100(-), SMA(-), CD34(+), SDX-10(-), CDK4(-), MDM2(-), CD68(-), CD99(±), BCL-2(+), Vim(+), and Ki-67(+) > 50%.
+Nevertheless, after 16 mo, magnetic resonance imaging (MRI) revealed that the patient had relapsed. Subsequently, the patient underwent three lumpectomies and radioactive particle implantation.
+Despite this, after 5 mo, the follow-up pathology results revealed another relapse. A new treatment plan was designed: five sessions of HIFU (which occurred on March 5, June 11, August 20, October 13, and November 24, 2021), using an integrated circuit -type HIFU tumor treatment system (Chongqing Haifu Medical Technology Co., Ltd., China), which mainly consists of an ultrasonic generator, a focused ultrasonic transducer, a motion system, a control system, and a B-ultra real-time guidance system. The vertical scanning mode with a slice thickness of 2 mm was used. The ultrasonic transmitter worked at frequencies of 0.85 and 1.5 MHz. The ultrasonic power was 150–238W. The duration of each treatment was 275–1325s. The focal length was 135 mm and the lesion had a diameter > 5 cm.
+The ablation effect was assessed by MRI. After the first HIFU session, MRI indicated grayscale changes for the whole mass at the lesion site, mild skin edema, and orange peel-like changes, without induration. MRI indicated coagulative necrosis in the treated region, with homogeneous enhancement at the edge of the tumor . Residual tumor cells were not found in repeated biopsies at 2 and 4 wk after 5 HIFU .
+During the course of the disease (April 26, 2017 to April 2, 2022), the patient underwent seven chest computed tomography (CT) scans, all of which were free of lung metastases, four whole-body bone scans (whole-body scans before and after HIFU are shown in Figure and ), all of which were free of bone metastases but showed localized bone damage, and ten MRI scans (MRI scans before and after HIFU are shown in Figure and ). HIFU completely ablated the tumor without complications except for localized bone damage. No further chemotherapy, radiotherapy, or biological therapy was required for tumor control.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1063_en.txt

@@ -0,0 +1,5 @@
+A four-year-old female presented to the emergency department (ED) with a five-day history of severe, intermittent abdominal pain. She initially had several bouts of non-bloody, non bilious emesis that resolved after one day. Two days later, she had intermittent, crampy abdominal pain and tactile fevers. She was seen by her primary medical doctor who treated her for presumed constipation. Two days later, she continued to have episodic severe abdominal pain, recurrence of vomiting and a decrease in appetite and urine output. Upon presentation to the ED, the patient was witnessed to have several bouts of severe abdominal pain.
+The patient’s medical history was significant for chronic otitis media requiring myringotomy tubes. She had no recent travel and no pets at home. Her brother at home had nausea and vomiting. The patient was born full-term by an uncomplicated repeat C-section. Medications included milk of magnesia, polyethylene glycol, and acetaminophen. She had no known drug allergies, and her immunizations were up to date.
+On examination her vital signs were within normal limits. She appeared non-toxic and playful. On abdominal examination there was mild distention, diffuse tenderness, and mild guarding in the left lower quadrant. Rectal examination was negative for occult blood. While in the ED, the patient continued to have recurrent episodes of colicky abdominal pain.
+Abnormal laboratory results were limited to an elevated white blood cell (WBC) count of 17.2 103/μL, elevated neutrophils of 12.4 103/μL, a urinalysis with WBC 22/HPF, and a low serum chloride level of 99 mEq/L. An acute abdominal series was unremarkable. A limited pelvic ultrasound (US) demonstrated a mass, measuring 2.9×2.7×2.4 cm, posterior to the bladder and left of midline, without peristalsis or internal vascularity . The radiologist reported the US as highly suspicious for intussusception because it demonstrated the classic target sign. A normal appendix was identified. The sonographic examination was limited due to sudden intense patient pain and consequently the ovaries were not visualized.
+The pediatric surgical team was consulted, and the patient underwent diagnositic laparoscopy for treatment of a presumed intussusception with a lead point. Laparoscopy, however, showed no bowel pathology but instead revealed a complete 720° ovarian torsion with necrosis of the entire right fallopian tube and presence of an ovarian mass . On inspection, the liver, diaphragm, peritoneal surfaces, omentum, and pelvis were without evidence of tumor involvement. A laparoscopic right salpingo-oophorectomy was performed. The mass was placed in an endobag and removed piecemeal through a 12 mm trocar. Hair and sebaceous material were noted in the mass, supporting the gross diagnosis of an ovarian teratoma. Pathology confirmed the diagnosis of a benign, mature teratoma. Tumor markers including beta-HCG and alpha-fetoprotein were normal. The patient recovered without complications, and was discharged the following day. She will be followed with an annual examination and US of the contralateral ovary.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1078_en.txt

@@ -0,0 +1,6 @@
+The patient is a 64-year-old Asian male with a past medical history of hypertension and hyperlipidemia. The patient had no known family history of malignancy, though he had a personal history of high-risk prostate adenocarcinoma, which was diagnosed 7 years prior to his presentation for OS. This was staged as cT2N0M0 with a Gleason score of 4 + 5 = 9. He was treated with definitive radiation and androgen deprivation therapy (ADT) with leuprolide depot for 2 years. While off ADT, his prostate specific antigen remained less than (nadir + 2) with a nadir of 0.12.
+The patient presented to his primary care physician with a right-sided thigh mass. Before further workup could be completed, the patient presented to the emergency department (ED) with progressive shortness of breath and right lower-extremity edema. In the ED, he was noted to be tachycardic and hypoxic and admitted for further workup. A contrast-enhanced computed tomography (CT) of the chest was negative for pulmonary embolism but positive for innumerable pulmonary metastases up to 4.0 cm in size. A contrast CT and magnetic resonance imaging (MRI) of the abdomen and pelvis demonstrated a large, multilobulated, destructive mass of the superomedial right thigh and pelvis with associated pathologic fractures, as well as multiple hepatic lesions . A core biopsy of the right lower-extremity soft tissue mass was consistent with high-grade OS and stained positive for vimentin . The patient’s respiratory symptoms subjectively improved, and he maintained oxygen saturation on 1–2 L of supplemental oxygen; he was discharged home on supplemental oxygen as well as mechanical support for ambulation.
+Approximately 1 week later, the patient was seen in an oncology clinic and noted to be tachycardic with 130 beats per minute, respiratory rate of 38 breaths per minute, and hypoxic to 87% on room air. He was admitted that same day for consideration of urgent chemotherapy given the size and number of his pulmonary metastases. CT-guided biopsy of right lung mass was consistent with high-grade OS. Orthopedic evaluation determined he was not a surgical candidate for a hemipelvectomy given the extensive lung disease and oxygen requirements. Systemic chemotherapy was initiated with a planned 28-day cycle of cisplatin (100 mg/m2) over 2 hours on day 1 and doxorubicin (25 mg/m2) over 4 hours on days 1 through 3. Prior to doxorubicin being started, the patient decompensated requiring additional supplemental oxygen support with high-flow nasal cannula (50 L, 60%). Laboratory results were not consistent with TLS; potassium and phosphorus were within reference ranges and unchanged from prior, while uric acid was slightly elevated (8.5 mg/dL, reference range upper limit of normal 8.2 mg/dL). Repeat CT scan was negative for pulmonary embolism. Given worsening bilateral lower-extremity edema and significant fluid administration with cisplatin, hypervolemia was determined to be the cause of his worsening respiratory status, and the patient was diuresed with intravenous furosemide. He developed a multifactorial acute kidney injury (AKI) (CT contrast, cisplatin), though it resolved over time without hemodialysis. As his respiratory status improved, he received 3 days of doxorubicin therapy to complete cycle 1 of cisplatin/doxorubicin. Ten days after the completion of doxorubicin, the patient was briefly transferred to the MICU for hypotension, while in the ICU he was found to have an extended spectrum beta-lactamase Escherichia coli bacteremia that was treated with meropenem. The remainder of his hospital course was uncomplicated, and he was discharged home with home intravenous (IV) antibiotics and oxygen on hospital day (HD) 28.
+The patient was readmitted 9 days later for scheduled cycle 2 of cisplatin/doxorubicin systemic treatment. Shortly after the cisplatin and doxorubicin infusions were started on HD 0 (34 days after initial cisplatin dose), he became more hypoxic, requiring bi-level positive airway pressure (BiPAP) support to maintain his saturation. IV fluids and chemotherapy were immediately held, and the patient was upgraded to the progressive care unit (step down). At the time, the patient was clinically volume overloaded with significant bilateral lower-extremity edema. Over the next several days, the patient was diuresed; he continued to require BiPAP support to maintain SpO2 ≥ 92%.
+Given persistent hypervolemia, the decision was made for a trial of reduced dose ifosfamide (1000 mg/m2) monotherapy, with the plan to give daily on days 1 through 5. The patient received his first dose of ifosfamide on HD 7. On HD 8, the patient developed worsening hypoxia and tachypnea. The patient developed worsening metabolic and respiratory acidosis, and the diagnosis of TLS was made. The patient's laboratory values are summarized in Table .
+The patient was treated with 4 mg of rasburicase, IV furosemide, and intravenous fluids. In accordance with patient and family wishes, the patient was not intubated for respiratory failure and hemodialysis was not offered. Overnight into HD 9, the patient continued to have worsening lactic acidosis despite maximal medical management and noninvasive ventilatory support. The patient’s sinus tachycardia decompensated to asystolic cardiac arrest on HD 9, and he was pronounced deceased.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1110_en.txt

@@ -0,0 +1 @@
+A 52-year-old female with complaints of the right knee pain and swelling was referred to us in the outpatient clinic with a diagnosis of Baker’s cyst. The pain increased on squatting and climbing stairs and was associated with swelling in the posteromedial aspect of the knee joint for the past 11 months. There was no history of the previous trauma, no intermittent locking of the knee joint, and unremarkable medical history. On examination, there was a solitary, firm, cystic, fluctuant, immobile, and slightly tender swelling on the posteromedial aspect of the right knee joint of size around 4 3 cm with no local signs of inflammation. There was joint line tenderness on the medial aspect with positive McMurray’s test for a medial meniscus tear and no ligamentous instability. Knee range of motion was 0–120 with terminal flexion painful. The plain radiograph showed evidence of early osteoarthritis of the medial compartment along with patellofemoral arthritis. MRI knee demonstrated a large well-defined cystic lesion medial to semimembranosus and semitendinosus at the posteromedial aspect of the right knee joint of size around 3.9 3.0 2.5 cm with few thin internal septations. The lesion was hyperintense on T2-weighted and fat suppression images while it was hypointense on T1 weighted image ( and ) also noted was a horizontal tear in the posterior horn and body of the medial meniscus and oblique tear in the posterior horn of the medial meniscus. The patient was posted for surgery and underwent arthroscopic partial medial meniscectomy and open excision of the cyst in its entirety along with its stalk through a medial incision under spinal anesthesia . The base of the cyst was traced and sutured with the synovial lining, thereby repairing the defect. The excised sample was sent for histopathological evaluation and found to be a cystic structure lined by flattened epithelium with walls made of fibrocollagenous tissue infiltrated sparsely with lymphonuclear infiltrate and foamy histiocytes which were consistent with a meniscal cyst. Post-operative period was uneventful and at 2-year follow-up, there was no recurrence, pain, instability, or locking of knee joint. The patient had 0–120 active, painless range of motion at the knee joint. The patient was able to return to her daily activities without any limitations.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1120_en.txt

@@ -0,0 +1,7 @@
+A 44-year-old male patient, residing in a village of Yunnan Province, was admitted to Xiangyun County People's Hospital in March 2021. He had a history of working in coal transportation. He was diagnosed with tuberculosis, tuberculous bronchostenosis, and silicosis by the local disease control center and a hospital due to repeated coughing and phlegm for up to 6 years. When he was discharged from hospital, he accepted the advice of anti-tuberculosis treatment and the anti-tuberculosis HRZE scheme (H: isoniazid, R: rifampicin, Z: pyrazinamide, E: ethambutol). However, after discharge, the patient did not take medicine every day according to the doctor's advice, and still had cough and expectoration symptoms, without obvious regularity of time.After taking anti-tuberculosis drugs on his own for five days, he was admitted to the hospital because of headache and fever for two days with rash, and a high body temperature up to 39.4℃. Rashes were observed on the face, head, neck, chest and abdomen, and limbs, distributing in patches with size ranging from a pinpoint to a grain of rice, which led to pruritus and a red halo at the base without rupture, separated by normal skin. The lips and mouth were slightly cyanotic, and the breath sounds of both lungs were coarse, with scattered moist rales. The other examination results were unremarkable.
+By laboratory examination, normal level of blood cells were observed as follows: white blood cells (7.3 × 109/L), hemoglobin (155 g/L), platelets (202 × 109/L), neutrophil percentage (90.6%) and lymphocyte count (7.8 × 109/L). Biochemical tests showed impaired liver function: elevated aspartate aminotransferase(AST) (50U/L), elevated gamma-glutamyl transferase(GGT) (64U/L), slightly lower prealbumin (145.5 mg/L), however normal alanine aminotransferase(ALT) (21U/L). Inflammatory biomarker tests showed procalcitonin at 0.63 ng/mL and C-reactive protein at 59 mg/L. Coagulation analysis showed a prolonged prothrombin time of 13.2 s. Plasma fibrinogen was elevated at 4.80 g/L. Routine urinalysis showed that the patient was positive for urine protein (+ , 0.2 g/L – 1.0 g/L), blood cells (+ , 5 -10 red blood cells observed in 400 × microscopic field), and urinary ketones (+ + , 1.5 mmol/L-3.5 mmol/L), suggesting the presence of impairment of renal function (Supplementary Table ).
+No acid-fast bacilli were detected by pooling the patient's nocturnal sputum, immediate sputum and morning sputum for testing. According to the patient's chest computed tomography (CT) scan (bilateral lungs and mediastinum) findings, the scattered nodular and lamellar shadows in both lungs were considered as tuberculosis most likely, and the lesions in the lingual segment of the upper lobe of the left lung and the lower lobe of the left lung were probably infectious lesions . The patient was tested for the antibodies (IgM and IgG) against OHV due to the patient from the natural epidemic foci of HFRS, but the results were negative.
+On the first day after admission, the patient suspended his anti- tuberculosis treatment and was given an acetaminophen oral suspension. Subsequently, his temperature decreased and anti-inflammatory treatments were provided with methylprednisolone sodium succinate. The blood gas analysis of the patient showed that the pH value was 7.48, the oxygen partial pressure was 53.2 mmHg, the oxygen saturation was 90.1%, and the potassium ion (K +) was 2.8 mmol/L. The presence of electrolyte disorders (hypokalemia, hyponatremia) was treated with sodium chloride and potassium chloride injections. On the second day after admission, the patient's temperature fluctuated between 38.1–38.7° C, and he still had headache, cough, expectoration and other uncomfortable symptoms. For the symptoms of headache and rash, he took rotundine and ebastine tablets for symptomatic treatment. Later examination showed that the rash on the patient's face, head, chest and neck, and limbs had subsided, and the patient felt relief from the headache. On the third day after admission, the patient continued with symptomatic treatment for anti-infection and cough suppression. The patient sometimes had fever, discomfort, cough and expectoration with little sputum, which was yellow-white sputum. On the Fourth day after admission, the patient was discharged after the rash and fever subsided at the request of the patient and his wife.
+In cases where serological and clinical examinations could not identify the specific cause of infection, rash and fever, we performed retrospectively etiological testing of the whole blood and serum from the collected patent previously. TIANamp Virus DNA/RNA extraction kit (DP315, TIANGEN, China) was used to extract viral nucleic acid and DNA of OT which is an intracellular parasitic microorganism with some characteristics of a virus and can be extracted as soon as the OT is lysed and DNA is released from the patient whole blood and serum according to the instructions. Configure the Carrier RNA working solution (final concentration of 1 ug/ul) using Carrier RNA lyophilized powder, buffer GB neutralization, and RNase-Free ddH2O according to the reagents provided in the extraction kit. Add 20 μl Proteinase K and 200 μl Carrier RNA working solution to a 200 μl serum or whole blood sample. Close the lid and mix well by vortexing for 15 s. Incubate at 56° C for 15 min, briefly centrifuge, add 250 μl of anhydrous ethanol, and let stand at room temperature for 5 min. Transfer all the mixed solution to the adsorption column, centrifuge at 8000 rpm for 1 min, and discard the filtrate. Add 500 μl buffer GD, centrifuge at 8000 rpm for 1 min, and discard the waste liquid. Add another 600 μl of rinse solution PW, cover the tube cap, let stand for 2 min, centrifuge at 8000 rpm for 1 min, discard the waste liquid, and repeat this step once. Afterwards, 500 μl absolute ethanol was added, centrifuged at 8000 rpm for 1 min, centrifuged at 12,000 rpm for 3 min, discarded the filtrate, opened the lid and left at room temperature for 3 min. Drop 40 μl RNase-Free ddH2O in the middle of the adsorption membrane, leave at room temperature for 5 min, centrifuge at 12,000 rpm for 1 min, completely elute the DNA/RNA on the membrane, and store the nucleic acids in a -80 °C freezer.The gene sequence was amplified by one-step nested reverse transcription-polymerase chain reaction(Nested RT-PCR) method using universal primers of OHV according to reference. Nested RT-PCRs were performed using the OneStep RT-PCR kit (Qiagen) for OHV. In each outer reaction, generating an about 600-bp fragment, 2 μl RNA extract was mixed with 10-nmol dNTPs, 2 × reaction buffer, 30-pmol forward primer (HAN-L-F1:5´-ATGTAYGTBAGTGCWGATGC3´), 30-pmol reverse primer (HAN-L-R1: 5´- AACCADTCWGTYCCRTCATC3´), and 1 μl of the supplied.enzyme mix, in a total volume of 25 μl. Cycling conditions were as follows: 30 min at 50℃ and 15 min at 95℃, followed by 35 cycles of 30 s at 94℃, 30 s at 47℃ and 1 min at 72℃. A final elongation step was performed at 72℃ for 10 min. For the inner reaction, generating an about 370-bp fragment, 2 μl of the outer reaction product was used. All reaction and cycling conditions were identical to the ones used for the outer reaction, with the exception of the used primer set (HAN-L-F2: 5´-TGCWGATGCHACIAARTGGTC-3´ and HAN-L-R2: 5´-GCRTCRTCWGARTGRTGDGCAA-3´) and the omission of the reverse transcription step at 50℃.PCR amplification was performed using the 56-kDa TSA gene of OT according to references [, ]. The outside primer pair comprised 56KD-F1: 5´-TACATTAGCTGCGGGTATGACA-3´ and 56KD-R1: 5´-CCAGCATAATTCTTCAACCAAG3´. The nested primer pair comprised 56KD-F2: 5´-GAGCAGAGCTAGGTGTTATGTA 3´ and56KD-R2: 5´-TAGGCATTATAGTAGGCTGAGG3´. PCR products were 306 to339 bp for the outside primer pair and 150 to 168 bp for the nested primer pair. PCR conditions were the same for both primer pairs, with initial denaturation for 5 min at 94 °C, followed by 35 cycles of 30 s at 94 °C, 30 s at 50 °C, and 1 min at 72 °C, and a final extension of 5 min at 72 °C.The agarose gel electrophoresis experiment was carried out under the imager .The PCR products were purified by gel cutting and sent to a sequencing company (Shanghai Sangon Biotech) for sequencing. The 362 bp sequence of OHV(accession no.OP392989) and the 172 bp DNA sequence of OT were obtained from serum samples. Then primers (ICRA-F2:5 '- CCTCAGTATAATGCCC-3' and ICR8A-R: 5 '- TCCTGCATGACGCTGCAA-3') were designed to obtain 449 bp DNA sequence of tsutsugamushi (accession no.OP392990).
+Nucleotide sequence similarity searches in the public databases were assessed by the Basic Local Alignment Search Tool, implemented in the National Center for Biotechnology Information website , using BLASTn, and BLASTn optimized for highly similar sequences (MEGABLAST) and BLASTp, algorithms. In BLAST, it was 92.54% and 97.69% that the highest identity of nucleotide(nt) and amino acid(aa) compared the OHV sequence(OP39298) in this study to SEOV L0199 strain(HQ992814) and SEOV Rn-SHY17 ( ADR32120.1). The highest nt and aa identity compared the obtained OT sequence(OP392990) to Gilliam genotype of HZ01034 strain (MT258795.1) and Orientia tsutsugamushi str. Gilliam (KJV51889.1) was 96.88%, 93.96% respectively (Supplementary Tables and ).
+Phylogenetic trees were analyzed for the obtained OHV sequences (362 bp) and OT sequences (449 bp), and the related sequences retrieved in the Genbank database. The each sequence set was aligned by Clustal-X, and phylogenetic relationships were reconstructed using MEGA X for the initial trees obtained by the maximum likelihood neighbor joining method. In the nucleotide substitution models, the K2 + I and T92 + G models were selected for Bootstrap analysis using 1000 replicates to improve the confidence level of the phylogenetic tree, respectively .The results showed that the patient had been infected with SEOV of Orthohantavirus and Gilliam genotype of O. tsutsugamushi.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1126_en.txt

@@ -0,0 +1,4 @@
+A previously healthy 14-year-old girl presented with cough, sputum and shortness of breath after activity. She had a history of trauma 10 days prior to presentation. She was previously admitted to another hospital and diagnosed with tuberculosis. Antituberculosis treatment was ineffective; therefore, she was transferred to our hospital. She had no family history of genetic or osteolytic disease. She was admitted to the respiratory department with dyspnea and persistent cough. Examination revealed tachypnea, diminished breathing sounds, a deformity on her back, and tenderness. She exhibited percussion pain in the T6–T9 vertebrae and an absence of motor power in the thoracic spine. Neurological examination was normal.
+Plain radiographs revealed an osteolytic lesion in the thoracic spine . Thoracic computed tomography (CT) showed a moderate right-sided pleural effusion and atelectasis . Her thoracic spine CT revealed the presence of ill-defined lytic lesions in the ribs and the T6–T9 vertebrae as well as a fracture in the T7 vertebra . Magnetic resonance imaging (MRI) scans revealed a pathological fracture and spinal canal stenosis at the T7 vertebra and high intensity in the T6–T9 vertebral bodies . Whole-body bone scintigraphy was performed, and radiolucent foci were observed in the fracture lesion on the radiographic images. Blood analyses indicated nearly normal biochemical levels, except for a high concentration of cross-linked N-terminal telopeptides of type I collagen (111.60 ng/ml) and decreased vitamin D (8.99 ng/ml).
+Recurrent chylothorax was managed via repeated thoracentesis, and percutaneous fine needle aspiration of the lesion yielded more than 1000 ml/day of a reddish turbid, nonodorous fluid. Analysis of the aspirate revealed a positive Rivalta test result, which was reported as chylothorax. The patient was transferred to the thoracic surgery department to control the pleural effusion. A thoracic duct ligation and pleurodesis along with chest drainage was planned. The biopsy could not be analyzed because insufficient tissue was taken from the lesion during the process. Chest CT showed bilateral pleural effusions 2 days after surgery , and the chest was drained on the left side. To investigate the lesion pathology, the patient underwent another incisional biopsy of the T6–T9 vertebral bodies at the department of spine surgery. The bones appeared honeycomb-like intraoperatively. Postoperational pathological examination of the incisional biopsy revealed many dilated sinusoids with hemorrhaging, mononuclear and lymphocytic infiltration, fibrous tissue and dead bone . Based on the clinical, radiological and pathological findings, we confirmed the diagnosis of GSS because the biopsy material was negative for bacterial and fungal growth, and osteolysis was clearly demonstrated in the imaging results.
+No treatment has been approved for GSS; thus, several treatment methods are used. In our case, the treatment plan was discussed and confirmed in a multidisciplinary clinic meeting. Bisphosphonates and vitamin D therapy were administered to treat the disease because the patient was vitamin D deficient, and the disease is self-limiting. Because the neurological exam showed no abnormalities, conservative treatment was considered, and a custom-made polypropylene body jacket was prescribed to prevent kyphotic deformity. Her clinical status improved steadily following the oral bisphosphonates and vitamin D supplementation. A final thoracic CT was performed 2 years after diagnosis and showed a successful reduction in the amount of pleural fluid and stabilization of the thoracic spine deformity.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_113_en.txt

@@ -0,0 +1,4 @@
+A 71-year-old Caucasian woman presented with acid reflux symptoms of substernal burning and significant dysphagia. A barium swallow and endoscopy showed distal esophageal narrowing and a hiatal hernia. A repeat upper gastrointestinal (GI) series revealed a type III complex hiatal hernia with a significant paraesophageal component . The paraesophageal component was causing the distal esophageal narrowing, which was confirmed by a computed tomography scan. Surgery was recommended because her symptoms were caused by both gastroesophageal reflux disease (GERD) and the external compression of the distal esophagus from the paraesophageal component.
+The patient underwent laparoscopic reduction and repair of the complex type III hiatal hernia with a Nissen fundoplication to treat GERD. She had a large hiatal defect (6cm) with what appeared to be a complex hernia with both paraesophageal and sliding components. The posterior esophageal dissection cleared the hiatus , but the diaphragm and both crura were extremely thinned out. Primary repair was carried out using O Ethibond sutures (ETHICON, Somerville, NJ, USA); however, owing to the condition of the hiatus it was reinforced with an 8 × 8cm piece of Strattice™ xenograft . The graft was cut into a modified U shape with very short arms in the U portion . The O Ethibond suture was used at the apex of the crural repair inferiorly up at the superior portion of the crural repair , and then on the left upper side. The area on the right side was insufficient to suture the overlay patch; therefore ARTISS fibrin glue (Baxter, Deerfield, IL, USA) was used underneath the graft to stick it to the underlying fascia . A posterior stitch was placed in the posterior fundus for marking. The fundus was brought around the retroesophageal space and the fundoplication was carried out. The patient tolerated the procedure well and was transferred to the recovery room in a stable condition.
+The patient was discharged on a soft diet and she did well over the ensuing months. Approximately 11 months after the initial surgery she was admitted to my hospital with severe nausea and vomiting. An upper GI series and subsequent endoscopy revealed a slipped Nissen, with the wrap around the proximal stomach and not at the esophagogastric junction.
+She underwent laparoscopic revision of the wrap. The previously placed PADM was well incorporated overlying the hiatus and it actually looked like normal fascia. It was still intact and well vascularized with minimal adhesions . The few adhesions were taken down with a suction device. The hiatus did dilate anterior to the graft, which was closed with three interrupted 0 Ethibond sutures to make the hiatus secure. At this point the slipped Nissen was repaired. Postoperative upper GI was normal and the patient has continued to progress over the ensuing nine months.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1146_en.txt

@@ -0,0 +1,4 @@
+The patient was a 37-year-old man (148 kg, 183 cm, body mass index [BMI] 44.2 kg/m2) with a history of tracheostomy due to hypertensive intracranial hemorrhage that occurred 4 years ago. He was diagnosed with grade I tracheal stenosis above the tracheostomy site 2 years ago. Despite conservative treatment, dyspnea developed and the patient underwent endoscopic tracheal dilatation under general anesthesia. Baseline peripheral capillary O2 saturation (SpO2) was 94% and Cormack-Lehane grade was 3 at the time of intubation. Surgery was performed using the intermittent apnea technique with extubation, and a total of six apnea events occurred, with a mean duration of apnea was 147 s. The lowest SpO2 was 64%, and SpO2 recovered to 96–98% after manual ventilation via endotracheal tube. The patient had been treated conservatively after balloon dilatation with portable O2 at home. Dyspnea worsened again 1 year ago, despite O2 therapy, and serial fiberoptic steroid injections to the subglottic stenosis site were planned. In our hospital, fiberoptic steroid injections are usually performed according to the following steps. Topical anesthesia at nostrils is followed by sedation, applied by surgeon. The fiberscope is inserted through the nostril, and the glottis and lesion are sprayed with additional local anesthetics. Then, the lesion is injected with steroid. The otolaryngologist consulted us for safe sedation and monitoring due to the possibility of emergency caused by airway edema or airway obstruction. Considering the patient’s general condition, symptoms, and experience of previous surgery, we decided to perform the operation under general anesthesia with spontaneous breathing in preparation for airway manipulation, because general anesthesia using the intermittent apnea technique could limit the view of surgical field and damage the larynx and subglottic lesions.
+On entering the operating room, the patient was placed in a 30° sitting position for the first steroid injection. Standard American Society of Anesthesiologists monitoring (non-invasive blood pressure [NIBP], electrocardiogram, and SpO2) and bispectral index (BIS) monitoring were applied. The baseline vital signs were as follows: BP, 105/52 mmHg; heart rate (HR), 66 beats per minute (beats/min); SpO2, 95%. Oxygenation was applied at 6 L/min O2 through a standard facial mask. End-tidal CO2 (EtCO2) was monitored continuously by capnography to confirm self-respiration. Dexmedetomidine was used for sedation. After delivering a loading dose of 1 μg/kg over 10 min, continuous infusion of 0.6 μg/kg/h was maintained. During infusion of the loading dose, the EtCO2 level decreased gradually until apnea was induced. An oral airway was inserted and the jaw-thrust maneuver was applied to maintain airway patency and support self-respiration. After confirming that the patient was unresponsive to verbal commands and tactile stimulus, the surgery was started while self-respiration was maintained. The surgeon requested lowering of the facial mask so that it would not interfere with the procedure and applied topical anesthesia by packing gauze soaked with Bosmin® (0.1% epinephrine) and Beracaine® (10% lidocaine) into both nostrils. The fiberscope was passed through the nostril to access the glottic and subglottic lesions, and additional 2% lidocaine was sprayed around glottis and lesions, and 3 ml of tamcetone® (Triamcinolone 40 mg/ml) was then injected. The procedure was interrupted by bag-valve-mask ventilation because SpO2 fell to 86%. After ventilator assistance for 117 s, SpO2 recovered to 96%. During surgery, HR remained within 20% of the baseline, but BP increased by more than 20% of the baseline. However, systolic BP remained below 160 mmHg, so no additional drug administration was necessary. The value of BIS was maintained between 55 and 80. The total surgery time was 20 min and the total anesthesia time was 40 min. The patient was discharged after 1 day of monitoring in the Intensive Care Unit (ICU), without dyspnea or complications.
+Dyspnea improved noticeably, but on physical examination, grade II subglottic stenosis and stridor remained, thus necessitating a second steroid injection 1 month later. Based on our previous experience, we considered that there was a need to improve oxygenation during the procedure, so we decided to apply Optiflow®. In the same manner as in the first operation, the patient was placed in the 30° sitting position, and standard American Society of Anesthesiologists and BIS monitoring were applied. Baseline vital signs were as follows: BP, 102/58 mmHg; HR, 70 beats/min; and SpO2, 94%. O2 (100% warmed, humidified) was supplied through a nasal cannula at a rate of 30 L/min for preoxygenation. The patient tolerated this well, without any complaints. Dexmedetomidine was used for sedation at the same dose as before. Once the patient was unconscious, the O2 flow rate was raised to 70 L/min. EtCO2 was monitored by placing the EtCO2 sampling line at the nostril next to the Optiflow® nasal cannula; however, a low value was obtained, so we could only confirm self-respiration by monitoring the shape of the waveform . Topical anesthesia was applied by packing gauze into both nostrils. This disturbed the O2 supply through the Optiflow® nasal cannula; therefore, we inserted an oral airway to maintain airway patency, and the Optiflow® nasal cannula was transferred to the opening of the oral airway. The EtCO2 line was also transferred to the opening of the oral airway, but it still showed a low value; thus, only the shape of waveform was monitored . SpO2 was maintained at 98–100%, and no intervention, such as mask ventilation or jet ventilation, was required during surgery. Despite self-respiration, there was a drop in SpO2 to 86% due to O2 leakage; the Optiflow® nasal cannula dislocated from the airway opening. After fixing the nasal cannula to the airway with plaster , SpO2 immediately recovered to 99% and no additional desaturation events occurred. The vital signs were stable within 20% of baseline. Additional bolus of midazolam was injected to prevent the event of awareness because the value of BIS was maintained between 70 and 79 when the procedure was performed; 1mg for oral airway insertion, 2 mg for gauze packing into both nostrils. During the operation, the value of BIS was well maintained between 35 and 50, and spontaneous breathing was generally maintained well. The patient endured the surgical stimuli without coughing and movement throughout entire operation. The total operation time was 15 min and total anesthesia time was 40 min. The surgeon had prepared jet ventilation because of the experience during the previous surgery, but ultimately did not use it; thus, the surgeon was highly satisfied with THRIVE. After the surgery, the patient was transferred to the ICU. Arterial Blood Gas Analysis (aBGA) was performed after arrival in the ICU; partial pressure of O2, 94 mmHg; partial pressure of CO2 (PaCO2), 49 mmHg; pH, 7.30; bicarbonate, 21.3 mEq/L. The patient was discharged after 1 day of monitoring without complications.
+This study was approved by the Institutional Review Board of Soonchunhyang University Bucheon Hospital (IRB No. 2020-02-026-001). And written informed consent, included the consent to publish images, was obtained from the patient in this study.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1174_en.txt

@@ -0,0 +1,2 @@
+A 70-year-old man (weight 70 kg, body mass index 25.7 kg/m2) with underlying hypertension and dyslipidemia underwent an elective open hernioplasty for right inguinal hernia under ambulatory surgery. He had normal airway features: good mouth opening, Mallampati score of 1, thyromental distance > 6 cm and normal tongue protrusion. General anesthesia was induced with intravenous propofol 200 mg plus fentanyl 100 μg and a size 4 LMA ProtectorTM Airway was placed smoothly in a single attempt by a senior resident. The cuff was inflated with 25 ml of air and the black line indicator on the cuff pilot valve remained within the green zone throughout the surgery. However, we did not check the intra-cuff pressure using manometry. The oropharyngeal leak pressure was 25 cmH2O. The sternal notch test and bubble test were performed after insertion to confirm the placement of the LMA protector . Anesthesia was maintained with a mixture of sevoflurane and oxygen/air. The patient’s breathing was supported with a pressure support of 8 cmH2O, which generated a tidal volume of 400–450 ml and the maximum minute ventilation attained was 12 L/min with peak pressures of 8–10 cmH2O. He was placed in a supine position with standard American Society of Anesthesiologists monitoring for the surgery which lasted for 180 minutes. The surgery was uneventful, and the patient’s vital signs were stable throughout. Postoperatively, the LMA was removed smoothly when he was awake. Moreover, blood stains or minimal secretions were not observed on the device.
+At the post anesthesia care unit, the patient complained of difficulty in chewing food and a weird tongue movement. He had no voice changes or altered taste sensation. On examination, the patient’s tongue was seen to be deviated to the left during active protrusion . All sensations of the tongue were intact and there were no tongue fasciculations or wasting. The neurological examination revealed no lateralizing signs or limb weakness. The gag and cough reflexes as well as other cranial nerves were normal. The patient was referred to the ENT surgeon the same day. The nasoendoscopy examination was unremarkable. The working diagnosis was that of an isolated left hypoglossal nerve palsy or neuropraxia. He was allowed to go home the same day with reassurance, oral prednisolone for one week, and instructed for follow up at the ENT outpatient clinic. Neuroimaging was not required. He achieved complete recovery 3 months after the injury (, ) and was subsequently discharged from the follow-up clinic.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1176_en.txt

@@ -0,0 +1,5 @@
+A 79-year-old white man presented to clinic with macroscopic hematuria for over 3 months. The patient denied a history of bladder cancer and physical examination revealed no palpable abdominal or renal masses. On multiparametric Magnetic Resonance Imaging (MRI), a lesion measuring 3.6 × 3.1 × 2.7 cm was seen in the interpolar region of the left kidney without involvement of the renal vein or collecting system . No left sided hydronephrosis or intraabdominal metastasis were appreciated. The right kidney was found to be atrophic. The patient’s medical history was significant for CKD as well as coronary artery disease (CAD) status post coronary artery bypass graft surgery (CABG). Serum creatinine was 1.3 mg./dL, Ca 9.2 mg/dL, albumin 4.2 g/dL, and hemoglobin was 13.7 g/dL. Urine culture was negative. Chest CT revealed no signs of thoracic metastasis.
+Initial workup cystoscopy was negative for a bladder mass or bloody efflux from either ureteral orifice, however prostatomegaly was noted. In addition, abdominal MRI images noted endophytic complex cystic mass with solid components making renal cell carcinoma the most likely suspected diagnosis. Considering the patient's comorbidities and the significance of preserving adequate renal function in patients with a solitary kidney, he elected for renal mass biopsy followed by immediate cryoablation as the treatment modality.
+The patient was taken to the Interventional Radiology suite for biopsy and cryoablation of the left renal lesion. Under Computerized Tomography (CT) guidance with the patient prone, three 18-gauge core pretreatment biopsies were obtained from the renal mass. Subsequently, three ice-rod probes were distributed across the lesion to maximize treatment margins and two freeze–thaw cycles were carried out. Repeat unenhanced and contrast enhanced CT showed evidence of complete lesion ablation with satisfactory margins. The pathology of the biopsy later confirmed low-grade UTUC. Given this diagnosis was not anticipated, further discussion was warranted regarding the patient’s increased risk of recurrence due to the pathology of his disease. Retrograde ureteroscopy, biopsy, and laser fulguration three months after cryoablation was elected as the next step in management.
+Under general anesthesia, full and thorough surveillance cystoscopy was negative for any bladder lesions and left retrograde pyelogram demonstrated no filling defects but an interpolar calyx appeared compressed . A Wolf fiber optic ureteroscope was utilized for complete pyeloscopy. Yellow-white discoloration with surrounding mucosal edema was visualized in the interpolar calyx consistent with necrotic tissue after cryoablation; however, no obvious papillary fronds of tumor were seen. A Segura four wire basket was deployed to biopsy the superficial necrotic and edematous mucosa followed by BIGopsy biopsy forceps for deep tissue samples. Holmium laser fulguration was applied for bleeding control and obliteration of any potential residual disease. The collected specimens were sent separately. Pathology results from the superficial biopsy demonstrated fragments of non-invasive low-grade papillary urothelial carcinoma. Deeper biopsies revealed cells of uncertain malignant potential in a background of extensive hyaline necrosis and fibrin deposition, corroborating scar hyperplasia and tissue transformation after cryoablation.
+The patient was monitored over a 5 year period with annual surveillance cystoscopy, bladder cytology, and multiparametric MRI/MRU. To our satisfaction, no visible recurrence of the lesion was observed, and the patient's renal function remained stable , suggesting the success of this unconventional treatment approach to achieve favorable outcomes. The lack of disease recurrence and preservation of renal function attest to the success of cryoablation in this case.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1178_en.txt

@@ -0,0 +1,7 @@
+We present a case of a 14-month-old male who was referred to our facility with complete failure to thrive since birth and had developed melena stools intermittently for 1 month. The haemoglobin at presentation was 7.0 g/dl. The patient was seen at a peripheral facility but the referral to a specialist was delayed. An ultrasound and contrast-enhanced CT of the abdomen was performed which showed a 2.4 cm × 2.2 cm tubular structure in the right hepatic lobe with early arterial filling from the left hepatic artery and draining into left portal vein . Early high flow retrograde arterial contrast filling of the left portal vein, the portal vein and the superior mesenteric vein, splenic vein and their tributaries was also seen. The portal vein, left portal vein, common hepatic and left hepatic artery were prominent. No other liver lesion was seen. There were also features of portal hypertension with periportal collateral vessels.
+A multidisciplinary meeting was held to discuss the treatment options between the paediatrician, paediatric surgeon and interventional radiologist. The child was a poor surgical candidate as he was severely malnourished with a fairly central lesion in the right lobe of the liver. Therefore, a decision was made to attempt to treat at least the arterial inflow via an endovascular approach.
+The procedure was performed under general anaesthesia. Under ultrasound guidance, a 4Fr 7 cm hydrophilic sheath (Angiogate TransRadial Introducer Kit by Kimal, United Kingdom) was placed retrogradely into the right common femoral artery. Intraarterial hourly heparin bolus was administered to prevent thrombosis at the access site and lower limb. Access to the celiac axis and then common hepatic artery was obtained using hydrophilic standard angled guide wire (Merit Laureate by MeritMedical, Ireland) and 4 Fr Cobra 2 catheter (Performa Angiographic catheter by MeritMedical, Mexico). The left intrahepatic arterioportal malformation was demonstrated receiving blood supply from the left hepatic artery and draining into left portal venous vein .
+A decision was made to perform coil embolization of the main feeder as distally possible using a 2.4Fr microcatheter (Progreat by Terumo) to deploy a 4 mm detachable micro-coils (Concerto by Medtronic, The Netherlands). There was some flow still noted and hence a second 5 mm detachable micro-coil (Concerto by Medtronic, The Netherlands) was put in place which stopped the flow .
+There was good outcome with one tiny feeder opening immediately post embolisation. Digital subtraction angiography of the superior mesenteric artery showed no additional supply to the fistula.
+An ultrasound scan performed 1 week after the procedure confirmed thrombosis of the fistula with antegrade flow in the portal vein . This was maintained on further follow up scans.
+A further hospital admission 2 months after the procedure was necessary to manage refeeding syndrome. However, the patient did well clinically for a number of months once discharge, gaining significant weight and no further melaena. Unfortunately, he succumbed 8 months after the procedure secondary to an unrelated, acute respiratory illness.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1182_en.txt

@@ -0,0 +1,4 @@
+A 49-year-old male presented to the emergency department at Bascom Palmer Eye Institute complaining of right eye pain and decreased vision about 17 h after being struck in the eye with a tree branch. On examination, he was noted to have a 1.5-mm corneal laceration with fibrin in the anterior chamber and signs of traumatic cataract with posterior synechiae and pigment on the anterior lens capsule. No signs of endophthalmitis were noted on B-scan. The laceration was repaired, and the patient was treated prophylactically with intravitreal ceftazidime 2.25 mg, vancomycin 1 mg, and voriconazole 50 μg. Aqueous humor cultures for fungi and bacteria were negative, and B-scan was unremarkable at initial follow-up.
+After an initially uncomplicated postoperative course, the patient returned 26 days later with pain and an elevated intraocular pressure (IOP) of 45 mm Hg. On B-scan, there were mobile subhyaloid and vitreous opacities indicative of endophthalmitis . The patient underwent pars plana lensectomy and vitrectomy with 1,000 cSt silicone oil injection, peripheral iridectomy, and administration of intravitreal vancomycin 1 mg, ceftazidime 2.25 mg, and voriconazole 100 μg. The lens capsule was left in place. The undiluted intraoperative vitreous sample demonstrated Gram-variable bacilli which were later identified as O. turbata.
+The immediate post-treatment course was uncomplicated. However, 1 month later, the patient returned with decreased vision and an acutely-elevated IOP of 55 mm Hg. The patient underwent silicone oil removal.
+The course was again stable for another 2 months until the patient presented with worsening eye pain and inflammation with an IOP of 45 mm Hg, keratic precipitates, and 4+ anterior chamber cell. B-scan demonstrated dense vitreous opacities with multiple focal hyperechoic foci and peripheral membrane formation. Ultrasound biomicroscopy revealed diffuse anterior chamber opacities and retained lens capsule adherent to the posterior iris . Intravitreal vancomycin 1 mg and ceftazidime 2.25 mg were administered. Anterior chamber paracentesis was performed, culture of which revealed no fungal or bacterial growth. B-scan about 1 month later revealed new vitreous opacities and inferior membranes. The patient was suspected to have chronic endophthalmitis and subsequently underwent pars plana vitrectomy and total capsulectomy with administration of intravitreal vancomycin 1 mg, ceftazidime 2.25 mg, and voriconazole 100 μg. Anterior chamber fluid cultures were ultimately negative, and no further organisms were identified in the lens capsule on pathology. The patient had sustained mixed mechanism chronic IOP elevation and eventually underwent glaucoma drainage implant surgery. The final aphakic best corrected visual acuity was 20/80 and IOP was 19 mm Hg. There have been no reactivations of inflammation or infection for 1 year after the last surgery .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1194_en.txt

@@ -0,0 +1,6 @@
+A 36-year-old female patient of Tatarian origin was referred to the Endocrinology Research Centre, Moscow, with a diagnosis of type 1 diabetes mellitus complicated by diabetic foot syndrome. According to the medical documents, generalized lipoatrophy developed during the first months of life, and from the early childhood she suffered from an umbilical hernia, muscular hypotonia and delayed motor development (without mental retardation). Later moderate amyotrophy of the muscles of the shoulder girdle developed, with a lack of reflexes in the legs, muscle weakness and myalgia of lower extremities. Between the ages of 17 and 20 the patient underwent multiple surgeries for dolichosigmoid, perforation of diverticula and peritonitis, which resulted in local muscular weakness and malabsorption leading to generalized muscular weakness and dysphagia. At 19 years of age diabetes mellitus type 1 was diagnosed with normal body weight but for 2 years the patient was well compensated by a diet with fast carbohydrates restriction. At the age of 21, she started insulin therapy. A wound defect (trophic ulcer) in the area of the inner surface of the right thigh was diagnosed at the age of 35; after a few months, diabetic neuro-osteoarthropathy of the right foot was also diagnosed. For 3 months, the patient used a Total Contact Cast with positive effects. The patient had amenorrhea with 2 episodes of menorrhagia in her life between the ages of 18 and 19. Bilateral cataracts were first diagnosed at the age of 22, and were treated surgically 12 years later. Marked diffuse osteoporosis was diagnosed at the age of 28 by a multi-layer spiral CT (Computed Tomography) scan.
+She had acromegaloid features, phlebomegaly and hypertrophy of the skeletal muscles in the upper and lower extremities, muscular hypotonia, generalized lipoatrophy, but no signs of hirsutism and clitoromegaly were found. Her height was 160 cm, weight 46.8 kg, BMI (Body mass index) 18.1 kg/m2.
+Skin fold measurements, impedancemetry and “Total body” densitometry showed a significant decrease of subcutaneous fat tissue. The skin fold measurements were as following: supraclavicular skin fold, 4 mm; subscapular skin fold, 6 mm; triceps skin fold, 4 mm; anterior surface of the abdomen skin fold, 4 mm; hip skin fold, 6 mm; anterior surface of the thigh skin fold, 6 mm; posterior surface of the tibia skin fold, 3 mm. Impedancemetry showed 11.9% of body fat, and “Total body” densitometry demonstrated 7.8% of total fat . An abdominal ultrasound showed hepatosplenomegaly with severe hepatic steatosis. There was no cardiac pathology, except sinus tachycardia shown in the electrocardiogram. The densitometry showed severe osteoporosis of the lumbar spine (T-score L1-L4: − 5.6), osteoporosis of the proximal femur (T-score Neck: − 5.4). The laboratory data is presented in Table .
+: a consanguineous marriage of grandparents (cousins) from the father’s side, type 2 diabetes (father and grandmother from the father’s side), breast cancer (father’s sister), acute myocardial infarction (2 father’s brothers), arterial hypertension (2 father’s brothers), bicornuate uterus and endometriosis (sister), Crohn’s disease (cousin from the father’s side), arterial hypertension and obesity (mother), death in early childhood from the unknown reason (mother’s brother and sister). The patient reported that the grandmother from the father’s side had a short stature.
+The patient received insulin therapy (insulin glargine 20 U/day, insulin glulisine 40 U/day), nephroprotective therapy (enalapril 2.5 mg/day), bisoprolol 5 mg/day for tachycardia, antihyperuricemic therapy (allopurinol 150 mg/day), the native form of vitamin D, alfacalcidol and calcium for osteoporosis. The patient also receives symptomatic therapy for gastrointestinal pathology and nutritional therapy.
+Based on typical clinical signs of generalized lipodystrophy (total lipoatrophy, muscular hypertrophy, phlebomegaly, acromegaloid features, hypertriglyceridemia, hepatosplenomegaly, steatohepatitis) and early onset of the disease, CGL was suspected. Taking into account muscular pathology, CGL type 4 appeared probable. Due to the variety of clinical features of different types of lipodystrophy syndromes and progeroid syndromes sequencing of 18 lipodystrophy candidate genes (AGPAT2, BSCL2, CAV1, CAVIN1, PSMB8, LMNA, PPARG, PLIN1, AKT2, CIDEC, LIPE, LMNB2, PIK3CA, PPP1R3A, POLD1, WRN, ZMPSTE24, BANF1) using a custom Ion Ampliseq panel and Personal Genome Machine (ThermoFisher Scientific, Waltham, MA, USA) semiconductor sequencer (Ion Torrent) was performed. A novel pathogenic homozygous variant c.631G < T: p.E211X was detected in the CAVIN1 gene , confirming the diagnosis of CGL type 4.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1201_en.txt

@@ -0,0 +1,4 @@
+Our patient, a 64-year-old woman who was a non-smoker with a background history of epilepsy, presented to our respiratory clinic in May 2008 with a six-month history of productive cough with whitish sputum associated with three episodes of hemoptysis. She had no constitutional symptoms. At a primary care clinic a diagnosis of tuberculosis (TB) was considered, but the results of a Mantoux test were negative and findings from the three sputum acid-fast bacilli samples and cultures for TB were also negative. Her symptoms were persistent despite a few courses with oral antibiotics such as oral amoxicillin, azithromycin and moxifloxacin. On examination, our patient was emaciated (body mass index of 19.3 kg/m2), hemodynamically stable, apyretic, eupneic and with peripheral oxygen saturation (SpO2) of 98% (FiO2 21%). She did not have clubbed fingers, palpable cervical lymph nodes or oral thrush.
+A bacillus Calmette-Guérin (BCG) scar was present. Her jugular venous pressure was not elevated, and her apex beat was not displaced. An examination of her respiratory system revealed reduced breath sounds at the bases. Based on our patient's history and the physical examination, the differential diagnoses were bronchogenic carcinoma, pulmonary tuberculosis and bronchiectasis.
+The results of initial investigations showed a normocytic normochromic anemia (hemoglobin level of 10.3 g/dL) with normal white cell and platelet counts. Her inflammatory markers were raised: her CRP was 3.24 mmol/L and ESR was 66 mm/hour. Other blood investigations were normal. An initial chest radiograph showed bilateral pleural effusion with bibasal consolidation . A thoracocentesis procedure was not performed as the pleural effusion looked minimal. Subsequently, bronchoscopy was performed, showing an edematous and white coated bronchial tree mucosa; the right lower lobe mucosa had an infiltrate appearance. The mycological bronchoalveolar lavage culture tested positive for Aspergillus niger. The mycobacterial cultures tested negative. Unfortunately, a transbronchial biopsy was not performed in the same setting.
+Fulfilling the proposed diagnostic criteria by Soubani et al. , a diagnosis of chronic necrotizing pulmonary aspergillosis was made based on the subacute presentation of six months' duration and microbiological culture that grew A. niger. Our patient was discharged with itraconazole 200 mg (syrup) to be taken once daily for an estimated duration of six months. The syrup form was chosen instead of the capsule form for better absorption. After two months of treatment, clinical and radiological improvements were noted on follow-up tests. The itraconazole syrup was continued, aiming for a minimum treatment duration of six months.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1206_en.txt

@@ -0,0 +1 @@
+A 48-year-old female, with height of 160 cm and weight of 55 kg, was found to have a left lower lobe nodule in the lung and was scheduled for thoracoscopic wedge resection of the left lower lobe. The anesthesia was induced with 0.04 mg/kg of midazolam, 0.6 μg/kg of sufentanil, 2 mg/kg of propofol and 0.6 mg/kg of rocuronium. Then, a left 35 Fr endobronchial tube (Covidien llc, USA) was successfully intubated at a depth of 28 cm to incisors. Fiberoptic bronchoscopy was used to confirm that there was no problem with the location of the tube after the posture of the patient was changed to the right lateral decubitus position. Anesthesia was maintained with sevoflurane 1.5 vol%, oxygen 2 L/min, remifentanil 250 mcg/hr., 4 mg/kg/h of propofol. The intraoperative pathological diagnosis of the excised mass was invasive adenocarcinoma. Subsequently, the patient underwent VATS combined with left lower lobectomy. The operation time was 1.5 h and the patient was transferred to post-anesthesia care unit (PACU) for decannulation. The patient recovered consciousness from anesthesia after 30 min, exhibiting effective spontaneous ventilation and meeting extubation criteria. Unpredictably, the tracheal tube seemed to be mechanically constrained and we were unable to withdraw the endotracheal tube (ETT). We had to administer propofol and remifentanil intravenously for sedation and checked the airway with a fiberoptic bronchoscope, which revealed that the surgical suture of the bronchial membrane was inserted into the distal end of the left branch of the tracheal tube . Thereafter, we held detailed consultations with respiratory physicians and thoracic surgeons. The thoracic surgeon assured that breaking the suture will not cause adverse effects on the patient. It took only 1 s for the respiratory doctor to burn the sutures using an argon electrode (ERBE 20132–177) with the aid of fiberoptic bronchoscope. The mode of the argon electrode was strong electrocoagulation and the power was 35 W. Finally, the bronchial tube was pulled out smoothly and the patient was safely sent back to the ward after CT review, which showed no abnormalities. On the 1, 3, and 7 days after the operation, we followed-up the patient, and there were no related complications such as bronchial leak or bronchial rupture.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_121_en.txt

@@ -0,0 +1,9 @@
+A 38-year-old man presented with decreased vision in both eyes for 2 years. The patient had undergone ICL (ICL V4 Visian, STAAR Surgical Co., Monrovia, California, U.S.A.) implantation in both eyes 6 years prior. Postoperatively, the uncorrected distance visual acuity (UDVA) of both eyes was 20/32. The corrected distance visual acuity (CDVA) was similar to the UDVA.
+On examination, ICLs were in situ with anterior subcapsular cataracts in both eyes . Both eyes underwent anterior segment optical coherence tomography (AS-OCT; CASIA SS-1000, Tomey Corp., Nagoya, Japan) imagining in the model of 3D. Then the ICL vault was manually measured from the back surface of the ICL to the front surface of crystalline lens, centered on the optic axis (shown as a white beam). The vault was shallow in the right eye and measured 72 μm through AS-OCT images. However, in the left eye, the ICL touched the anterior capsule, existing “0” vault . The endothelial cell density, calculated by the noncontact autofocus specular microscope (EM-3000, Tomey Corp., Nagoya, Japan), was 2587 cells/millimeter squared (mm2) in the right eye and 2531 cells/mm2 in the left eye.
+The patient had planned explantation of the ICL with FLACS after obtaining written informed consent. Considering the unsatisfactory CDVA of the patient after ICL implantation, the surgeon suggested a monovision design for the patient with the implantation of monofocal IOLs rather than multifocal IOLs. And the LenSx laser system (LenSx Laser, Alcon Laboratories, Inc., Fort Worth, Texas, U.S.A.) was used for capsulotomy (5.1 mm diameter, 8 μJ energy) and chop nuclear pre-fragmentation (5.0 mm diameter, 6 chops, 8 μJ energy).
+The surgery was performed first in the left “0” vault eye. Cavitation bubbles were trapped in the shallow space beneath the ICL around the capsulotomy area during the capsulotomy, developing from small bubbles into big ones . No additional cavitation bubbles appeared during nuclear pre-fragmentation.
+Then, a 2.0 mm primary superior corneal incision was made with a keratome at 135 degrees (°). The sodium hyaluronate 1.7% ophthalmic viscosurgical device (OVD, Amvisc Plus, Bausch & Lomb, Inc.) was injected into the anterior chamber. At first, we attempted to remove the ICL directly without rotating it but failed with the rupture of the ICL. Next, we carefully rotated the ICL. After its vertical angle faced the incision, the ICL was grasped with forceps and extracted through the corneal incision. After the removal of the ICL, the capsulotomy was found to be incomplete between the coordinates of nine o’clock and two o’clock. A second capsulorhexis according to the laser tracks was safely made . The nuclear pre-fragmentation was unsuccessful and could not be tracked.
+The phacoemulsification was manipulated in a standard stop-and-chop manner with the Stellaris system (Bausch & Lomb Laboratories, Rochester, New York, U.S.A.), followed by the implantation of the hydrophobic IOL (Tecnis ZCB00, Abbott Medical Optics Inc., Santa Ana, CA) in the capsular bag.
+The surgery was performed on the right eye one and a half months later. Learning from the experience of the left eye surgery, we made a 3.0 mm temporal corneal incision in the right eye, and the ICL was extracted smoothly without rotation. This time, the capsulotomy was complete. Lots of small cavitation bubbles appeared, dispersing to the central area, and no big bubbles formed . The nuclear pre-fragmentation, however, failed again. Other steps of the surgery were the same as in the previous surgery and proceeded uneventfully. Both IOLs were well centered in the capsular bag at the end of the surgery.
+However, it is worth noting that during the process of laser identification, the anterior ICL surface was accidently confused with the anterior capsule, not only in the shallow vaulted right eye, but also in the “0” vaulted left eye. Manual adjustment by the surgeon was needed to assign treatment zones to the anterior capsule surface in both eyes .
+The patient was instructed to apply topical dexamethasone tobramycin for 2 weeks and pranoprofen for 1 month postoperatively. At the two-week follow-up for the right eye (two-month follow-up for the left eye), in both eyes, the UDVA was 20/32, and the near uncorrected visual acuity (UCVA) was 20/25.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1241_en.txt

@@ -0,0 +1 @@
+A healthy 13 month-old boy was receiving oral propranolol hydrochloride for a large IH. There was no history of hypoglycemia or other medications. The initial dose of propranolol hydrochloride was 0,5 mg/kg/day and over several weeks was titrated to 1mg/kg/d. He received the treatment for about 9 months and had a significant reduction in the size of IH. The night prior to hospitalization, the child looked tired, drowsy and had a very poor oral intake. Due to his sleepiness, he didn’t receive the evening dose of propranolol. With the child's poor feeding, it was important to skip the propranolol dose and hold it temporarily. Since his mother had no clear information about the importance of taking propranolol with food, as well as when to stop temporarily the propranolol, she gave him the missed dose during the night, without food (about six hours before hospital admission). In the morning the child was unresponsive, unarousable, with a grey pallor. The clinical situation was critical: in a deep coma, with a severe hypothermia (34°C), cold sweats, slow heart beats (60-65 beats/minute) and a low blood pressure (85/46 mmHg). After immediate suspicion, we confirmed a severe hypoglycemia (26 mg/dl). After confirming the hypoglycemia, we asked about the presence of any medication at home, in order to exclude the possibility of a drug poisoning. The mother didn’t inform us at the first moment that the child was taking propranolol for IH. No advices were given to the parents about adverse effects of propranolol and how recognizing signs of its serious adverse effects (including hypotension, bradycardia, wheezing, and hypoglycemia). The child was given initially 30 ml of 10% dextrose solution intravenously, which resulted in stabilization of his glucose level. We continued the treatment with 7.5% dextrose for a few hours after. Clinical condition was completely normalized.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1258_en.txt

@@ -0,0 +1,8 @@
+A 4-year-old female was hospitalized in the Republican Center of Pediatric Surgery (Minsk, Belarus) in 2017 with the signs of chronic GI bleeding, iron deficiency anemia, episodes of melena, and a rapid deterioration in her general condition.
+During the first year of observation in our clinic, the child underwent seven procedures of blood transfusions due to low hemoglobin levels before the first sclerotherapy was performed.
+The patient’s birth (per via naturalis) had resulted from the mother’s first pregnancy, which was also full-term. Her birth weight was 3760 g and length was 51 cm. The patient’s mother noticed a roundish dark blue, soft-elastic formation on the skin of the child’s thigh at 8 d after the birth. A few months later, new formations appeared on the skin of the child’s head (at the border of the forehead and parietal ridge) and lumbar, perianal and plantar areas.
+Anamnesis vitae yielded report of venous malformations involving the gluteo-femoral region, which had been partly excised at the age of 3 mo. Several complaints of melena were also disclosed. In addition, the parents reported that, at the age of 2 years, the child had developed periodic lethargy, drowsiness, and pallor of the skin; clinical assessment at that time yielded the first detection of a significant decrease in hemoglobin levels. Thus, iron supplements were prescribed. Several other episodes of a critical decrease in hemoglobin reportedly occurred over the next few years, all of which required a blood transfusion.
+The patient has no family history of BRBNS.
+The patient’s skin showed an overall paleness and several vascular skin lesions were found in the lumbar region, the inner part of the left thigh, the lower leg, the forearm , and on the sole of the right foot. The formations were of various sizes but all had a soft, elastic-like consistency and showed a cyanotic coloration.
+The patient’s blood parameters were low, with hemoglobin of 95 g/L (normal range: 110-140 g/L), mean corpuscular hemoglobin concentration of 32.8 (normal range: 31.9-35.6 g/dL), erythrocytes of 4.4 × 1012/L (normal range: 3.9-5.3 × 1012/L), and hematocrit of 29% (normal range: 34%-40%).
+Ultrasound showed vascular malformations in the left lobe of the liver, pancreas, bladder, and left ovary. Magnetic resonance imaging of the soft tissues of the lower extremities showed vascular malformations in the upper third of the left thigh. Although gastroscopy and colonoscopy were unsuccessful in detecting the source of GI bleeding, capsule enteroscopy revealed multiple (-10) vascular formations in the wall of the small intestine . All formations appeared round in shape and bluish-purple in color; the largest reached 2 cm in diameter.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1263_en.txt

@@ -0,0 +1 @@
+A 43-year-old African American woman presented with a painful cystic mass on the left labia majora. Preoperatively, the lesion was diagnosed as Bartholin's abscess. During the excision and drainage, an additional 2.0 × 0.8 × 0.8 cm tan-brown dermal nodule was identified and submitted for histological analysis. Microscopic examination revealed multiple pieces of fibro-necrotic tissues associated with a well-circumscribed papillary neoplasm with cystic dilation . The papillary projections and cystic areas were lined by basophilic cuboidal to columnar cells with outer compressed myoepithelial cells . There were foci of active decapitation secretion and apocrine differentiation . The diagnosis of Bartholin's abscess arising in hidradenoma papilliferum was made.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1288_en.txt

@@ -0,0 +1 @@
+A 49-year-old man was referred to our hospital with a diagnosis of advanced right kidney cancer. He had visited the former doctor because of asymptomatic gross hematuria. Urine cytology was negative. Enhanced CT revealed a large right kidney tumor exceeding 20 cm in diameter, which was surrounded by abnormal neovascularization, and was pushing the liver and intestines to the left . On chest CT, multiple lung nodules were observed , which the diagnostic radiology team at our hospital diagnosed as multiple metastases. Therefore, a clinical diagnosis of cT3aN0M1 mRCC was made. A percutaneous needle biopsy provided us the pathological diagnosis of clear cell RCC . Among six International Metastatic RCC Database Consortium (IMDC) risk factors, time from diagnosis to treatment was applicable while other five factors were not; Karnofsky performance status was 90% and hemoglobin, neutrophils, platelets, and corrected calcium level were within the normal range. We considered systemic therapy as suitable for this patient, because immediate CN for this huge primary tumor and total metastasectomy for multiple lung tumors seemed too invasive. In addition, since IO-TKI combination was thought to be better suited for achieving remarkable tumor reduction than IO-IO, lenvatinib plus pembrolizumab combination therapy was administered as the first line of treatment. Starting dose of lenvatinib and pembrolizumab was 14 and 400 mg, respectively. During systemic therapy, the starting dose was maintained and no severe adverse event was observed, although the patient had grade 2 hypertension, grade 2 hand–foot syndrome, grade 1 diarrhea and grade 1 elevated transaminase levels. Nine weeks after administration of the combination therapy, the lung metastases disappeared, and the primary tumor and surrounding neovascularization shrank remarkably as revealed by the CT scan. An additional 10 weeks of treatment maintained the complete remission of the lung metastases and resulted in further shrinkage of the primary tumor to 13 cm in diameter , leading to a decision to perform DCN by a robot-assisted laparoscopic procedure. Twenty-three weeks after the treatment initiation (final administration of pembrolizumab in 19th week, and cessation of lenvatinib on pre-operative day 8), robot-assisted radical nephrectomy was successfully performed . The operative time was 219 min, and the console time was 146 min. The estimated blood loss was 330 mL without blood transfusion. No major surgical complication was observed. Histopathological analysis revealed ypT3a grade 2 clear cell RCC without sarcomatoid feature, and the surgical margin was negative. More than half of the specimen demonstrated coagulative necrosis, and viable cancer cells were observed in approximately 30% of the specimen. Dense lymphocyte infiltration was observed in juxtaposed necrosis and viable tumor tissue, suggesting an immune response activated by IO therapy . Immunohistochemistry confirmed CD4 and CD8 staining of these infiltrated lymphocytes . Surgical CR was achieved in this patient, and he is now in a treatment-free state.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1314_en.txt

@@ -0,0 +1,6 @@
+A 60 years-old man was referred to our department due to painless gross hematuria. The patient had no risk factors including smoking, previous radiation therapy, occupational risk factors or hereditary factors. In addition, no other pre-existing conditions were known. The patient was painless and did not have any B-symptoms including weight loss or night sweats, furthermore, no neurological deficits were reported.
+After exclusion of urinary infection as cause for hematuria, cystoscopy has been performed revealing a 6 cm solid tumor on the right bladder wall. Urinary cytology (voided urine and bladder washing) remained negative.
+Consequently, a transurethral resection of the tumor has been performed and the tumor was macroscopically totally removed. Primary histology of the tumor specimen showed a muscle invasive small cell neuroendocrine carcinoma pT2a GIII. Moreover, tumor cells were positive for synaptophysin and AE1/AE3, with a high proliferation rate (KI-67) of 95 % on immunohistochemical analysis . In contrast, chromogranin A, CD56, CD3, CD20, TdT, S-100 and HMB45 confirmed negative staining.
+18 FDG-positron emission tomography/computed tomography (PET/CT) performed at the time of primary diagnosis did not show any lymph node or visceral metastatic tumor spread. A subsequent cranial magnet resonance tomography (MRT) also confirmed no tumor infiltration into the brain.
+As there are reports of increased survival rates upon neoadjuvant chemotherapy in patients suffering from SCBC , the patient underwent four cycles (day 1–3; 1 cycle = 21 days) of cisplatin (25 mg/m2)/etoposide (100 mg/m2) without any complications. In addition, we performed a prophylactic WBRT with a total dose of 26 Gray. Subsequently, the patient underwent radical cystoprostatectomy and ileal neobladder with bilateral extended pelvic lymphadenectomy (including 32 resected tumor-free lymph nodes). Final pathology confirmed complete response to neoadjuvant chemotherapy, with no vital small cell carcinoma tissue formations in both the lymph nodes and the cystoprostatectomy specimen (ypT0, N0, L0, V0, Pn0). An uneventful intra- and postoperative course was observed. The time from transurethral resection to chemotherapy start was 28 days. 34 days after chemotherapy was stopped, radical cystoprostatectomy has been performed.
+Currently, the patient undergoes 6-monthly regular follow-up controls including urinary cytology (voided urine), measurement of residual urine, blood gas analysis and imaging studies (chest/abdominal CT scan every second visit or chest radiography in combination with abdominal ultrasound). We noticed no evidence for relapse, even 33 months after initial diagnosis of SCBC.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1315_en.txt

@@ -0,0 +1,2 @@
+A 49-year-old woman with a 1-month history of dyspnea was admitted to our hospital. Her medical history included hypertension, hyperlipidemia, and uterine fibroids. Chest computed tomography (CT) and echocardiography revealed a large epicardial effusion (A). The patient underwent pericardiocentesis to remove 1.2 L of hemorrhagic pericardial fluid. Cytology of the fluid was negative for malignant cells. Contrast-enhanced CT after pericardiocentesis showed a tumor measuring 24 × 33 mm in the right atrium (B). Following pericardiocentesis, the patient's symptoms were alleviated, and she was discharged. Two weeks later, transthoracic echocardiography and cardiac magnetic resonance imaging (MRI) showed progression of the epicardial effusion. Since there were no severe symptoms, we did not intervene. MRI showed a 25 × 28-mm mass in the right atrium exhibiting high signal intensity on T2-weighted images (C). Blood test results for tumor markers were negative. Coronary artery angiography revealed a feeding artery from the sinus node branch to the tumor. We investigated for embolization of the feeding artery, although we could not find any previous report of such embolization treatment of the feeding artery in the case of a cardiac tumor. These examinations were insufficient to make a definitive diagnosis. However, the tumor was resected to alleviate the persistent tamponade.
+Preoperative transesophageal echocardiography, performed under general anesthesia, showed a mass measuring 28 × 41 mm originating from the free wall of the right atrium. It was not adherent to the tricuspid valve or septum and was thus resectable. Upon pericardiotomy, the tumor was visualized in the right atrium, adherent to the pericardium. The tumor was highly vascularized and had rough borders . Cardiopulmonary bypass was established between the ascending aorta and superior vena cava. A venous cannula was subsequently inserted into the right femoral artery, through the inferior vena cava, and into the front of the right atrium so as not to interfere with the tumor. We made an incision on the right atrium near the tumor and observed the presence of endocardium on the smooth surface of the mass. We biopsied a part of the tumor surface to obtain an intraoperative frozen section, which revealed the presence of a sarcoma. The tumor and adherent right atrial wall were removed with adequate margins to the greatest extent possible. The resected right atrial wall was reconstructed using a bovine pericardial patch. Pathological examination of the resected tumor revealed fusiform tumor cells in frequent mitosis and a rich blood supply with intraluminal red blood cells. Immunological staining was positive for CD34 expression . A pathological diagnosis of angiosarcoma was made; the resected end of the superior vena cava was tumor-free. The patient was discharged on postoperative day 12. Postoperative CT and echocardiography showed no residual tumor, while positron emission tomography revealed normal findings. Two months later, the patient received radiotherapy (heavy ion therapy) to the right atrium for a month at a dose of 64 Gy in 16 Fr. There was no local recurrence 6 months after surgery. However, metastasis to the lungs was identified. Although the patient received chemotherapy (paclitaxel and cisplatin), lung and liver metastases progressed . Unfortunately, the patient died of multiorgan failure due to multiple metastases 17 and 18 months after surgery and diagnosis, respectively.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1325_en.txt

@@ -0,0 +1,7 @@
+An 84-year-old man with primary open-angle glaucoma (POAG) developed decompensated IOP in the right eye. Since 2003, his topical regimen has included tafluprost (15 ug/mL once daily), brinzolamide, and timolol (in combination, twice daily) and, during the last year, oral acetazolamide (250 mg twice daily) was added to the topical treatment. The preoperative best-corrected visual acuity (BCVA) was 6/10 in the right eye and 4/10 in the left eye (Snellen chart). The slit-lamp examination of the anterior segment revealed transparent cornea, normal anterior chamber, and nuclear lens opacity in both eyes with no other notable findings. The preoperative IOP was 24 and 20 mmHg in the right and the left eyes, respectively. On fundus examination, both eyes showed a large cup-to-disc ratio (CDR = 0.9) and neuroretinal rim narrowing in all the disc sectors. Despite the maximally tolerated medical therapy (both oral and topical), a noticeable bilateral visual field progression, most evident in the right eye, was confirmed in June 2020 .
+Considering the patient’s demographic and ocular characteristics and ideal IOP target, XEN45 implantation was selected as the most suitable glaucoma filtering surgery. In July 2020, XEN45 implantation with a subconjunctival injection of mitomycin C (0.2 mg/mL) was performed in the right eye. No intraoperative complications occurred. The day after surgery, the IOP was 10 mmHg, the filtration bleb appearance was excessively diffuse, and the anterior chamber was flat. Nasal and temporal CDs were visible on fundus examination, and their serous nature was confirmed by eco-B scan .
+To counter possible inflammation and complications due to surgery and hypotony, topical dexamethasone (2 mg/mL, three times a day), atropine 1% (once a day), and oral prednisone (50 mg) were added to the routine postoperative antibiotic–corticosteroid combination. The patient was examined every week and showed a gradual improvement; after one month, the prednisone was gradually tapered, the IOP was 13 mmHg, and the CD completely resolved.
+In March 2021, the left eye (similar to the fellow eye) underwent an uneventful ab interno XEN45 device implantation. The day after surgery, the IOP was 7 mmHg, the bleb morphology was diffuse, and the anterior chamber was deep. Seven days later, similar to the right eye, nasal and temporal CDs were observed on fundus examination and confirmed as serous CDs on eco-B scan .
+The same topical and systemic therapies based on corticosteroids and cycloplegics were prescribed. However, due to persistent left CDs, surgical transscleral drainage was performed 2 months later to restore normal anatomy and avoid vision loss. After surgery, the IOP of the left eye stabilized between 10 and 12 mmHg, and the CD resolved permanently. On the slit lamp, the bleb appeared diffuse and normally vascularized, the anterior chamber was deep, and the gonioscopy evaluation showed a well-positioned XEN45 device in both eyes. BCVA in the left and right eye was affected by a dense subcapsular and nuclear lens opacity, so the best visual acuity could not be accurately assessed.
+In April 2022, phacoemulsification and intraocular lens (IOL) implantation were performed in the right eye after the risks and benefits of further surgery were discussed with the patient. During surgery, immediately after the capsulotomy, the lens material was aspirated through the hole with a small (30 gauge) needle to avoid the rupture of the capsulae due to swelling of the lens material. Then, capsulodesis and hydrodissection were performed, and phacoemulsification was completed. One week later, the BCVA in the right eye was 10/10 (Snellen chart), and the IOP was 10 mmHg. With the addition of the spherical lens + 3.00, the patient could read the 1° De Wecker (DW). Amsler’s test was slightly positive because of the pre-existing degeneration of the retinal pigment epithelium, but hypotony maculopathy apparently did not affect vision clinically.
+The phacoemulsification and IOL implantation were performed in the left eye in November 2022 using the same cataract surgical approach. One week after surgery, the BCVA was 6/10 (Snellen chart) and with the spherical lens + 3.00, the patient could read the 2° DW. Amsler’s test was positive because of the perifoveal accumulation of lipofuscin, classifiable as age-related macular degeneration (AMD), which was already observed in 2018.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_132_en.txt

@@ -0,0 +1,7 @@
+A 56-year-old man presented with numbness and pain in both lower limbs for 2 wk and dysuria for 1 wk.
+Two weeks previously, the patient developed numbness and pain in both lower limbs with no obvious origin and dysuria for 1 wk. Gradually, the symptoms of both lower limbs extended upward to the root of the thigh and the hips. There was no fecal incontinence at that time. The patient was referred to a local hospital, where he tested positive for serum syphilis antibody, but enhanced lumbosacral magnetic resonance imaging (MRI) as well as brain MRI showed no obvious abnormalities. The patient was first considered to have neurosyphilis and received 2 d of anti-syphilis therapy (ceftriaxone 2 g b.i.d and dexamethasone 5 mg b.i.d, combined with long-acting penicillin 2.4 MU, intramuscular injection). However, the patient’s symptoms did not improve; thus, he came to our hospital to seek further diagnosis and treatment.
+The patient previously had TB, chest computed tomography (CT) found similar lesions 7 years ago, but the patient had no symptoms and no standardized treatment was added.
+The patient had no relevant personal history and denied a family history of TB or myelitis.
+The muscle strength of the patient’s bilateral lower limbs was graded as level 3 using the muscle strength grading scale (maximum score 5). The examination also revealed impaired pinprick sensation (bilateral) below the T10 dermatomes and hyporeflexia in both legs. The patient had a neurogenic bladder, and his temperature ranged between 37.5 and 38.8C since the disease onset. Other physical examination showed no abnormality.
+The patient’s results indicated positive serum syphilis and tuberculous serology [Toluidine red unheated serum test (TRUST) 1:8 and Treponema pallidum particle agglutination assay (TPPA)+, Mycobacterium tuberculosis specific T lymphocyte (T-SPOT)+, respectively]. The rapid HIV test and other blood tests revealed no obvious abnormalities. Lumbar puncture was performed, and the pressure was 185 mmH2O (June 4, 2020). CSF analysis revealed high WBC count (310 × 106/L) with lymphocytic predominance (90%), high protein level (159.2 mg/dL; normal range, 8–43 mg/dL), low glucose (0.99 mmol/L, normal range 2.2–3.9 mmol/L), and low chloride levels (118.3 mmol/L; normal range, 120–130 mmol/L). CSF TRUST and TPPA were also reactive with a titer of 1:1 for the TRUST. Subsequently, tuberculous-infected T cells indicated a positive T-SPOT result. For making a definitive diagnosis, mNGS was conducted and MTB DNA was detected in the CSF sample. Routine urine/fecal test and urinary ultrasound were normal.
+MRI of the thoracic cord showed multiple lesions along the cervicothoracic junction on T2-weighted imaging . Chest CT also showed patchy cord shadows in the apical posterior segment of the left upper lobe and the dorsal segment of the lower lobe . Re-examination of brain MRI did not reveal any abnormalities.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1346_en.txt

@@ -0,0 +1,2 @@
+A 32-year-old young man was transferred to the emergency department with sudden chest pain lasting for 80 min. He has had high blood pressure for 4 years but on no medication, and had a blood pressure of 174/113 mmHg and a pulse rate of 78 beats per minute. Electrocardiography showed ST-segment elevations in leads II, III, aVF, V3R, V4R, and V5R . Serum creatinine was 73 μmol/L, and serum troponin T was 7.97 ng/ml. Killip classification was class I. Aspirin 300 mg and ticagrelor 180 mg were chewed just before the coronary angiography (CAG) was performed, followed by a routine antithrombotic therapy of oral DAPT (aspirin 100 mg qd, ticagrelor 90 mg bid) lasting for 1 year. The treatment was approved by Hainan Hospital of PLA General Hospital ethics committee, and informed consent was signed. The CAG showed that the left circumflex (LCX) was completely occluded by a large amount of thrombus in the distal portion . A bolus of unfractionated heparin (11,250 IU) was administered intravenously. A Runthrough guidewire was advanced through the thrombus to the distal end of the occluded LCX. The distal end of a 2.5 mm × 15 mm Sprinter Legend balloon was cut off, leaving a metal marker at the tip. Then, the balloon was inserted over the Runthrough guidewire and through the stenotic section of the occluded coronary artery .
+A total of 300,000 units of urokinase, 15 ml physiological saline, and 5 ml iopromide were mixed, forming a 20-ml cocktail. Following this, 1 ml of the cocktail was bolus-injected through the cut balloon, which was repeated every 30 s . After injection, the mixture of contrast agents and thrombolytic agent retained in the distal end of the occluded lumen, exerted its thrombolytic effect while visualizing the occluded vessels during this process. After 7 min of ICART, the thrombus in the proximal segment disappeared, but the thrombus in the distal location still existed. An aspiration catheter was used for thrombus aspiration, but it was unable to pass through the lesion because of the tortuosity of the blood vessels. The occluded segment was dilated up to 5 atm with a 2 mm × 20 mm Sprinter Legend compliant balloon at the distal portion of the LCX. Blood flow improved to TIMI grade 2. Diltiazem 200 μg was given through the intracoronary artery. The blood flow in the coronary artery was restored to TIMI grade 3 . The chest pain was completely relieved, and the ST-segment elevation was resolved . Intravenous infusion of tirofiban was maintained for 36 h after PCI. Oral administration of aspirin (100 mg/day), ticagrelor (180 mg/day), rosuvastatin (10 mg/day), bisoprolol (5 mg/day), nicorandil (15 mg/day), and perindopril (2 mg/day) was continued. Low molecular-weight heparin was administered subcutaneously after stopping tirofiban. No significant bleeding complications occurred after ICART. The patient was discharged 10 days after ICART. At a follow-up time of 1 year, there was no recurrent myocardial infarction, re-hospitalization, or death happened.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1354_en.txt

@@ -0,0 +1,6 @@
+A 54-year-old Caucasian woman with open angle glaucoma and a history of suboptimal medical therapeutic compliance owing to an intolerance to drops was referred to our Ophthalmology Department. She was severely obese (body mass index 37 kg/m2) and had type 2 diabetes but was using insulin with good metabolic control. Her best corrected visual acuity (BCVA) in both eyes was 1.0. Her IOP was 35 mmHg without the use of medication, though she achieved values of 18 mmHg in her right eye and 16 mmHg in her left eye with the use of tafluprost once daily. No changes were identified in an examination of her anterior segment. The papillary cup was 0.3 in her right eye with a temporal notch and her left eye had a normal appearance.
+Our patient’s compliance to medical therapy continued to be poor, because she blamed her drops for coughing and dyspnea attacks. Without the use of drops, her IOP values remained consistently in the 30s. After continuous non-compliance with several other ocular medications, surgery was discussed as an alternative treatment option. The risks and potential complications of surgery were explained to our patient. No signs of cornea or ocular media opacity, retinal hemorrhage, macular or peripheral detachments, or other contraindications were observed in either eye. Our patient decided to opt for surgery. Her right eye was operated on first with an uneventful mitomycin C trabeculectomy (0.3 mg/ml, 3 minutes).
+On the first postoperative day, our patient presented with a diffuse, functioning, and non-leaking filtration bleb, associated with a well-formed anterior chamber, and an IOP of 8 mmHg, with a normal appearance on fundoscopy. Two weeks postoperatively she complained of decreased visual acuity; her BCVA was 20/32 and her IOP was 10 mmHg without medication. Fundoscopy exhibited multiple superficial, flame-shaped retinal hemorrhages located centrifugally from the optic disc associated with optic disc edema . There was no evidence of choroidal effusion. A fundus examination of her left eye was unremarkable.
+Optical coherence tomography (OCT) revealed folding of the macular retina associated with a small detachment of the neurosensory retina . The angiographic pattern showed macular microaneurysms associated with fluorescein diffusion, peripapillary hemorrhages, and late optic disc leakage, without ischemic areas or neovascularization . One month later the overall fundoscopic changes resolved spontaneously . Given this situation, a suspected diagnosis of DR was proposed. Other possible diagnoses were retinal venous occlusion or Valsalva retinopathy, but these were considered unlikely given the diagnostic results pattern. Subsequent follow-up visits were satisfactory, with our patient maintaining a steady IOP of 8–14 mmHg without medication. The peripapillary hemorrhages and optic disc edema spontaneously recovered during the second postoperative month, and our patient’s BCVA reached 20/25.
+Three months later, she underwent an uncomplicated left eye trabeculectomy with mitomycin C (0.3 mg/ml, 3 minutes). No postoperative hypotony was registered. On the first postoperative day, the anterior chamber was formed, the bleb was diffuse, her IOP was 8 mmHg, and results from fundoscopy were normal, without choroidals. The pattern of clinical evolution of this eye was similar, with decreased vision complaints 10 days after surgery (her BCVA was 20/32). Her IOP was 9 mmHg, with no medication. A fundus examination revealed identifiable multiple peripapillary retinal hemorrhages, optic disc swelling, and macular edema . OCT revealed macular folding and neurosensory retinal detachment . Choroidal striation, optic disc leakage, and signs of macular microangiopathy and epitheliopathy were visible on angiography . The localized hemorrhages and sectorial optic disc edema reduced progressively and her macular edema recovered spontaneously during the first postoperative month . Her left eye IOP on the last follow-up visit was 16 mmHg without hypotensive medication and her BCVA was 20/25.
+Given the occurrence of the same pattern in the contralateral eye, our patient’s complete medical history was reviewed again, with inquiries about possible hypertensive peaks, usual medication, and frequent Valsalva maneuvers. A summary infectious test was performed to rule out any possible systemic causes of bilateral papillitis. Results for the infectious study were negative.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1359_en.txt

@@ -0,0 +1,3 @@
+A 68 year-old Asian woman was admitted to our hospital presenting with a two-day history of high grade fever, diarrhea and nausea. The patient's symptoms began one day after eating grilled chicken and beef at a restaurant; however, she did not complain of abdominal pain, vomiting, or hematochezia. The patient was diagnosed with diabetes mellitus at the age of 50, had undergone haemodialysis due to diabetic nephropathy for the past 2 years, and was under three times weekly haemodialysis. She had also undergone an aortic mechanical valve replacement operation for aortic stenosis 7 months prior to the current admission.
+Upon admission to our hospital, the patient's height was 149 cm and her body weight were 61.0 kg (dry weight). The patient's temperature was 106°F, blood pressure was 150/90 mmHg, heart rate was 152/min, and respiratory rate was 24/min. Cardiovascular examination revealed a Levine IV/VI systolic murmur at the right second intercostal space. Her bowel movements were slightly hypoactive and physical examination did not reveal any abdominal tenderness or rebound. No evidence of embolization including Osler node, Janeway lesion and petechiae was observed. No other abnormalities were noted on the systemic examination. Initial laboratory examinations revealed the following results: hemoglobin, 115 g/L [110-146 g/L]; total leukocyte counts, 10300/μL [3500-8200/μL] without left shift (Myelo 0.5%, Meta 0.5%, Stab 2.0%, Seg 90.0%, Lym 1.5%, Mono 5.5%); normal platelet counts, 1.42 × 103/μL [1.40-3.89 × 103/μL]; significantly elevated C-reactive protein, 18.54 mg/dL [<0.30 mg/dL]; Na 131 mEq/L, K 4.3 mEq/L, Cl 97 mEq/L, HCO3- 18.9 mmol/L; BUN 43.6 mg/dL, Cre 7.25 mg/dL (before haemodialysis); serum glucose, 173 mg/dL; and HbA1c, 7.3% [4.3-5.8%]. In addition, the patient was tested negative for HIV antibodies.
+Salmonella enteritis or campylobacter enteritis was suspected due to the history of eating grilled chicken. Treatment was initiated with ciprofloxacin 300 mg q24hr, ceftriaxone 2 g q24hr, and clindamycin 600 mg q12hr intravenously, started on day of admission. Three days post-admission, a serial blood culture taken on admission revealed Salmonella enterica serotype Enteritidis (O9, H-g) that was sensitive to ceftriaxone (MIC <= 1) and ciprofloxacin (MIC <= 0.25) . After detection of the causable microorganism, ceftriaxone and clindamycin treatment was ceased, and the patient was treated with ciprofloxacin alone. Since the patient's aortic valve was a prosthetic, and Salmonella species have a high affinity for intravascular intima, there was a concern about prosthetic infective endocarditis. Therefore, the patient underwent transthoracic echocardiography (TTE) on day 7; however, no abnormalities were detected by TTE. On day 9, the patient showed a sudden disturbance in mental status, left conjugate deviation, and right hemiplegia. Diffusion-weighted imaging of the brain via MRI showed an acute cerebral infarction of the middle cerebral artery region . Following this discovery, the TTE was re-examined, followed by a transesophageal echocardiography (TEE) on day 13. The TEE revealed floppy vegetation on the mitral valve, which was 12 × 8 mm in size . We could not find any aberrance of the replaced aortic valve. Although surgery to remove the vegetation was considered, acute cerebral infarction contraindicated her from undergoing the operation. The ciprofloxacin dose was increased to 400 mg q24hr and was combined with ceftriaxone 2q q12hr, on day 12. Consequently, the patient was treated solely with ciprofloxacin for 8-day period (from day 4 to day 11). Although the patient's neurological deficit ameliorated gradually, she experienced another infarction at the left occipital lobe and the right cerebellar hemisphere on day 18. Conservative therapy with antibiotics was continued; however, her mental status progressively decreased and blood pressure deteriorated. Blood culture examinations were repeated, but they were all negative. haemodialysis ceased on day 35 due to the unstable haemodynamic status, although treatment with ciprofloxacin and ceftriaxone were continued. On day 39, the patient died of respiratory failure and cardiac arrest. Her clinical course is shown in figure . Autopsy revealed a rigid node on the mitral valve , associated with septic emboli (mass of gram-negative microorganisms) at the left occipital lobe .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1360_en.txt

@@ -0,0 +1,7 @@
+A 61-year-old male with a history of recurrent falls and a previous left proximal humerus ORIF procedure in January 2022 following a fall on December 26, 2021, presented to an external hospital in June 2023 after experiencing a ground-level fall. On arrival, the patient was unable to raise his left arm due to severe pain. He was promptly splinted and referred for a higher level of care. The patient underwent an evaluation 3 days later, and radiographs were taken, revealing a peri-implant fracture located below the previously implanted plate at the level of the proximal humerus .
+On clinical examination, the patient remained incapable of actively using his arm. However, he exhibited intact neurovascular function, showed no signs of infection, and displayed well-healed wound sites from the previous ORIF procedure. The patient’s pertinent medical history includes being HIV-positive, actively receiving antiretroviral therapy, former tobacco use, and reportedly abstaining from alcohol consumption for the past 2 years.
+The patient was thoroughly informed about the available treatment options, associated risks, and benefits. He expressed a preference for wide-awake local anesthesia surgery over non-operative management and GA. The patient desired surgery but wished to avoid hospital admission, thus opting for wide-awake local anesthesia to prevent the need for GA. The patient admittedly also wanted a more affordable surgery. The patient was consented and booked for surgery.
+Wide Awake Local Anesthesia Humerus Technique.
+The patient was positioned supine with their arm well-supported, and manipulation was avoided until the patient received adequate anesthetic. First, to manage pain, 15 mg of ketorolac was initially administered intramuscularly. Next, the surgical assistant prepared the local anesthetic solution by combining 25 mL of lidocaine with adrenaline and 10 ml of bicarbonate, diluting the mixture to 200 mL with normal saline. The solution was then gently administered systematically, with an initial entry point in the upper arm anteriorly, followed by circumferential injections around the upper arm, along the planned anterolateral incision line (taking into account any previous scars), and into deep subcutaneous tissues approximately 8–10 cm above and below the fracture site. The periosteum and bone around the fracture site and incision line were also adequately anesthetized. The surgeon waited for 20 min between the initial injection and the first incision to allow the local anesthetic sufficient time to take effect. During the initial incision, the patient was monitored by asking for feedback, and they reported not feeling the incision. The patient’s comfort and anesthesia adequacy were actively monitored throughout the procedure, with additional local anesthetic administered as needed.
+An incision was made through the patient’s previous scar. Meticulously, the soft-tissue envelope was exposed and retracted until the plate and fracture were adequately visualized. The previous plate and hardware were then removed, and the fracture was reduced using a new plate and screws. Since no intraoperative imaging is presently available at the hospital, the reduction and internal fixation were carried out solely under direct visualization, depending on the expertise of the surgeon.
+The incision was then closed, and the patient’s neurovascular status was assessed by having the patient flex and extend his elbow as well as his wrist and digits. The total duration of the procedure was 85 min though from incision to close was only 65 min accounting for the 20-min window for the anesthetic to take effect. The patient received appropriate care and instructions postoperatively, ensuring a successful and pain-free surgical experience. The patient followed up in the clinic 4 weeks later, having no issues with a well-healed wound . Radiographs were also obtained at that time . The patient was instructed to begin physical therapy at that time. The patient was seen in the clinic at 8 weeks and 12 weeks postoperatively and was once again found to have no issues, he was progressing appropriately with his physical therapy.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1367_en.txt

@@ -0,0 +1,5 @@
+A 19-year-old female Thai patient had been diagnosed with SJIA 10 years previously and had been developing progressive proteinuria for 1 year. Her initial manifestations of SJIA were quotidian fever, polyarthritis, and pericardial effusion. Although she received pulse methylprednisolone, high-dose prednisolone, and multiple disease-modifying anti-rheumatic drugs from her previous hospital (including methotrexate, sulfasalazine, and cyclosporine A), her disease activity remained mostly active. At the age of 13 years, she was referred to Ramathibodi Hospital for proper management by a pediatric rheumatologist. Her blood samples were negative for antinuclear antibody, anti-double-stranded DNA, and HLA-B27 with normal levels of C3 (1550 μg/mL; reference range, 900–1800 μg/mL) and C4 (551 μg/mL; reference range, 100–600 μg/mL). No underlying disease was found in her family members. During the first year of follow-up at Ramathibodi Hospital, the patient was treated with 25 mg/week of etanercept [an anti-tumor necrosis factor (TNF) agent], 25 mg/week of methotrexate, 2 g/day of sulfasalazine, and 5 mg/day of prednisolone. After 6 months of treatment with etanercept, she still had severe polyarthritis. Therefore, the etanercept was discontinued, and tocilizumab, a humanized anti-interleukin (IL)-6 receptor antibody, was started at that time. However, we could not use a standard dose of tocilizumab for SJIA (8 mg/kg every 2 weeks) in the early treatment period because of the patient’s socioeconomic situation. Therefore, she received tocilizumab at a dose of 8 mg/kg every 4 weeks. She partially responded to the tocilizumab; her IL-6 level slightly declined from 1105.0 to 574.2 pg/mL 5 months after starting the treatment. Her disease course still waxed and waned. Her arthritis relapsed while receiving the tocilizumab. Therefore, pulse methylprednisolone at 1 g/month, leflunomide at 20 mg/dose, and hydroxychloroquine at 200 mg/day were gradually added to the tocilizumab regimen. The rheumatologist noticed her first episode of albuminuria when her urine albumin dipstick result was 2+. This proteinuria showed evidence of progression at her 1-year follow-up, when her urinary protein-to-creatinine ratio (UPCR) exhibited deterioration from 0.87 to 3.00 (normal ratio, <0.2). A nephrologist was then consulted to diagnose the cause of the progressive proteinuria on the background of refractory SJIA.
+On physical examination, her vital signs were normal. She was cachectic (body weight, <3rd percentile) and had a short stature (height, <10th percentile). Her wrists, knees, and ankles were stiff and inflamed. There were no signs or symptoms of edema. Other physical findings were unremarkable. Her urinalysis showed an inactive sediment. Significant proteinuria was confirmed by a 24-h urine collection method, which showed a total urine protein of 1295 mg/day (1792 mg/1.73m2/day). Blood chemistry analysis showed hypoalbuminemia (2.68 g/dL), a normal serum cholesterol level (152 mg/dL), and a normal serum creatinine level (0.47 mg/dL). Infectious screenings were negative for hepatitis B, hepatitis C, and human immunodeficiency viral infection. Other diagnostic investigation results are listed in Table .
+The renal tissue contained eight nonsclerotic glomeruli. The glomeruli were unremarkable. The mesangium showed focal expansion without hypercellularity. Depositions of acellular eosinophilic amorphous material were seen in the glomerular hilum, mesangium, arteriolar wall, and interstitium . The material demonstrated fuchsinophilic staining, and Congo red staining was positive with apple green birefringence under polarized microscopy. Mild tubular atrophy and interstitial fibrosis were also seen. An immunofluorescence study was negative for IgG, IgM, IgA, C3, C1q, fibrinogen, kappa, and lambda. Electron microscopy revealed randomly oriented fibrils of 8 to 10 nm in diameter in the mesangium, interstitium, and arteries . The glomerular basement membrane was unremarkable, but the podocytes showed partial foot process effacement under electron microscopy. These biopsy findings confirmed renal amyloidosis.
+Because the amyloidosis was secondary to uncontrolled SJIA, the tocilizumab was increased from a dose of 8 mg/kg every 4 weeks to a dose of 8 mg/kg every 2 weeks. We also started enalapril at 5 mg/day (0.12 mg/kg/day) for an additional antiproteinuric effect. The other drugs were continued at their same dosages. Two months later, the patient’s Childhood Health Assessment Questionnaire Disability Index score decreased. Her UPCR had also decreased from 3.00 to 0.92, and her arthritis improved 3 months after the tocilizumab increment. At the 1-year follow-up, her UPCR had decreased to 0.23 and renal function remained stable, with a serum creatinine concentration of around 0.42 to 0.52 mg/dL. Her C-reactive protein concentration had returned to normal and her IL-6 concentration had slightly decreased. Other follow-up investigation results are listed in Table .
+A 3-mL venous blood sample was collected from the patient for DNA extraction. Next-generation sequencing was performed by SureSelect V5 using the Illumina HiSeq 4000 platform. Sanger sequencing was performed for variant verification. Variants of the MEFV gene (NM#000243, transcript ID: ENST00000219596) were analyzed. A heterozygous c.442G > C (pE148Q) mutation in the MEFV gene was identified.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1381_en.txt

@@ -0,0 +1,15 @@
+A 69-year-old lady presented to our hospital with a few days’ history of intermittent episodes of breathlessness, and reduced exercise tolerance to a few yards. On the morning of her admission, she described a brief episode of chest pain, which her family had thought was a panic attack.
+She had a background history of alcoholic liver disease with cirrhosis (Child-Pugh score A), portal hypertensive gastropathy, hiatus hernia, healed duodenal ulcer, and chronic anxiety. She was a current smoker of over 30 pack years and had been abstinent from alcohol for 3 years.
+On arrival, our patient was alert and oriented. Her observations showed a pulse rate of 127bpm, blood pressure (BP) of 166/78 mmHg, respiratory rate of 34, oxygen saturation of 86% on 5 L oxygen, and temperature of 36.3°C. Auscultation of her chest revealed bilateral wheeze, with normal heart sounds. She had cold peripheries with a prolonged capillary refill time and no peripheral oedema.
+Her first arterial blood gas (ABG) revealed acute decompensated type two respiratory failure (T2RF) . Given her background, she was treated initially as an infective exacerbation of likely underlying, undiagnosed COPD, and was started on antibiotics, nebulizers, and steroids.
+Within a couple of hours, she became increasingly agitated and subsequently less responsive. A repeat ABG revealed worsening T2RF and non-invasive ventilation (NIV) in the form of bi-level positive airway pressure was commenced.
+Chest X-ray revealed hyperinflation with upper lobe diversion , and her ECG showed ST elevation in the anterior leads . Blood tests revealed an elevated white cell count, troponin, brain natriuretic peptide, and D-dimer . She was reviewed by intensive care, and the working diagnosis was ST-elevation myocardial infarction with LV failure resulting in T2RF. ACS treatment with aspirin, clopidogrel, and fondaparinux was commenced, and urgent cardiology opinion was requested.
+Upon cardiology review, a bedside echocardiogram showed severe LV systolic dysfunction, with dyskinesis of the mid and apical septal and lateral walls, with preservation of basal function. The mid and apical segments of the RV free wall were dyskinetic with preservation of basal function. A possible diagnosis of BTC was proposed. However, based on the presence of Q waves across the chest leads on the ECG, and the fact that BTC is a diagnosis of exclusion, the differential diagnosis was that of a prior infarct with persistent ST elevation.
+A computed tomography pulmonary angiogram (CTPA) ruled out pulmonary embolism, and the patient was responding well to NIV, with a repeat ABG 3 hours after initiating NIV showing resolution of acidosis and hypercapnia, but persistent hypoxaemia .
+Her troponin increased to 2000 ng/L, and in view of the patient’s complex background and acute illness, she was managed in our intensive care department. She was deemed too unstable to undergo invasive coronary angiography.
+On her second day in hospital, she became hypotensive with a BP of around 90/60 mmHg. Repeat ECG showed resolution of Q waves, and a new right bundle branch block with deep T-wave inversion. Her troponin had further risen to 3000 ng/L. Repeat bedside echocardiogram remained consistent with BTC . The systolic pulmonary pressure (SPAP) was elevated at 47–52 mmHg, estimated from the moderate tricuspid regurgitation. Metaraminol and subsequently dobutamine and noradrenaline were commenced for BP support. Our local tertiary centre advised switching these to a levosimendan infusion for 24 hours, and intra-aortic balloon pump support was felt unnecessary. Our patient haemodynamically stabilised with improved BP and urine output.
+Over Days 4 and 5, following the cessation of levosimendan, our patient still required low dose inotropic support.
+On Day 6, our patient developed rate-controlled atrial fibrillation (AF) with ST elevation in V1-V4 with biphasic T waves, although, she remained free of chest pain . In spite of her new AF, repeat echocardiogram ( revealed complete recovery of the LV systolic function with no evidence of regional wall motion abnormality. Her right ventricle continued to show basal wall preservation of function and mid to apical RV dilatation and dyskinesis, and SPAP of 54 mmHg. Troponin level had further fallen to 329 ng/L. Supportive management continued.
+Over the next 48 hours, after clinical improvement, inotropic support was weaned. On Day 8, repeat echocardiography showed that in addition to the prior recovery of her LV function, her RV function had also fully recovered (, ). The previously documented SPAP remained >56 mmHg, which was interpreted as her baseline due to her COPD. Invasive coronary angiography confirmed no obstructive coronary artery disease , thus we could confirm that our patient had indeed suffered from BTC, as up until this point, we had been unable to rule out myocardial infarction. Her ECGs continued to show persistent anterior ST elevation with biphasic T-wave changes.
+Our patient continued to improve and was stepped down to the coronary care unit and was engaging well with inpatient rehabilitation. Unfortunately, on the morning of Day 15, she developed another episode of T2RF, possibly due to aspiration following a choking episode on breakfast. Focused echocardiography ruled out the recurrence of TC, and she responded swiftly to NIV, requiring less than 24 hours. She was transferred to the respiratory ward for ongoing management of her airway disease and discharged 2 weeks later.
+Co-incidentally, her thyroid function tests (TFT) on Day 6 showed raised T4 and undetectable thyroid-stimulating hormone level . After confirmation with repeated blood tests, the diagnosis of thyrotoxicosis was made. The endocrine review and subsequent thyroid-receptor antibody levels suggested autoimmune thyroiditis or Graves’ disease. At a later stage, carbimazole treatment was commenced and beta-blocker continued with regular endocrine follow-up. Our patient had a brief admission in September 2020 with mild shortness of breath. Repeat echocardiography showed normal biventricular systolic function, normal LV diastolic function and filling pressures and an SPAP of 40 mmHg.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1382_en.txt

@@ -0,0 +1 @@
+A 47-year-old female Asian with intermittent involuntary movements of the left upper limb was admitted to our facility. The limb shaking was coarse, rhythmic and flapping wing-like, accompanied by neck torsion while sparing the face and trunk (Supp2.Video.). The first episode occurred 14 h before admission when the patient had arisen from supine position, and another episode also occurred when a similar postural change occurred soon after admission. Both episodes lasted 2–3 min and stopped 20 s after the patient changed back to the supine position. The patient had no consciousness disturbances, urinary incontinence, dystonia posture or tongue biting during the attacks. The patient reported a nonremarkable personal history and had no history of epilepsy, stroke, hypertension and other cerebrovascular disease risk factors, together with no report of any major trauma, surgery or any other events in the previous 6 months. Physical examination showed no neurological deficits except mild weakness in her left limb (Medical Research Council scale: 4). The neuropsychological evaluation was normal. Cardiological evaluations, including echocardiography, electrocardiography and cardiac biochemical markers (pro-brain natriuretic peptide, creatine kinase MB isoenzyme, troponin T), were without apparent abnormalities. Video-electroencephalogram and diffusion-weighted imaging were performed immediately after admission with no remarkable findings, whereas time-of-flight imaging magnetic resonance angiography (TOF-MRA) revealed multiple irregular stenoses of the right ICA accompanied by multiple filling defects . On native source TOF-MRA images, a "dual lumen sign" with an intimal flap was detected in the right ICA . Spontaneous right ICA dissection was suspected. Before further investigation, statin therapy with dual antiplatelet therapy (hydroclopidogrel, 75 mg per day, combined with aspirin, 100 mg per day) was administered for three days with no recurrence of limb shaking. More examinations were performed afterwards. On contrast-enhanced magnetic resonance angiography (CE-MRA) and sagittal black-blood T1WI, an intravascular haematoma with irregular lumen stenosis was observed, which overall indicated right ICA dissection . The fact that TIA occurred in a relatively young female with no cerebrovascular risk factors led us to evaluate the cervical and cerebral vasculature more thoroughly and precisely. Thus, digital subtraction angiography (DSA) was performed. The DSA further confirmed the dissection because a "line-like" change was observed , while the renal artery was normal. Meanwhile, in the left ICA, we detected a “string-of-beads” appearance , which led to a suspicion of FMD. Although the ICA dissection related to the limb shaking TIA was not at the same site as the “string-of-beads” appearance, we still highly suspected that the ICA dissection was probably secondary to FMD. Sustained dual anti-platelet therapy was prescribed after discharge, and we suggested that she measure her blood pressure daily. Three months later, the patient returned to our department with no recurrence of limb shaking or neurological deficits. High-resolution magnetic resonance vessel wall imaging (HRMR-VWI) was performed to detect pathological changes in the vessel wall. The previous dissection in the right ICA had been mostly resolved, and only a few spotted intramural haematomas were left . Notably, a characteristic "string-of-beads” appearance was observed on the right ICA at this time . Considering the overall clinical data, the patient was diagnosed with limb shaking TIA due to ICA dissection with FMD.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1554_en.txt

@@ -0,0 +1,6 @@
+A 46-year-old Brahmin woman with a history of a hormone receptor-negative invasive ductal type of adenocarcinoma of her left breast (stage pT3N3aM0) presented with pain and blurring of vision of her right eye.
+Diagnosis of left-sided stage IIIc breast carcinoma was made 2 years ago when she developed pain in her left arm. She subsequently underwent a left-sided modified radical mastectomy. Postoperatively she started treatment with docetaxel 80 mg, adriamycin 60 mg, and cyclophosphamide 600 mg. After completion of six cycles of chemotherapy, external beam radiation of her thoracic wall was performed once a week for 8 weeks.
+Two years after initial diagnosis, she presented with temporal headache and pain on temporal aspect of her right eye. Visual acuity in her right eye was “counting fingers” close to face and 6/9 in her left eye. A slit lamp examination revealed a tender subconjunctival swelling with localized congestion in superotemporal aspect of her right eye underneath the upper eyelid . With this finding alone, an initial clinical diagnosis of anterior scleritis was made until posterior segment was examined. Her pupil was sluggishly reactive with no relative afferent pupillary defect (RAPD).
+Fundus evaluation under mydriasis revealed a shallow retinal detachment with underlying amelanotic subretinal mass, superotemporal to macula, causing retinal folds in macular area. A shallow serous inferior retinal detachment could be appreciated inferior to inferotemporal arcade . Intraocular pressures were normal in both her eyes (10 mm of Hg in right eye and 16 mm of Hg in left eye).
+Magnetic resonance imaging (MRI) orbit revealed a 2 × 1 cm subretinal mass in superior and temporal aspect of her right eye with enhancement after injection of contrast . The lesion was of high intensity in T2-weighted images. Brain imaging was normal.
+Following this, computed tomography (CT) of her chest was done which showed metastasis in both lungs, mediastinal lymphadenopathy, and right-sided pleural effusion .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1555_en.txt

@@ -0,0 +1,4 @@
+A 47-year-old male patient was admitted with esophagogastric hemorrhage secondary to portal hypertension derived from decompensated cirrhosis. At the initial consultation, his chief complaint was hematemesis and two episodes of melena. His past medical history was viral hepatitis B with HBsAg + and HBcAb + for more than 10 years, and his surgical history included splenectomy and periesophagogastric devascularization for portal hypertension, hypersplenism and splenomegaly, and cholecystectomy for gallstones one year before, at a different hospital. His vital signs were as follows: temperature, 36.7 °C; blood pressure, 120/68 mmHg; respiratory rate, 20; and heart rate, 84. He had scleral icterus in both eyes. Physical examination showed negative chest and cardiac findings. Tenderness and rebound pain was marked, and shift dullness was remarkable. His blood work results were as follows: white blood cell count, 16.6 × 109/l; red blood cell count, 2.47 × 1012/l; platelet cell count, 183 × 109/l; and hemoglobin, 67 g/l. Stool hemoccult test results were positive (+++). His liver function profile was as follows: total bilirubin, 84 μmol/l; ALT, 319; AST, 347; albumin, 32.3 g⁄l; C-reactive protein, 107 mg/l; alpha-fetoprotein, normal; carcinoembryonic antigen concentration test, normal; and amylase, unremarkable. The patient’s coagulopathy parameters were as follows: PT, 19.3 s; PT%, 43.6 %; fibrinogen, 1.4 g/l; APTT, 120.9 s; and TT, 21.3 s.
+Paracentesis fluid revealed serosanguinous ascites, and bacterial culture showed that no bacteria were present. Enhanced computerized tomography results showed hepatic nodular regeneration, moderate ascites, a dilated bowel, and emboli in the portal vein and the superior mesenteric vein that extended to the distal and tributary veins . Melena and hematemesis reoccurred after administering coagulants including thrombase and tranexamic acid, which were administered for a few days. The patient was moved to transplant surgery to await a donated liver.
+Two days later, the liver from a 35-year-old deceased male with ABO-compatibility was available, and liver transplantation and thrombectomy were planned. After entry into the abdominal cavity, approximately 2.5 l of ascites was removed using suction. The abdominal cavity was explored; the liver had several nodules, the spleen and gall bladder had been excised, complete occlusion of the portal vein and the superior mesenteric vein (Grade III-IV) was found, and two segments of the proximal jejunum were purplish-black in color. A short distal vein arcade was fully occluded, and there was intestinal necrosis with intestinal tone and no perforation . Ascites culture results were negative, which suggested that there was no bacterial translocation. Intra-operative ultrasound confirmed the permeability of the superior mesenteric artery, which had a palpable pulse. Further histology results showed nodular hyperplasia that excluded small cancer. Orthotopic LT was then performed using a piggy-back caval anastomosis, and portal vein eversion was then conducted to remove the thrombi in the portal and superior mesenteric veins. These veins were cavernous, with numerous small thrombi that were flushed out via blood flow. Portal venous blood flow was restored and confirmed intra-operatively using a Doppler ultrasonic flow meter (data not shown), and 25 units of plasma and packed red cells were transfused. Approximately 100 cm of gangrenous jejunum was subsequently resected from Treitz’s ligament, and an end-to-end anastomosis of the jejunum was performed to maintain intestinal continuity. The patient recovered fully, although a fistula occurred, which resolved upon draining.
+Medications such as the following were administered: immunosuppressive therapy to treat immune rejection, potent broad-spectrum antibiotics to treat potential infection, anti-coagulant agents to treat re-embolism, and lamivudine and immunoglobulin to prevent hepatitis B viral infection recurrence. The allograft functioned well, and ALT, AST and bilirubin levels decreased daily, while albumin levels increased. Thirteen days after OLT, a fistula occurred in the anastomosis, and laparoscopic surgery was performed again to allow suction and access to the abdominal cavity. A 4-cm mushroom-shaped tube was inserted into the near jejunum to allow drainage, and a feeding tube was also inserted into the distal intestine. After about 3 weeks, the patient was recovering well. Seventy months after surgery, the patient’s allograft was functioning well and his medical history has been uneventful.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1565_en.txt

@@ -0,0 +1,5 @@
+Fecal blood, diarrhea and thrombocytopenia over one year.
+A 1-year-old Chinese male patient with WAS was admitted for UCBT. He presented with fecal blood, diarrhea and thrombocytopenia at age 4 d, and was admitted to the West China Second University Hospital of Sichuan University. Admission to our hospital for hematopoietic stem cell transplantation.
+None.
+Nothing special.
+Complete blood count revealed that white blood cell (WBC) count was 13.64 × 109/L, hemoglobin 99 g/L, platelet count 7 × 109/L, and neutrophil count 3.53 × 109/L. Bone marrow (BM) aspiration revealed that the granulocyte/erythrocyte ratio was 0.7:1, thromocytogenic megakaryocyte 15/50, and platelets were deficient. WAS gene sequencing identified the mutation c.777 + 1G>A (IVS8).

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_158_en.txt

@@ -0,0 +1,5 @@
+A 29-year-old female patient was admitted to the Gynecology and Obstetrics department at a district Southern Governmental hospital for normal delivery. The patient was later scheduled for urgent caesarean section (CS) due to foetal distress. In the operating theatre she developed sudden cardiac arrest and a full cycle of CPR as per guidelines was immediately initiated. After 5 min of effective CPR her cardiac rhythm returned to sinus rhythm, and her haemodynamic state stabilised without further use of inotropic drug support. An intra-operative general surgical team consultation was sought, and a chest CT scan was performed. She was believed to be complicated with haemopneumothorax, for which a chest drain was inserted. A CS was performed, but unfortunately, the baby died after delivery.
+The patient was referred to the National Heart and Lung Institute at the university teaching hospital for further evaluation and management.
+The clinical data and results of the imaging studies were reviewed and discussed by a multidisciplinary team, and the diagnosis of left-sided diaphragmatic rupture with herniation of abdominal organs through a large defect into the chest cavity was confirmed .
+The patient was then prepared for urgent surgery and underwent subcostal open laparotomy, with intraoperative findings of a collapsed left lung, spleen, pancreas, dilated stomach, transverse colon and omentum that were displaced in the left hemithorax. Reduction of the contents was performed, and the diaphragmatic defect was repaired through primary closure with proline sutures. Lung expansion was then assisted by means of a bronchoscopy .
+The postoperative period was uneventful, with no complications, and the patient showed excellent improvement in her clinical condition and was discharged 7 days post-operatively. At –month follow-up at our outpatient clinic, the patient was in excellent clinical condition with no complaints, and a chest x-ray was completely normal .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1604_en.txt

@@ -0,0 +1,4 @@
+A 51-year-old man had previously undergone a vertebral body resection, bone grafting and internal fixation surgery due to eosinophilic granuloma of the 9th thoracic vertebra in Dec 2014. In June 2015, the patient presented to our hospital with symptoms of chest tightness and lower back discomfort. Computed tomography (CT) scan revealed a pseudoaneurysm of the thoracic aorta and recommended surgical intervention. However, the patient declined the surgery because he considered the risk, especially paraplegia, to be high. Six months later, follow-up CT examination revealed no improvement in the condition of the pseudoaneurysm, leading to the decision to seek further treatment at our hospital in Jan 2016.
+Preoperative X-rays showed an abnormal bulging shadow in the descending aorta and a slightly enlarged aortic arch. CT scans revealed that a screw used in spinal surgery penetrated the wall of the descending aorta and locally formed a pseudoaneurysm, with the size of 27*42 mm, in the mid-segment of the descending aorta, with a significant amount of intraluminal thrombus and shell-like calcifications. The proximal landing diameter is approximately 23 mm, and the distal landing diameter is approximately 22 mm.
+Under general anesthesia, the right femoral artery was accessed, and angiography confirmed the pseudoaneurysm in the mid-segment of the descending aorta, just located at the level of the spinal column fixation instruments. No significant AKA was identified during the procedure, and several pairs of intercostal arteries of similar sizes were visible. A 28–80 mm stent graft (Lifetech, Shenzhen, China) was placed via the right common femoral artery to seal the lesion. Subsequent angiography showed slight type Ia endoleak. Considering the risk of endoleak and the potential durability problems caused by friction between the stent graft and the screw, we decided to implant a second stent graft. Subsequently, a 28–140 mm stent graft (COOK, Bloomington, USA) was deployed just inside the first one. The second stent graft lengthened the proximal landing zone and strengthened the local abrasion resistance. The final angiography revealed complete exclusion of the pseudoaneurysm with no endoleak . Due to the orthopedic consultation determining that the removal would pose significant risks and the patient’s refusal of further open surgery, the screws were not extracted. Extubation was carried out in the operating room under general anesthesia, and assessment of lower limb function was performed. The operation was successful, the patient recovered well and was discharged from hospital 5 days later. There were no complications such as paraplegia, paresis or infection. Postoperative CT scans showed excellent apposition of the two stent grafts with no evidence of endoleak.
+During a follow-up period of nearly 8 years, CT scans indicated that the descending aortic stent grafts keep patency, and the lesion became smaller year by year and gradually absorbed. He recovered well and remained asymptomatic. The quality of life has not been affected in any way.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1632_en.txt

@@ -0,0 +1 @@
+A 61-year-old male patient who was operated due to laryngeal carcinoma six months ago. First, MDCT and then, whole body PET-CT scan (643 MBq F-18-FDG i.v.) was performed for the patient due to the lesion monitored on the right apical in PA radiography of the patient, who was followed up stably. The patient’s routine blood test results were within the normal ranges. A lesion of 15x10 mm with radially spiculated extensions, in irregular appearance and containing a few microcalcifications was monitored in the apical region of the right lung in thoracic CT (, ). No lymphadenopathy was detected in the mediastinum. It was observed during the PET-CT that the lesion had a moderate F-18FDG uptake (2.40 SUVmax) . Apart from that, no significant pathologic finding was detected in the chest. In addition, no focus was detected during the PET-CT scan outside the thorax. The patient was first considered to have metastasis in the light of the existing findings. A wedge resection was performed for the patient’s lesion . Microscopic examination of the surgical material showed a group of fungal hyphae, and the patient was diagnosed aspergilloma. The patient was not given any antifungal treatment because the entire region was cleaned within the surgical borders and there was not any other focus.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1633_en.txt

@@ -0,0 +1,5 @@
+A 37-year-old man, with a history of surgery for right cryptorchidism at age 8 and no other medical history, consulted our department for primary infertility for 3 years. Clinical examination revealed a hypotrophic right testicle with a left varicocele and minor pain in the left testis, Ultrasound showed a heterogenous zones on the right testicle measuring 16 mm. , and testicular tumor markers were: alpha fetoprotein (AFP) 5.52 ng/mL (N: 0–13.4), human chorionic gonadotropin (HCG) < 2.3 mIU/mL (N: 0–5), and lactate dehydrogenase (LDH) 215 U/ L (N: 125–243).
+Cytological analysis of the sperm showed no abnormalities that could help us make a diagnosis.
+An inguinal right testicular biopsy was performed for anatomopathological study. The photomicrograph showing multiple seminiferous tubules containing large atypical cells with abundant eosinophilic cytoplasm; nuclei are hyperchromatic and angular with prominent nucleoli (H&E, ×100), suggestive of intratubular germinal neoplasia .
+We proposed surveillance for our patient because he has an infertility, but the patient wishes to have radiotherapy for his intratubular germinal neoplasia.
+The patient received 20 Gy of irradiation in ten fractionated sessions by oncologists, with disappearance of the intratubular germinal neoplasia on control imaging, the patient was satisfied with the treatment, especially with the preservation of his testicle.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1635_en.txt

@@ -0,0 +1,3 @@
+Two cases of STS of the lower limb characterized by DVT and pulmonary embolism (PE) as the initial presentation were observed in our Orthopedic department: a 47-year-old man diagnosed with an idiopathic DVT of the right distal femoral vein and the popliteal vein and a 44-years-old woman with a massive PE . The patient with DVT was treated with therapeutic doses of subcutaneous enoxaparin for 6 months. After 2 months of enoxaparin, the case with PE was referred to our outpatient clinic for worsening of leg swelling and dyspnea. Neither of the patients had a past or family history of VTE. Physical and radiographic examination did not reveal any mass in either case, but only the signs of DVT or PE. Due to the persistence of symptoms and the inefficacy of anticoagulant therapy, patients underwent magnetic resonance imaging (MRI) of the lower limbs and excisional biopsy of the visualized mass.
+In the first case , MRI showed a large mass in the anterior muscle compartment of the right thigh, with inhomogeneous appearance after gadolinium administration. The lesion was associated with multiple lymphadenopathy in the inguinal and external iliac region, and thrombosis of the right common femoral vein involving the ipsilateral common iliac vein and the inferior vena cava until the confluence of the renal veins. An excisional biopsy of the mass was performed. The lesion was found to be adherent to the femoral vein. The dissection of the vein showed a thrombus that obliterated the lumen of the common iliac vein. The histological examination revealed a high-grade leiomyosarcoma. The patient subsequently underwent chemotherapy and radiotherapy. A computerized tomography (CT) scan performed 6 months after surgery showed multiple pulmonary metastases. The patients is currently receiving chemotherapy in the Oncology division of our hospital.
+In the second case, MRI showed a large mass located in the middle third of the right thigh, with low signal intensity in T1- and T2-weighted sequences and enhancement after gadolinium administration . The lesion was in close proximity to the superficial femoral artery that appeared deformed and was adherent to the superficial femoral vein that appeared compressed and showed signs of thrombosis. After arterial embolization, an excisional biopsy was performed, followed by intraoperative brachytherapy. The histological examination of the bioptic specimen revealed a high-grade leiomyosarcoma. At one year of follow-up the patient was asymptomatic and showed no evidence of recurrence of malignancy at MRI.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1641_en.txt

@@ -0,0 +1,2 @@
+An 11-year-old girl presented to another hospital with lower abdominal pain and vomiting that lasted for 2 days. Acute appendicitis was suspected, and she was referred to our department. On initial physical examination, her body temperature was 38.2 °C, and pulse and blood pressure were within normal ranges. Her abdomen was soft and mildly distended with tenderness localized to the lower abdomen. Laboratory data showed elevated levels of white blood cells (1.29 × 104/μl) and C-reactive protein (3.69 mg/dl). Hemoglobin level was normal (14.1 g/dl). Abdominal enhanced computed tomography showed an abscess in the lower abdomen with ascites in the pelvis . The patient was diagnosed with a localized intra-abdominal abscess and the decision was made to treat with antibiotics. However, her abdominal pain worsened, with abdominal distension, tenderness, and muscle guarding. She was diagnosed with panperitonitis and underwent surgery 5 h after admission. Laparoscopic observation from the umbilical region revealed 200 ml of fresh blood throughout the peritoneal cavity . The appendix looked normal, and the possibility of acute appendicitis was unlikely. Therefore, the umbilical incision was extended to identify a bleeding site, and an MD was detected associated with mesenteric bleeding . During surgery, the exact perforation point was undetectable. Small bowel resection was performed, and she was discharged without complication on the 5th postoperative day.
+Gross inspection of the resected specimen revealed an ileal perforation adjacent to MD junction . Microscopically, the ileum had a peptic ulcer that perforated muscular layer. The MD mucosa in the vicinity of the junction was composed of ectopic gastric glands, and foveolar epithelia were filled with gastric juice .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1642_en.txt

@@ -0,0 +1,2 @@
+A 52-year-old female, 153 cm tall, weighing 57 kg, American Society of Anesthesiologists score of 2, was scheduled to undergo lumpectomy for adnexal uterine surgery. The preoperative laboratory findings showed that her complete blood count was normal with hemoglobin at 138 g/L, erythrocyte volume at 42.4%, WBC count at 3.8 × 109/L, and platelet count at 134 × 109/L. There were no significant abnormalities in coagulation, renal, and liver functions. The electrocardiogram (ECG) showed a normal range ECG. The computed tomography (CT) examination of the mandible/part (spiral) (CT imaging + 3D reconstruction) and neck (spiral) (CT plain + 3D reconstruction) showed that the patient had arthritis of the temporomandibular joint, which was obvious on the right side, and degenerative degeneration of the cervical spine with central type herniation of cervical 3 to 5 disc .
+During the preoperative visit, the patient had a Mallampati grade IV due to severe mouth opening restriction with only 1 finger of mouth opening . After a thorough preoperative evaluation and preparation, the patient was prepared for surgery and anesthesia after discussing the associated risks with the surgeon, the patient, and her family. Vital signs before induction of anesthesia included a heart rate of 82 beats per minute, arterial blood pressure of 120/80 mmHg, and oxygen saturation of 99% on room air. After preoxygenation with 100% oxygen, anesthesia was induced with 20 mg of etomidate, 2 mg of midazolam, 25 µg sufentanil, and 12 mg cisatracurium benzoate. After induction, laryngoscopy was first attempted with a visual laryngoscope, but the attempt failed because the mouth opening was too small to place the visual laryngoscope lens in. Then, the anesthesiologist tried to guide the intubation via the lightwand. The left hand lifted the lower jaw, and the right hand inserted the lightwand along the pharynx. The tip of the lightwand was bent 90 degrees along the tongue root at the midline, and the red light at the tip of the lightwand was transmitted and positioned at the cricothyroid membrane of the neck. The tracheal tube was then gently inserted into the neck where there was light, and finally, the tube was successfully intubated. Heart rate, oxygen saturation, ECG, end-tidal carbon dioxide, invasive arterial blood pressure, and temperature were monitored intraoperatively. Additionally, intraoperative anesthesia was maintained with a combination of remifentanil 0.1 ug·kg−1·min−1, dexmedetomidine 0.5 µg·kg−1·h−1 continuous pumping, and 2% sevoflurane by static inhalation. The operation progressed smoothly with a fluid intake of 1000 mL of sodium lactate Ringer solution and blood loss of 50 mL. The operation lasted 1.25 hours. After extubation, the patient was transferred to the postanesthesia care unit. After awakening, the patient was in good condition and returned to the ward without any significant perioperative complications.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1644_en.txt

@@ -0,0 +1,7 @@
+A 55-year-old postmenopausal woman had intermittent chest pain for 3 years.
+Three years ago (on January 20, 2016), the patient experienced chest pain following an emotionally stressful event (quarrel with her husband) without any signs of infection, such as cough or diarrhea. Twelve-lead electrocardiograms (ECGs) indicated ST-segment and T-wave dynamic changes in the inferior and anterior leads. The peak troponin I level was 0.81 ng/mL (normal range < 0.03). A transthoracic echocardiogram (TTE) showed hypokinesis of the apical and mid-distal segments of the left ventricle with a reduced ejection fraction of 48%. A coronary angiogram showed no evidence of coronary artery disease. The patient was discharged home on diltiazem and an angiotensin-converting-enzyme inhibitor (perindopril) with a suspected diagnosis of coronary artery spasm. The TTE demonstrated completely normal cardiac structure and function with an ejection fraction of 68% on July 27, 2018. On August 9, 2018, the patient presented with chest pain again following the same emotionally stressful event (quarrel with her husband). The peak troponin I level was 0.338 ng/mL. The 12-lead ECG indicated ST-segment depression in the inferior leads and T-wave inversion in the inferior and anterior leads. The TTE showed hypokinesis of the apical and mid-distal segments of the left ventricle (ejection fraction of 52%). A coronary angiogram was performed again without evidence of coronary artery disease. A left ventriculogram was not performed again. The patient was discharged with trimetazidine and an angiotensin-converting-enzyme inhibitor (perindopril). On February 9, 2019, the patient presented with similar chest pain following another stressful event (business failure) without any signs of infection.
+The patient had a history of pacemaker implantation.
+The patient had a free personal history. The patient had no family history of premature coronary artery disease.
+Vital signs were stable. There was no obvious abnormality during pulmonary or cardiac examination. There was no jugular vein engorgement or peripheral edema.
+The peak troponin I level was 2.228 ng/mL (normal range < 0.03), and the peak B-type natriuretic peptide level was 166 pg/mL (normal range < 76).
+Twelve-lead ECGs indicated ST-segment and T-wave changes in the inferior and anterior leads . The TTE showed hypokinesis of the apical and mid-distal segments and a hyperdynamic basal segment of the left ventricle with a depressed ejection fraction of 47% . Myocardial perfusion single photon emission computed tomography imaging (resting state) demonstrated decreased uptake in the left ventricular apical, anterior, inferior and lateral walls of the myocardium . Adrenal computed tomography and hormone results excluded pheochromocytoma. She had no evidence of coronary artery disease detected by the coronary angiogram; however, the left ventriculogram revealed apical akinesia with ballooning of the apical region and hypercontractile basal segments consistent with the typical diagnosis of TCM .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1707_en.txt

@@ -0,0 +1,5 @@
+A 30-year-old, ill-appearing South Asian male patient presented to the emergency department with new-onset fever, chest discomfort, macular exanthema, abdominal pain, coughing, mild dyspnoea, and tachypnoea for a couple of days. The patient’s medical history was unremarkable except for a recent infection with SARS-CoV-2 about a month prior to the current presentation. There was no history of smoking or a family history of cardiovascular disease and the patient had a mildly increased body mass index of 29. The course of the COVID-19 disease was mild with only minor symptoms of respiratory infection, most notably coughing, did not require further medical attention, and the patient recovered completely without any residual symptoms. The patient had not been vaccinated prior to COVID-19 infection or since then. Upon admission to the emergency department, the patient tested negative for SARS-CoV-2 nucleic acids in consecutive nasopharyngeal swabs. Antibody-testing for SARS-CoV-2 was positive with 164 U/mL, confirming past COVID-19 infection.
+On examination, a widespread, itching, non-scaling macular exanthema was evident, which originated at the lower legs and had since spread to the trunk. Additionally, mild abdominal tenderness was localized in the epigastric area and pulmonary auscultation revealed bilateral fine rales in the lung bases. Upon cardiac auscultation, no murmurs or pathological heart sounds were evident and peripheral volume status appeared euvolaemic. The further physical exam was unremarkable and vital signs were initially stable. Laboratory work-up showed significant inflammation [white blood cells 11.7 G/L and c-reactive protein (CRP) 155 mg/L] and a mild increase of markers of myocyte necrosis and myocardial stretch [high-sensitive cardiac troponin I (hs-cTnI) 84 ng/L and N-terminal pro-B-type natriuretic peptide (NT-proBNP) 476 ng/L] . Upon chest X-ray, bilateral diffuse reticular abnormalities were described in both lungs . The patient was started on i.v. broad-spectrum, empiric antibiotics after blood cultures were drawn (ceftriaxone 2 g i.v. and azithromycin 500 mg p.o.) and was subsequently admitted to the department of pulmonary medicine. High-resolution chest computed tomography (CT), which was issued to further characterize the X-ray findings, showed mild bilateral, multilobular interstitial abnormalities, and ground-glass opacities most notably in the basal sections of the lung . These findings were compatible with a history of SARS-CoV-2 infection and there were no signs of acute bacterial pneumonia or severe respiratory disease.
+Upon laboratory follow-up, a significant increase of both hs-cTnI and NT-proBNP was noted. The electrocardiogram was unremarkable except for sinus tachycardia with a heart rate of 120 beats per minute and peripheral low voltage. Transthoracic echocardiography showed mildly reduced left ventricular ejection fraction of 49% without evidence of regional wall motion abnormalities (, ). Since the patient continued to suffer from chest discomfort referral for acute coronary angiography was issued, which excluded coronary artery disease. Ventriculography confirmed mildly reduced left ventricular systolic function with an ejection fraction of 43%. . The patient was then transferred to our cardiological ward for haemodynamic monitoring and further management. To confirm the current tentative diagnosis of acute myocarditis, cardiac magnetic resonance imaging (MRI) was arranged. Pulmonary embolism may also be considered as a potential differential diagnosis in this setting. However, since the pre-test probability for pulmonary embolism was low (Wells Score of 1.5), echocardiography showed normal right ventricular function nor any other signs of pulmonary embolism and a different diagnosis was considered more likely, a second CT scan was omitted to reduce radiation exposure in this young patient.
+During the next couple of days, despite continuous antibiotic treatment, symptoms did not improve and clinical findings further deteriorated: heart rate further rose and blood pressure dropped to 90/60 mmHg. In addition to the aforementioned symptoms, we found bilateral redness of the eyes, consistent with conjunctivitis and a generalized arthralgia. Autoimmune diagnostics returned negative and we did not find any signs of acute human parvovirus B-19 infection, mononucleosis, streptococcal infection, influenza, or rubella upon diagnostic work-up, which have to be considered as potential differential diagnoses in this case. The complex, multi-organ symptom constellation with a failure of clinical improvement despite broad-spectrum antibiotics facilitated the diagnosis of MIS-A following recent mildly symptomatic SARS-CoV-2 infection. According to current literature, the patient was started on a 100 mg daily dose of aspirin and an intravenous hydrocortisone drip with 200 mg/day after an initial bolus of 100 mg. The patient’s symptoms and haemodynamic parameters improved drastically following the start of steroid treatment. We also observed a prompt and steady decrease of inflammatory markers and the last fever spike of 39°C was documented on the day of steroid initiation. Cardiac MRI finally confirmed acute myocarditis with findings of myocardial oedema, late gadolinium enhancement and small pericardial effusion—at this point, in time the patient was already feeling better and only suffered from intermittent and mild chest pain .
+After 6 days of intravenous corticosteroid treatment—stopped without tapering—the patient was discharged from hospital care without significant residual symptoms. The necessity of strict, physical activity restriction for 3–6 months was discussed with the patient. There were no adverse or unanticipated events secondary to corticosteroid treatment. Upon 2-week follow-up, the patient was feeling well and there was no symptom recurrence. Echocardiography at 6-week follow-up revealed a normalization of systolic left ventricular function alongside a normalization of laboratory markers of myocardial injury. Antithrombotic treatment with aspirin was also stopped at this point.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1729_en.txt

@@ -0,0 +1,3 @@
+A 48-year-old man presented with lateral pain in his left elbow. A diagnosis of lateral epicondylitis was made and the patient was initially treated conservatively with physiotherapy, elbow straps, and corticosteroid injections at another institution. However, the pain did not improve and the patient was referred to our hospital. Physical examination revealed tenderness over the lateral epicondyle of the humerus and pain induced by resistance to the middle finger or on wrist extension. He also experienced discomfort and catching around the posterior radiocapitellar joints during extension and flexion of the elbow. Although there were no restriction of range of motion of the elbow, the patient’s grip strength had decreased to 45 kg on the left side compared with 52 kg on the right side. A radiograph of the elbow showed no abnormal findings. Magnetic resonance imaging (MRI) showed increased effusion in the humeroradial joint, but there was no marked signal change at the origin of the ECRB tendon . No obvious intra-articular abnormal tissue, except for posterior synovial plicas, was identified on pre-operative MRI. Arthroscopic surgery was planned for debridement of the ECRB tendon and to examine the cause of posterolateral discomfort and catching in the elbow.
+Intra-articular observation of the radiocapitellar joint was performed through the anteromedial portal. Degenerative changes in the lateral capsule with synovitis were observed, but there was no synovial plica interposed in the humeroradial joint . Debridement of the ECRB tendon and synovium was performed using a shaver inserted through the anterolateral portal . Subsequently, a posterior viewing portal was made 1 cm proximal to the midpoint of the line connecting the olecranon and the lateral epicondyle of the humerus. Posterior observation revealed a tendon-like abnormality running longitudinally along the articular surface from the humeroradial joint to the capitulum of the humerus . This structure was mobile during extension and flexion of the elbow. The abnormality was resected easily using a shaver inserted through the soft-spot portal .
+The elbow joint was splinted at 90° of flexion for 1 week, after which active motion exercises were initiated. The discomfort and catching of the elbow disappeared immediately after cast removal. At 24-month postoperatively, the pre-operative visual analog scale and the patient-rated tennis elbow evaluation scores improved from 45 mm to 5 mm and from 48 points to 9 points, respectively. At 12 months postoperatively, MRI revealed decreased effusion in the lateral humeroradial joint compared with that on pre-operative MRI .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1756_en.txt

@@ -0,0 +1,11 @@
+A 76-year-old Caucasian female with known hypertension and dyslipidaemia presented with 2 weeks of intermittent palpitations, orthopnoea, and New York Heart Association functional class III–IV shortness of breath. On exam, the patient was not in acute distress; however, extremities were cool and clammy. Heart auscultation revealed normal heart sounds, no murmurs, rubs, or gallops but the rhythm was irregularly irregular at ∼100 b.p.m. The jugular venous pressure was elevated at the angle of the jaw and there was a positive abdominojugular reflux sign. Auscultation of the lungs revealed bilateral crackles up to mid chest with decreased air entry at the bases. The abdomen was soft, non-tender, and non-distended.
+In the emergency department, she was in uncontrolled atrial fibrillation (AF) with a left bundle branch block with clinical evidence of decompensated heart failure and her chest X-ray confirming evidence of pulmonary oedema with bilateral pleural effusions. There was no prior electrocardiogram for comparison. She was admitted for intravenous diuresis [initially with Furosemide 80 mg intravenously (IV) once then Furosemide infusion 20 mg/h] and rate control (initially with metoprolol 5 mg IV once then transitioned to oral metoprolol with an intravenous digoxin load). Over the next few hours, she became increasingly diaphoretic, tachycardic, and hypotensive at 60/30 mmHg. High-sensitivity troponin increased to 2040 ng/L (reference value ≤30 ng/L) from 13 ng/L, and serum lactate was 7.1 mmol/L (reference value 0.5–2.2 mmol/L). She also developed anuric acute kidney injury with an increase in serum creatinine from 58 to 122 μmol/L (reference value 50–98 μmol/L). Other admission labs are shown in . She was started on dual antiplatelet therapy (ASA 81 mg orally daily, clopidogrel 75 mg orally daily, and fondaparinux 2.5 mg subcutaneously daily) for suspected acute coronary syndrome and vasopressors to maintain perfusion. Point-of-care ultrasound demonstrated significant biventricular systolic dysfunction, a plethoric non-collapsible inferior vena cava, and diastolic flattening of the interventricular septum suggesting volume overload of the right ventricle.
+The following differential diagnoses were considered at that time:
+Acute coronary syndrome and possible mechanical complication with right ventricular (RV) infarction.
+Underlying cardiomyopathy and/or pulmonary hypertension and superimposed acute decompensation.
+Massive pulmonary embolism.
+As the patient was in extremis, she was intubated for emergent cardiac catheterization. She was initiated on epinephrine, norepinephrine, and vasopressin prior to arrival to the catheterization lab. Angiographically, the left main coronary artery (LMCA), left anterior descending (LAD), and left circumflex (LCx) arteries were very large, ectatic vessels with no flow-limiting stenosis. The right coronary artery (RCA) ostium could not be engaged from the aorta despite multiple attempts. Contrast injection into the left coronary system showed what appeared to be retrograde filling of the RCA via multiple left-to-right collateral vessels ( and Video 1A and B). On further review, it was felt that the RCA was emptying back into the pulmonary artery/right ventricular outflow tract (RVOT).
+The possibility of an anomalous coronary artery (ACA) as the underlying aetiology of the patient’s shock prompted an ad hoc right heart catheterization for haemodynamic assessment. Measurements are shown in . An oximetry run did not suggest the presence of an intra-cardiac left-to-right shunt. Pulmonary artery angiography did not identify any pulmonary embolus or fistula involving the RVOT. The pulmonary vascular resistance was 0.87 Wood units and the systemic vascular resistance was 6.39 Wood units. An RV angiogram demonstrated significant tricuspid regurgitation (TR) with a dilated and severely dysfunctional right ventricle. It was felt that the cause of the patient’s cardiogenic shock was due to underlying severe RV dysfunction with either AF or other catecholaminergic state triggering decompensation. The elevated cardiac index prompted consideration of sepsis on the differential diagnosis and the patient accordingly received empiric antibiotics (Piperacillin/Tazobactam 4.5 g IV every 6 h, Vancomycin 1 g IV every 12 h, and Doxycycline 100 mg orally twice daily). She returned to the cardiovascular intensive care unit (CVICU) for further physiologic support.
+Formal echocardiography while in the CVICU demonstrated severely reduced RV systolic function, right atrial dilatation, and severe TR. The overall left ventricular systolic function was low-normal with an ejection fraction between 50% and 55% and no regional wall motion abnormalities. A transoesophageal echocardiogram ruled out vegetations but corroborated findings from the patient’s cardiac catheterization including a dilated and tortuous LMCA and branches, as well as a dilated and tortuous vessel draining into the pulmonary artery. This vessel was felt to be likely the RCA. Overall, these findings were consistent with a diagnosis of ARCAPA (see and Video 2).
+In the CVICU, the patient was maintained on inotropes and vasopressors. High-sensitivity troponin plateaued at 26 040 ng/L and this was felt to be consistent with an RV infarction. In the setting of concomitant volume overload and anuric acute kidney injury, continuous renal replacement therapy was initiated. She was subsequently found to be bacteremic with positive blood cultures for Streptococcus bovis but not stable enough to pursue a colonoscopy to rule out a gastrointestinal malignancy; management consisted of antimicrobial therapy (ceftriaxone/metronidazole) with consultation from infectious diseases.
+The patient’s clinical status eventually stabilized enough to be extubated and transferred to the cardiology ward, although she remained dependent on intermittent haemodialysis without expected renal recovery. Potential therapeutic options for ARCAPA were discussed at interdisciplinary heart team rounds but unfortunately, she was felt not to be a surgical candidate in view of her age and clinical status. The patient decided to pursue comfort measures and requested cessation of dialysis. She was transferred to a hospice for palliative care and passed away just over a month later.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1789_en.txt

@@ -0,0 +1,11 @@
+A 23-year-old man of Chinese descent presented to the emergency department for dyspnoea and pain in the left upper back. He had initially presented to the emergency department after an episode of severe vomiting following alcohol consumption and mild back pain three days prior, and was treated symptomatically and discharged. The patient denied any recent trauma. He had no other past medical issues nor known congenital conditions.
+Upon review, the patient was in severe respiratory distress and haemodynamically unstable with blood pressure of 95/70 mmHg, heart rate 162 beats per minute, respiratory rate of 40 breaths per minute and peripheral capillary oxygen saturation (SpO2) of 87% on 100% oxygen administered via non-rebreather mask. Although unable to lie still, he was oriented and able to speak in short phrases. His trachea was deviated and lung sounds were absent over his left chest.
+A chest X-ray (CXR) performed was interpreted as a moderately large left-sided pneumothorax with herniation of bowel into the left hemithorax . Due to patient instability, no computer tomography (CT) scan was performed after the CXR. A 14-gauge intravenous cannula was inserted into the second intercostal space along the mid-clavicular line for needle decompression in the sitting position.. However, air, followed by approximately 900 ml of faecal fluid, was aspirated, with no improvement in the patient’s symptoms. A repeat CXR showed a slight improvement of tracheal deviation, but with further bowel herniation taking up most of the left lung field. There was still concern that the pneumothorax had not been completely relieved.
+Arterial blood gas (ABG) indicated severe combined respiratory and metabolic acidosis (pH 7.212, PaCO2 34.6 mmHg, PaO2 282 mmHg, base excess -14 and serum bicarbonate 13.9 mmol L-1. Serum lactate levels were elevated at 3.2 mg dL-1).
+The patient was immediately transferred to the operating theatre for surgical intervention of his left diaphragmatic rupture, complicated by visceral herniation and possible left tension pneumothorax, with iatrogenic puncture of the herniated bowel. After discussion with the surgeons, a repeated needle decompression or chest tube insertion prior to induction of anaesthesia was not attempted due to the high failure rate attributed to the herniated bowel’s position, uncertain anatomy and the patient’s inability to cooperate.
+After adequate preoxygenation, rapid sequence induction was performed with cricoid pressure and intravenous propofol 150 mg, rocuronium 50 mg, and remifentanil target-controlled infusion at 1 ng ml-1. The SpO2 before induction was 92%, and the lowest SpO2 obtained while the airway was being secured was 80%. A left-sided double-lumen tube (DLT) was inserted and both the tracheal and bronchial cuffs were inflated immediately prior to the commencement of one lung ventilation. Rapid deflation of the left lung using a suction catheter was then carried out. Position of the left bronchial cuff was finally confirmed to be in the left main bronchus with a fiberoptic scope. Although the SpO2 improved to 100%, there was significant hypotension post-induction to lowest 63/45 mmHg, which was quickly addressed with boluses of phenylephrine and adrenaline to a total of 1000 μg and 30 μg respectively. An ABG obtained after induction showed pH 7.091, PaCO2 61.5 mmHg, PaO2 194 mmHg, base excess -11 and serum bicarbonate 18.7 mmol L-1.
+Intraoperatively, a 10 cm by 6 cm Bochdalek diaphragmatic hernia defect with herniation of the greater curve of stomach, spleen and long loop of transverse colon into the left hemithorax was found. A large perforation with necrotic edges in the greater curve of the stomach was also noted, with feculent material in the pleural and peritoneal cavity. No other obvious defects of the small and large bowels were seen.
+Simultaneous assessment and resuscitation of his persistent hypotension, tachycardia and hypoxia was carried out while surgery was ongoing. Based on the patient’s clinical history and operative findings, it was likely that he had a combination of obstructive, hypovolemic and distributive shocks due to tension pneumothorax, intravascular depletion and feculent peritonitis. He was aggressively fluid resuscitated with 1.8 litres of intravenous crystalloids and 2 litres of colloids. Noradrenaline and adrenaline infusions were commenced shortly after induction and maintained on 0.2 μg kg-1 min-1 for both infusions. His antibiotics were escalated from intravenous (IV) ceftriaxone and metronidazole to IV piperacillin-tazocin, and additional fungal coverage with IV anidulafungin was given. IV hydrocortisone was also administered. At the end of the surgery, he remained on noradrenaline 0.2 μg kg-1 min-1 and vasopressin 0.03 units kg-1 hr-1.
+As the tension pneumothorax could not be surgically relieved until the herniated abdominal structures had been reduced, attempts were made to decompress the left pleural cavity with continued suction via the bronchial lumen of the left-sided DLT, to limited success. Eventually, a wedge gastrectomy of the stomach, diaphragmatic hernia reduction and left chest tube insertion was performed, followed by a temporary abdominal closure with the diaphragmatic defect being reinforced with surgical towels. Estimated blood loss was 800 ml and surgery lasted approximately 3 hours.
+A repeat ABG at the conclusion of the surgery showed persistent combined respiratory and metabolic acidosis (pH 7.153, PaCO2 54.5 mmHg, PaO2 128 mmHg, base excess -10 and serum bicarbonate 19.1 mmol L-1). The double-lumen tube was exchanged for a single-lumen tracheal tube and the patient was sent to the Intensive Care Unit (ICU) for continued resuscitation. Postoperatively, a repeated CXR showed reduction of the left diaphragmatic hernia with re-expansion of the left lung . Dual vasopressor support was weaned off on Day 2 of admission and the patient did not have high ventilatory requirements.
+The patient returned to the operating theatre for a relook surgery on Day 3 of admission. The hernia defect was repaired with a synthetic mesh and primary abdominal closure was performed uneventfully. The patient was extubated on Day 5 of admission and discharged from the ICU on Day 6 of admission. CXR on Day 6 of admission showed resolution of pneumothorax and reduction of diaphragmatic hernia . After an additional 2 weeks’ stay for total parenteral nutrition and post-operative recovery, he was discharged home 22 days after admission.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1794_en.txt

@@ -0,0 +1,6 @@
+An 80-year-old Caucasian woman was admitted to our hospital with a 12-year history of an endocrine inactive steady sellar mass lesion (13 mm in diameter; Figure ). Our patient had been previously asymptomatic with no pituitary hormone deficiency or visual impairments. Moreover, our patient had a medical history of good health with only minor health issues that included hypertension and osteoporosis. However, prior to hospital admission, she had recently experienced two severe headache attacks; the last episode was accompanied by nausea, vomiting and blurred vision. Hyponatremia (120 mEq/L) with low serum osmolality (247 mOsm/L) and highly elevated urine osmolality (695 mOsm/L) were detected. An endocrinological investigation revealed hypocortisolism with no other hormone disturbances. Fundoscopy showed no pathological findings. However, further ophthalmologic examination with Goldman perimetry confirmed a bitemporal hemianopsia accentuated on her right side. Her neurological examination results were otherwise normal. After substitution therapy with hydrocortisone, our patient rapidly improved and her headaches subsided.
+Findings from a magnetic resonance imaging (MRI) scan were suggestive of an acute hemorrhage of the sellar process, consistent with pituitary apoplexy . Except for an age-consistent vascular leukoencephalopathy, the diagnostic imaging showed no further pathological findings. Our tentative diagnosis at this point was a pituitary adenoma with pituitary apoplexy.
+Due to these clinical and radiological findings, the decision was made to surgically remove the tumor. A gross total extirpation using a transnasal, transsphenoidal approach to the pituitary mass was successfully performed. Intraoperatively, the tumor appeared yellowish-brown, was relatively firm and was located within a sellar hematoma cavity, which was evacuated.
+Postoperatively, our patient's visual field deficits improved markedly on clinical examination and Goldman perimetry confirmed a partial recovery of her bitemporal visual field deficits. Endocrinological studies showed panhypopituitarism with partial and transient diabetes insipidus. Our patient received substitution therapy with hydrocortisone, levothyroxine and transient therapy with desmopressin. Overall, our patient remained in good health with a satisfactory level of performance. A repeat MRI scan taken 16 months after surgery showed good chiasmatic decompression with no residual tumor mass .
+The resected tumor was examined with light microscopy, which revealed a small, well circumscribed, non-adenomatous tumor surrounded by slightly compressed remnants of adenohypophyseal parenchyma . The tumor was richly vascularized with an observable reticular mesh of thin-walled capillaries interspersed with large epithelioid-looking cells . Pale eosinophilic cytoplasm showed xanthomatous or vacuolar change . Immunohistochemistry confirmed the expression of the endothelial-associated markers CD31 and CD34 in the intratumoral capillaries, although not in the stromal cells themselves. Conversely, the stromal cells were diffusely immunoreactive for vimentin, with a minority of cells also coexpressing S100 protein and epithelial membrane antigen . No inflammatory infiltrate was detected except for the occasional mast cell . Staining for cytokeratins tested negative, as did the Langerhans-cell-associated marker CD1a. Less than 1% of lesional cell nuclei were labeled with the cell proliferation-associated antigen Ki-67.
+Given the above findings, we identified the tumor as an intrapituitary example of capillary hemangioblastoma (World Health Organization grade I). Since our patient displayed no clinical stigmata of VHL disease, genetic testing was not performed.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1797_en.txt

@@ -0,0 +1,5 @@
+A 48-year-old woman underwent a skin-sparing mastectomy for ductal carcinoma of the right breast.
+We immediately reconstructed the breast using a deep inferior epigastric artery perforator (DIEP) free flap from the lower abdomen. The pedicle of the recipient was the thoracodorsal artery and its venae comitantes, which are commonly used in breast reconstruction. The surgery was successfully performed, and the patient was on the usual course without any postoperative complications . However, on postoperative day 7, she suffered a deep second- to third-degree contact burn over 30 percent of the reconstructed right breast due to incorrect application of a heating pad at the flap site .
+Ductal carcinoma of the right breast.
+The burn wound was initially treated with a conventional dressing; however, the necrotic changes progressed with eschar formation . Therefore, we performed en bloc resection of the necrotic tissue at the 21st d postburn. During eschar resection, we confirmed flap survival by observing surviving glistening yellow adipose tissue in the subdermal layer .
+As the Doppler sound of the flap pedicle was also traceable, we applied a V.A.C. dressing (KCI International, San Antonio, TX, USA) to promote healing of the burn wounds. We sealed it entirely over the exposed area of the patient’s right breast under a pressure of -125 mmHg in continuous mode. However, after four days of V.A.C. application, the burn wound worsened, and the exposed adipose tissue changed to dry and brown-colored necrotic tissue . Upon further debridement, we observed an obstructed vascular pedicle with multiple thrombi in the transferred DIEP flap tissue . We also observed the presence of unviable adipose tissue. First, we performed daily dressing to demarcate the necrotic tissue.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1809_en.txt

@@ -0,0 +1,7 @@
+The 3-year-and-9-month old girl was born at term with uneventful maternal pregnancy, delivery and family history. Her birth weight and body length were both within normal limits. She had the first afebrile seizure at night sleep presented as generalized tonic-clonic seizure lasting for 1–2 min while she held the normal developemtal milestone of social smiling at her age of 2 months. Topiramate was prescribed, but seizures still happened, until oxcarbazepine monotherapy employed that seizure temporarily resolved for half a year. Later, afebrile seizure flared up and the frequency was around 1–2 fits per month, even several convulsive status epilepticus. She came to our attention 1 year later. Physical and neurologic examinations, including the head circumference, muscle tone and deep tendon reflex, and the laboratory data were all unremarkable. Metabolic survey of amino and organic acids, brain magnetic resonance imaging (MRI) and fluorodeoxyglucose (FDG)-positron emission tomography (PET) demonstrated unremarkable findings . The test of Wechsler Preschool and Primary Scale of Intelligence (WPPSI-IV) showed mild cognitive impairment (full scale IQ = 66). Interictal electroencephalogram (EEG) revealed normal background activity without obvious epileptiform discharge. Ictal video EEG recorded the seimology of generalized tonic, tonic-clonic seizures, and generalized electrical decrement with superimposed fast activity at EEG ictal onset . Phenytoin (5 mg/kg/day), valproic acid (20 mg/kg/day), levetiracetam, clonazepam were ever tried, but there was little benefit. Meanwhile, short-term seizures that were provoked by low-grade fever developed then.
+Genetic counselling was recommended because her seizures were poorly controlled. High-throughput sequencing of exons of disease-causing genes were performed on the patient and her parents. Genomic DNA extraction and library preparation followed the standard Illumina protocols (Illumina, San Diego, USA) with minor adaptation provided by Joy Orient (Joy Orient Translational Medicine Research Center Co. Ltd., Beijing, China). Agilent Bioanalyzer 2100 (Agilent Technologies, USA) was used for quality control of DNA size distribution and enrichment. Target capturing was performed using Roche (Roche AG., Basel, Switzerland) product customized by Joy Orient, which uses 91,867 probes to capture total 7,465,978 bp of exons regions of 3372 genes that are potentially associated with 4213 known Mendelian genetic diseases. A HiSeq2500 sequencer was used to perform high-throughput sequencing. Exon-enriched DNA was sequenced by the Illumina hiseq2500 platform following the manufacturer’s instructions (Illumina). Raw image files were processed by the BclToFastq (Illumina) for base calling and generating the raw data. The low-quality variations were filtered out using the quality score ≥ 20 (Q20). The sequencing reads were aligned to the NCBI human reference genome version hg19 using BWA. Samtools and Pindel were used to screen SNP and indel of the sequence. All genetic variants were screened by pathogenicity, mode of inheritance and clinical phenotypes .
+Importantly, a de novo heterozygous mutation c.3953A > G in SCN8A (the coverage of the variant (DP) is 174, allele frequency (AF) = 70/174 = 0.4) was identified and confirmed by Sanger Sequencing . The detailed information of this variant is as the followings: SCN8A (NM_014191.4), missense mutation, c.3953A > G (exon22), p.N1318S (de novo), location: chr12, 52,180,336. This missense mutation causes an amino acid substitution of an asparagine residue with a serine residue (p.N1318S) which occurs at a highly conserved LINKER position between the S4 and S5 segments in the third transmembrane domain (DIII) of SCN8A protein . This mutation site is absent from ClinVar and HGMD Public . It is neither recorded in the Exome Aggregation Consortium (ExAC) , which contains exome sequencing data from 60,706 unrelated individuals, nor in our 100 in-house controls. The substitution p.N1318S is predicted to be highly deleterious by bioinformatic tools, which predict possible impact of an amino acid substitution on the structure and function of a human protein, such as Polyphen2 (HumDiv score = 1; HumVar score = 0.998), SIFT (score = 0), Mutation Taster (score = 1) and a comprehensive index CADD phred score (C score = 23.2) .
+Since the probable causative gene mutation was found, levetiracetam was stopped, but her family reported more seizures. Accordingly, the therapeutic regimen of a sodium channel blocker, lamotrigine (5 mg/kg/day), valproic acid (24 mg/kg/day) and levetiracetam (10 mg/kg/day) were employed, then she had a second temporary seizure-resolved period of 5 months, even under high fever.
+SCN8A is widely expressed in the central and peripheral nerve systems during the neuronal maturation [, ]. It is mapped to chromosome 12q13, encoding neuronal voltage-gated sodium channel α 8-subunit Nav1.6, which forms a complex combined with β subunits to modulate current conductance [, , ]. Nav1.6 consists of four transmembrane domains (DI-DIV), each containing six segments (S1-S6). Four S4 transmembrane segments are responsible for the voltage sense which contain positively charged arginine and histidine residues. There are fast and slow inactivation phases. Fast-inactivation phase is provided by internal DIII-DIV linkers to occlude the ion-conducting pores. Slow-inactivation phase is involved in a collapse of the pore, which is composed of S5-S6 segments of four domains .
+Missense mutations of SCN8A accounting for 1% of EE are associated with a wide-spectrum phenotype of heterogenous epilepsy, and SCN8A missense mutations are recently recognized to be associated with early infantile epileptic encephalopathy type 13, ref. [–] which displays multiple seizure types, including focal seizures, generalized seizures (tonic, myoclonic, absence) and epileptic spasms. These patients may experience stormy epilepsies [, ]. Fever rarely triggers seizures [, , ]. Severity of psychomotor delay ranges widely after seizure onset [, ]. MRI studies are typically normal . There is no clear correlation between phenotypic severity and genetic mutations so far [, ]. SCN8A mutations lead to premature channel opening, impaired inactivation and increased persistent current. Stormy seizures are reported resulting from gain-of-function effects . It could explain that some patients respond well to sodium channel blockers in halting seizures [, , , ].
+As to our patient, she was categorized as the intermediate phenotype of EE, who manifested mild psychomotor retardation and infrequent seizure episodes, though developing stormy onset of generalized tonic and tonic-clonic seizures concomitant with normal EEG background activity [, , ]. Fever barely triggered seizures in our patient as previously reported [, , ]. MRI demonstrated no significant findings. She responds well to the sodium channel blockers. Targeted exome sequencing revealed a heterozygous missense mutation (c.3953A > G, p.N1318S) in SCN8A which is located in the internal S4-S5 linker of the DIII. This mutation could alter the function of the down-stream protein. Since SCN8A (c.3953A > G, p.N1318S) is a de novo missense mutation, it is necessary to further validate its function in the future.