diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1020_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1020_en.txt
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index 0000000000000000000000000000000000000000..0dfc28539afa82e9db35bd30aaece1453cdf4c7a
--- /dev/null
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@@ -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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1056_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1056_en.txt
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index 0000000000000000000000000000000000000000..46e94f0af0cb74a0d0372f066cd2e0e48ed11623
--- /dev/null
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+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1063_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1063_en.txt
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index 0000000000000000000000000000000000000000..271e44856f8f6d58c35368fdd601731f7c0dd490
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+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1078_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1078_en.txt
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index 0000000000000000000000000000000000000000..184ce5ee508d0a1b9c5b0761578b1cbb10949eea
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+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1110_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1110_en.txt
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index 0000000000000000000000000000000000000000..2a2e820b9926e28bafbae55adc2d28d500bdb0b3
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1120_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1120_en.txt
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index 0000000000000000000000000000000000000000..da0f4b8476410815d1406a5a3ab4fadc62a5b048
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+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1120_en.txt
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+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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1126_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1126_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..11c95009ced99da75b58bd55adf63e40e5f2e4e4
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_113_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_113_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5582ebc6f0e29b519c5f825704601cf83e4b1711
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1146_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1146_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b80ca6c7e5a1694b89d5a87fa879e5461bcb240
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1174_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1174_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..83b5d91fe88270fe0f810412646a9a611fdc3356
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1176_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1176_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..657212941f842fb1037de2245a5101863af7b212
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1178_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1178_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0a088b1feb9fa617d91fb34c0f1cd1041d39d86f
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1182_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1182_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7662bea02ffe1e173ffacee7f19fff530eded28c
--- /dev/null
+++ b/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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1194_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1194_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..17c2b390851911e58bbdbae328d9f60f6fe58559
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1201_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1201_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..96a122f0c507e03e208f3939ebf4f0d25805f584
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1206_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1206_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..682e1c8f54d6799847fbbd94667d7387f4558dc9
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_121_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_121_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..619c4f06242ccdcf05c4ff94368f993601183e75
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1241_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1241_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cbd2c2f8c5eea09491b638cb672341940d5c39e2
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1258_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1258_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8c7656c91657965d410c31df1b3fccc49e4fb068
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1263_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1263_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..665cbd4c5bd79c903fb0e5654d72830b37ad9c03
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1288_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1288_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7135ed9bb2cf252a48bb2f226114b81c3a6da091
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1314_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1314_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..52ca06b88861de1a9e21ad2f182a287d40567dc4
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1315_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1315_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e1d64db54d126c1ade0592d4ad1b5d2a46e8cd9c
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1325_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1325_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4a392ba23ede99161b63e774baa3da6aaec8e62c
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_132_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_132_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..24af349dc4c84e0f4d5fa22c98eb4aa2c4881608
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1346_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1346_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4476860bf75c04301a41661618e22a15362d33f6
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1354_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1354_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..da5ca3f96d59ef169f8e73b8c40dd9bcb0d87f4d
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1359_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1359_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a4f1f8544b7e12be56d13c5f210355fefba2e32f
--- /dev/null
+++ b/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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1360_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1360_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3cf21cb20d16ac424e7627189df66f8d64873875
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1367_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1367_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2939716be16279b9ea0dde542364ff69730fe032
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1381_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1381_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eccbd12125d23999e2ed9f9e14b465a027df53e0
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1382_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1382_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..444547078add846550899bc569af1aa2b8810586
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1554_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1554_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..cf1a0811b90f0ff34172382abd9d96da530688cb
--- /dev/null
+++ b/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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1555_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1555_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..37c465ee22df0518f6ee66e64f0a2f4e52ee1834
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1565_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1565_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..09294f66e1252925c61401e97cea5af96563abc9
--- /dev/null
+++ b/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).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_158_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_158_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d02f0a430b3237b6869b2304a7e10729ba17e636
--- /dev/null
+++ b/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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1604_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1604_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..891f81565fcc64a1b201ea84dbf534ea098777a4
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1632_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1632_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d4ecd365a1a73b78280aa0b1477e5c737f78bf36
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1633_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1633_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..79fa9e06ab3d1a1affdd04faccd5e296457ccd2a
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1635_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1635_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d19595ba586d29a394d6fcedbd18cfea2a632745
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1641_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1641_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9028b57933c532e223473218e5db3328c0626a54
--- /dev/null
+++ b/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 .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1642_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1642_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e02f16ed846b27bf24f4cb30cd43fd40a9b711a2
--- /dev/null
+++ b/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.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1644_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1644_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d0648d92c858a00fdfe08276616ccc6827e3bfb
--- /dev/null
+++ b/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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1707_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1707_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3806fed64e3cf4782fa997050c1b004e9967a2c8
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1729_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1729_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea7bdeaf914191d138655af8413db4ac0540d8fd
--- /dev/null
+++ b/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 .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1756_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1756_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9d8d1007faff0124643135e81048818831af5eb8
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1789_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1789_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..86353db7f67f5a8d0d55785c27be16b36dbe6de9
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1794_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1794_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0fe9e1927d4a16414af5f63b32c28a0d1349f479
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1797_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1797_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..52cef39d125f1915426345d2a7590295db99fe2d
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1809_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1809_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a67e19c3724e986dfed5012cdf16066a4d9cf55b
--- /dev/null
+++ b/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.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1815_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1815_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7dc0ea6248865b892f8f95bc458ea3f737a0c3b1
--- /dev/null
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+The patient was a 46-year-old man who complained of painful numbness in the left little finger for 4 mo with no apparent cause.
+The numbness and pain in his left little finger had gradually worsened over the past 4 mo but was not of serious concern.
+The patient had a 13-year history of ANLL and a 20-year history of psoriasis; both diseases had been fully treated previously by systemic therapy.
+Notably, there was no family history of the same disease.
+Physical examination of the whole body revealed no palpable lymph nodes. Specialized examination of the left hand revealed atrophy of the first dorsal interosseous muscle, numbness of the little finger and ulnar aspect of the palm, weakness of the ring and little finger, inability to adduct fingers, positive paper-clip test results, and loss of manual dexterity; all other examination outcomes were normal.
+The laboratory results were: White blood cell count (WBC), 14.14 (normal range: 3.50-9.50) × 109/L; neutrophil count (NEUT), 12.12 (1.80-6.30) × 109/L; lymphocyte count (LYMPH), 0.78 (1.20-3.20) × 109/L; monocyte count, 1.22 (0.10-0.60) × 109/L; eosinophil count (EOS), 0.00 (0.02-0.52) × 109/L; %NEUT, 85.8 (40.0-75.0)%; %LYMPH, 5.50 (20-50)%; %EOS, 0.0 (0.4-8.0)%; red blood cell count (RBC), 4.0 (4.3-5.8) × 109/L; haemoglobin count (HGB), 126 (130-175) g/L; haematocrit, 36.2 (40.0-50.0)%; rheumatoid factors, 22.05 (≤ 18.00) IU/mL; hypersensitive C-reactive protein, 4.67 (≤ 4.00) mg/L; uric acid, 463.02 (202.00-416.00) μmol/L; and interferon-γ, 34.21 (≤ 20.36) pg/mL.
+X-rays showed that the bones of the left elbow were regular in shape, with cortical continuity and clear trabecular structures, a normal alignment of the elbow joint with a moderate joint space, and no significant abnormalities in the surrounding soft tissues . Magnetic resonance imaging (MRI) showed a slightly abnormal left brachial plexus nerve alignment with local thickening, entanglement, and a high signal on compression lipid imaging, while the right brachial plexus nerve bundle alignment was normal with no obvious abnormal signal. There were multiple somewhat large lymph nodes in the neck, with the largest being approximately 0.8 cm in short diameter located in the left carotid sheath area .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1820_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1820_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..186ee70af49ba25d7c6b880546ddfca3339a521d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1820_en.txt
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+A 40-year-old woman, G4P1, was admitted in October 2021 due to pain in the right lower abdomen that had persisted for eight years. Additionally, she had been experiencing an aggravation of this pain, accompanied by a sensation of abdominal expansion, for the past month. The patient had a cesarean in 2009 and a laparoscopic myomectomy in 2012 for a uterine fibroid (5 cm) at A hospital. She experienced right lower abdominal pain from 2013. In 2015 and 2018, she had surgeries to remove uterine fibroids and ovarian cysts at B and C hospitals, followed by six cycles of GnRH-a therapy. In November 2018, she received a hysteroscopic levonorgestrel-releasing intrauterine system at D Hospital and underwent an ultrasound-guided endometriomas puncture in 2019. In 2020, she had a total abdominal hysterectomy, right adnexectomy, left salpingectomy, left ovarian cyst removal, and intestinal adhesion lysis at D hospital. Pathology post-surgery revealed a pelvic nodule, leiomyoma, uterine and cervical adenomyoma, right accessory endometriosis, and left ovarian endometrioma. Following three cycles of postoperative GnRH-a therapy, an ultrasound re-examination revealed a 4 cm solid mass.
+However, the surgery did not alleviate the patient's right lower abdominal pain. As the pain gradually increased, oral painkillers became necessary for relief. In August 2021, a pelvic MRI and a contrast-enhanced MRI were conducted. They revealed a larger pelvic lesion (9.3 cm × 8.6 cm × 8.6 cm) than before, encroaching on the anterior rectum. Additionally, several nodules in the peritoneum and mesentery raised suspicions of malignancy (at E hospital). A subsequent biopsy of the pelvic cystic lesion suggested a smooth muscle tumor. However, the evidence for malignancy was inconclusive (at F hospital) . The patient declined oral medication with highly effective progestogen, fearing thrombosis.
+Exacerbating right lower abdominal pain, a heavy feeling, and sporadic back pain led the patient to seek help at the Aerospace Center Hospital. This pain lasted one to 7 h and could be alleviated with oral tramadol. Finally, it is noteworthy that the patient had a two-year history of smoking, consuming seven cigarettes daily. However, she quit smoking five years ago.
+Physical examinations showed the patient in visible pain with a forced posture. The abdomen was soft and tender in the lower part, with no rebound tenderness. A pelvic examination revealed no hymen or obstruction in the vagina, and the previously sutured end remained smooth. A 10 cm mass was palpable in the pelvic cavity, fixed in the anterior rectum. It had a clear boundary, hard texture, significant tenderness, and limited mobility. The rectal mucosa was smooth, with another hard mass palpable 7 cm from the anus. This mass was mobile and without tenderness or bleeding upon digital rectal examination.
+An MRI and CT scan of the pelvic area revealed an irregular mass and multiple nodules considered malignant (A–G). During surgery, a solid mass sized 1 cm × 0.9 cm x 1 cm was found in the lower pelvis. Many nodules were scattered over the pelvic and abdominal organs (A–D). The patient's CA125 level was 35.08 U/ml (see ).
+The exploratory laparotomy was performed in October 2021 at Aerospace Center Hospital. There were no detectable free ascites. Miliary nodules were present beneath the original incision site. The peritoneum of various areas had scattered miliary nodules ranging from 0.2 to 0.5 cm. Denser nodules of 0.5–1.5 cm were seen in the descending colon and related areas. Neoplastic adhesions sealed the pelvic cavity. During the operation, tissue was collected for pathology. Results hinted at a recurrent LPD spindle cell tumor. The patient then underwent CRS. Multiple resections were performed, including of the pelvic peritoneum, vaginal stump, and others. Full cytoreduction was achieved, denoted by a CC score 0 (E and F).
+The patient had extensive abdominal nodules. Frozen section pathology indicated potential malignancy. Following family consultation, HIPEC treatment with 80 mg cisplatin in 4000 ml saline occurred. It was a challenging seven-hour surgery, with a blood loss of 900 ml. The patient was moved to intensive care afterward. Postoperative pathology showed multiple spindle cell tumors across various areas, with sizes from 0.5 cm × 0.5 cm × 0.5 cm–10 cm × 8 cm × 8 cm. Other findings included a pelvic tumor from endometriosis, a corpus luteum and corpus albicans in the left ovary, and chronic appendicitis. The fibrofatty tissues in the ligamentum teres hepatis and tumors were not detectable. Immunohistochemistry showed positive results for CD34, SMA, desmin, focal CD10, ER, PR, and 2% Ki-67, but negative for CD117, S-100, and Dog-1 (A–I).
+Eleven days post-surgery, the patient was discharged. She was followed up for 13 months, showing tumor-free survival (H–I). While abdominal pain was gone, menopausal symptoms arose. Hormone tests showed luteinizing hormone at 44.87 IU/L, follicle-stimulating hormone at 108.8 IU/L, prolactin at 6.62 μg/L, progesterone at 0.16 ng/mL, estradiol less than 15 pg/ml, and testosterone at 12.08 ng/dL. The CA125 level fell to 4.0 U/ml.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1836_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1836_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..060ebb19459fffb0d29b28d1f8f710f386dd5f06
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1836_en.txt
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+A 28-year-old pregnant woman, was in the first pregnancy, has not delivered and was in good health. She denied a history of familial or genetic disease. Routine obstetric care was performed during pregnancy. Serological prenatal screening showed low risk and no abnormalities in prenatal ultrasound (double kidney size between –1 SD). In the pregnant metaphase, 2 ultrasounds showed that good fetal heart and fetal movement, but did not indicate the size of both kidneys. At the 33 + 4 weeks of pregnancy, ultrasound examination showed that the size of the left kidney was 21*12 mm (–5.09 SD, average longitudinal diameter is 44.72 mm), the anteroposternal diameter of the left renal pelvis was 6.7 mm, and the size of the right kidney was 31*23 mm (–2.94 SD) . The echo of both kidneys was slightly stronger, and the amniotic fluid volume was normal. Ultrasound examination of adult urinary system of fetal parents showed no abnormality.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1851_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1851_en.txt
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index 0000000000000000000000000000000000000000..bee6eecb5e645a54a661c4929bb136e49a88b14b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1851_en.txt
@@ -0,0 +1,4 @@
+A 51-year-old female patient with a 27-year history of bipolar disorder was admitted to the psychiatric clinic in September 2017 due to depressed mood, ideas of reference, delusions of persecution and anxiety. It was known from her medical history that her first psychotic episode (acute paranoid syndrome) occurred in 1990. The patient was hospitalized for a few weeks and was treated with antipsychotic drug (perazine) with a good result. Within the next 10 years the patient was hospitalized 4 times and diagnosed with depression and mania. The depressive episodes were treated with different antidepressant drugs (imipramine, perazine and venlafaxine) in combination with mood stabilizers (carbamazepine and/or lithium), whereas antipsychotic drugs were used to treat the mania. After the last hospitalization (in 2000) for depression, the patient continued her treatment (imipramine, perazine, lithium and carbamazepine) as an out-patient until 2008. The treatment of the patient was modified due to fluctuations in her mental state. Imipramine and carbamazepine were withdrawn and fluoxetine was commenced. In 2015, the patient was hospitalized owning to acute intoxication with lithium (> 1.2 mmol/l), renal failure and extrapyramidal symptoms. Lithium was withdrawn and gabapentine was initiated for the extrapyramidal symptoms. In addition, hypothyroidism was diagnosed and levothyroxine was prescribed, which patient took until 2016. Within the next 2 years the patient was taking fluoxetine (60 mg/d), perazine (150 mg/d) and gabapentine (800 mg/d). During that time carbamazepine was commenced (200 mg/d, max. to 800 mg/d) to stabilize the patient’s mood, but owing to severe deterioration of her mental state (intensification of both psychotic and depressive symptoms), the drug was withdrawn and lithium (max.1000 mg/d) was reintroduced. Additionally, olanzapine (5 mg/d) for psychotic symptoms and biperiden (4 mg/d) for muscle stiffness were added. Throughout the disease (since the first psychotic episode in 1990 until the last hospitalization in 2017), there were no psychiatric comorbidities diagnosed. Periodic hypothyroidism (in 2015) treated with levothyroxine and renal failure caused by acute intoxication with lithium were notable for the patient’s history.
+The patient was admitted to the psychiatric clinic in September 2017 due to depressed mood, ideas of reference, delusions of persecution and anxiety. During her admission disturbances of consciousness were not observed and the patient was auto- and allopsychically orientated. The patient’s general condition was good (blood pressure: 115/70 mmHg, pulse 72, respiratory rate16/min and BMI 27,22). A regular systolic murmur was noted and lungs were clear bilaterally. The abdomen was symmetrical without distention and bowel sounds were normal in quality and intensity in all areas. The patient had dry skin and varicose veins of the lower extremities. Her laboratory results showed lithium levels of 1.48 mmol/l, GFR 35 ml/min, creatinine 1.56 mg/dl and WBC 10.42 × 10^3/ml. A urinary tract infection was diagnosed (leukocytosis 10.2 × 10^3/ml, positive result of urine inoculation-Klebsiella oxytoca) and antibiotic therapy was initiated (sulfamethoxazole with trimethoprim). After 5 days of treatment her physical state deteriorated, she developed a fever of 38.4 °C and her laboratory results revealed a toxic level of lithium carbonate 2.34 mmol/l, creatinine 2.05 mg/dl and GFR 25 ml/min. Acute renal failure was diagnosed by a nephrologist and as a result the lithium was withdrawn and the antibiotic therapy was replaced with ceftriaxone 2 g/d (lower nephrotoxicity). Normal saline was administered to the patient for two days in order to decrease the toxic level of lithium. The patient’s general condition and laboratory findings improved (level of lithium 1.34 mmol/l, creatinine 1.94 mg/l, GFR 27 ml/min), and 7 days later the antibiotic therapy was discontinued. Other laboratory results (biochemistry, hematology, lipidemia, ions and hormone levels- TSH, fT3, fT4) were found to be within normal range, so other somatic disorders, apart from renal failure, were excluded.
+After stabilization of her somatic condition, and despite her treatment (the patient was continuing treatment with fluoxetine 60 mg/d, olanzapine 5 mg/d, gabapentin 800 mg/d, perazine 150 mg/d and biperiden 4 mg/d), the patient’s mental state deteriorated significantly (depressed mood, ideas of reference, aggravated delusions of persecution), so the treatment was changed accordingly. All drugs taken by the patient so far were gradually withdrawn (olanzapine and perazine over 6 days; fluoxetine over 4 weeks, gabapentine over 3 weeks and biperiden over 1 week) and lamotrigine (200 mg/d) and aripiprazole (30 mg/d) were initiated. Lamotrigine was used to replace lithium, as it is a good mood stabilizer without any nephrotoxic influence on the kidneys. Lamotrigine was commenced at a dose of 25 mg/d, which the patient took for 2 weeks. The dosage was then increased to 50 mg/d for a week, and then incrementally increased each week up to the final dose of 200 mg/d. Aripiprazole was initiated at a dose of 7.5 mg/d in order to reduce delusions and was uptitrated to the final dose of 30 mg/d over 2 weeks. As a result of the insufficient effectiveness of aripiprazole and lamotrigine treatment, which lasted 6 weeks, (ideas of reference, delusions of persecutions were maintained and problems with sleep), quetiapine was added (50 mg/d) in the 6th week. A partial good response to the treatment was observed after 7 days (partial reduction of delusions and mood stabilization), so the doctors decided to uptitrate the quetiapine dose to 400 mg/d, which took 9 days. Further treatment with aripirazole, lamotrigine and quetiapine resulted in NMS development. A description of NMS and its treatment is presented in Table .
+To assess and quantify the causal role of antipsychotic drugs in the mediation of NMS, the Adverse Drug Reaction (ADR) Probability Scale was used. According to this scale each drug was assigned to a probability category on the basis of points, which were calculated as follows: aripiprazole 2, lamotrigine 3 and quetiapine 5. Number of points: > 9 means definitive adverse drug reaction; 5 to 8 points- probable adverse drug reaction; 1 to 4- possible adverse drug reaction and 0- doubtful adverse drug reaction .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1856_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1856_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b764f08da50662af7095a1e382884c942b01bb08
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1856_en.txt
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+We report the case of a 59-year-old female patient of Southeast-Asian descent who underwent deceased donor renal transplantation at our institution in August 2016. At the time of initial referral for transplant evaluation in 2011, she had advanced chronic kidney disease but had not started dialysis. Medical records indicated that she had a slow rise in serum creatinine since 2006 but had never undergone a renal biopsy. No specific etiology had been ascribed to her kidney disease. Due to a history of 5 pregnancies that culminated in 3 live births and 2 miscarriages, she was broadly sensitized to human leukocyte antigens (HLA). Routine screening for anti-HLA antibodies with a Luminex-based solid-phase assay using single-antigen beads detected multiple class I and class II HLA antibodies in April 2016. Based on our institutional policy to denote HLA, to which antibodies of a strength greater than 4,000 mean fluorescence intensity (MFI) units are detected in the transplant candidate serum, as unacceptable, our patient's calculated panel reactive antibody (CPRA) level was 93%.
+After an approximate wait-time of 5 years, she received an organ offer from a 46-year-old male deceased donor, who succumbed to a self-inflicted gunshot wound to the head. The deceased donor had a terminal creatinine of 1.2 mg/dL, and the organ offered was assigned a kidney donor profile index of 38%. Pre-implantation biopsy of the transplanted kidney demonstrated glomerulosclerosis in 4 out of 78 sampled glomeruli. Fibrosis affecting up to 10% of the tubule interstitium, mild arteriosclerosis, and patchy areas of acute tubular necrosis were also noted. Donor and recipient were blood type compatible (ABO type A). Complement-dependent cytotoxicity and flow cytometry-based cross-match testing of the current recipient's serum with donor T and B lymphocytes were negative. However, donor-specific antibodies (DSA) to class I antigen-HLA B45 (MFI 3,182) and class II antigen-DQ6 (MFI 3,802) were detected by Luminex-based solid-phase assay in the serum sample from April 2016. We consider antibody strength of MFI 2,000 or greater to be clinically significant. Since this suggested prior sensitization to donor HLA, the risk of early antibody-mediated rejection (AMR) due to a memory B-cell response was predicted to be high. Transplant surgery was uneventful with minimal intra-operative blood loss, and the organ incurred a cold-ischemia time of 15 h.
+Immunosuppressive therapy for induction consisted of 6 mg/kg of intravenous (IV) antithymocyte globulin given in divided doses over 4 days; tapering doses of IV methylprednisolone given on postoperative days (PODs) 0–4. In addition, 375 mg/m2 of rituximab was administered on POD 1 to suppress humoral alloimmune response. For maintenance immunosuppressive therapy, the patient began receiving 1,000 mg of oral mycophenolate mofetil twice daily from POD 0. Excellent urine output of 1.3 L was noted in the first 12 h after transplant, and tacrolimus was initiated on POD 1. Tapering doses of oral prednisone were started on POD 5. The serum creatinine levels declined steadily from 7.9 mg/dL (pre-transplant) to 1.9 mg/dL by POD 5, and the patient did not require dialysis.
+However, the hemoglobin trended down to 6.8 g/dL (baseline: 9.8 g/dL), and the platelet count gradually decreased to 61,000/µL (baseline: 302,000/µL) by POD 6. Alarmingly, the patient's creatinine rose to 2.9 mg/dL and then to 3.3 mg/dL in the 24-h period between POD 5 and POD 6. Lactate dehydrogenase was elevated at 1,016 U/L (reference range: 313–618 U/L), and haptoglobin was <10 mg/dL (reference range: 30–200 mg/dL). The corresponding tacrolimus trough level was 5 ng/mL. Renal allograft ultrasound demonstrated mildly heterogeneous echotexture of the transplant kidney, and Doppler evaluation of the intraparenchymal vessels showed resistive indices ranging from 0.80 to 0.83. One unit of apheresis platelets was transfused, and the patient underwent an urgent ultrasound-guided renal allograft biopsy. In the 6 h preceding the biopsy, the patient's recorded urine output was 100 mL. The patient's blood pressure remained stable with a systolic blood pressure of approximately 140 mm Hg throughout the hospitalization leading up to the biopsy.
+An adequate biopsy sample consisting of 2 cores of cortical tissue exhibiting 26 glomeruli and 4 interlobular arteries was obtained. No immediate biopsy-related complications occurred. The most prominent finding on light microscopic examination was the demonstration of fibrin thrombi involving 1 arteriole and capillary loops in 2 glomeruli . Isometric cytoplasmic vacuolization of tubular epithelial cells and arteriolar myocytes was also apparent. There was no evidence of microvascular or tubulointerstitial inflammation. C4d was negative by immunofluorescence microscopy. Electron microscopy revealed diffuse swelling of glomerular capillary endothelial cells and cytoplasmic vacuolization of tubular epithelial cells. Histologic correlates of acute AMR were striking in their absence. DSA that were scored positive in the pretransplant serum sample were not detectable in the serum sample tested on the day of the biopsy (HLA B45: pretransplant MFI 3,182 vs. POD 6 MFI 1,438; DQ6: pretransplant MFI 3,082 vs. POD 6 MFI 640). Histopathologic features noted on the renal allograft biopsy, taken together with clinical and laboratory findings, suggested that CNI-induced de novo post-transplant HUS was the most proximate cause of acute oliguric renal failure in this case .
+Tacrolimus was discontinued. A reversal of the upward trend in creatinine was immediately apparent after withholding the CNI. Creatinine improved to 2.4, 1.8, and 1 mg/dL in the 3 succeeding days. The patient received a transfusion of 1 unit of packed red blood cells after the kidney biopsy following which hemoglobin improved from 6.8 to 8.6 g/dL and steadily improved to 10.1 g/dL in the following 2 weeks. In the same period, a significant improvement in platelet count occurred (61,000–348,000/µL). Substitution of tacrolimus with another CNI, cyclosporine (CsA), was considered, but we favored the introduction of maintenance immunosuppression with a costimulatory blocker, belatacept, instead, given emerging evidence of its efficacy in highly sensitized renal transplant recipients. The first dose of IV belatacept (5 mg/kg) was administered on POD 9 (3 days after the diagnosis of TMA). The patient received 5 mg/kg of IV belatacept every 2 weeks thereafter for 2 months and was then transitioned to a 5 mg/kg once monthly dosing regimen. Twelve months after transplant, she continues to have excellent renal allograft function with a serum creatinine of 0.7 mg/dL and has had no recurrence of hematologic abnormalities. Her most recent hemoglobin and platelet count were 12.3 g/dL and 271,000/µL, respectively .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1874_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1874_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5dfa7fa623c5ce0db1a5ddc2ed10565769ec495b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1874_en.txt
@@ -0,0 +1,3 @@
+A 25-year-old male presented to our hospital in drowsy state with history of headache for 3 years progressively worsening for 6 months. His Glasgow Coma Scale was 13/15, magnetic resonance imaging (MRI) brain revealed giant left lateral sphenoid wing meningioma measuring 8 × 7 × 5 cm3 with no encasement of major blood vessels . Preoperative embolization was not feasible. Hence left external carotid artery (ECA) was exposed in the neck and kept occluded. Large fronto-temporal scalp flap was raised after adequate infiltration of local anesthetic with adrenaline, and use of Raney's clips. Large fronto-temporal free bone flap was raised with craniotome and temporal bone rongeured flush with middle cranial fossa. Profuse bleeding of bone edges was controlled with bone wax. Bipolar coagulation of middle meningeal artery and other vessels over the dura was carried out. Dura was opened just around the tumor, and reflected as a flap detaching it from the underlying tumor. The tumor surface was studded with blood vessels. Bipolar coagulation was performed all around the exposed tumor surface thereby devascularizing and shrinking the tumor. Gradually the tumor started to separate from the arachnoid plane and started to bulge in a pulsatile manner . Progressively deeper circumferential dissection carried out with placement of patties protecting the adjacent arachnoid layer. It appeared as if the brain pulsations were gently pushing the tumor out of the dural defect. No retractor or tumor manipulation was used throughout the procedure and finally, the whole tumor was delivered en bloc . The blood loss was around 500 ml, most of which occurred during craniotomy. Patch duraplasty was carried out using pericranium, and layered closure performed. Postoperatively the patient had improved remarkably, contrast enhanced computed tomography (CECT) showing no residual tumor, and was discharged in good functional status on fourth day . This ‘en bloc’ technique, as elaborated below, has been utilized in a series of seven more large meningiomas (>5 cm) safely with less blood loss.
+Patients with meningioma were positioned intraoperatively so that tumor was more superficial than brain. Sufficiently large basal craniotomy was carried out. Meningiomas with suspected encasement of neurovascular structures and significant interposition of brain around the tumor attachment were considered for internal decompression before dissection of tumor capsule. However, meningiomas with no contraindication as above were taken up for surgery with the rule of 4 D's: Devascularization, Diminutive dural opening, Detachment, and either Debulking followed by dissection or Dissection without debulking. After extensive coagulation of dural surface vessels, dural opening was made just at the tumor margin, so that surrounding brain was not exposed. The decision on performing internal decompression was made following early severance of dural attachment. Whenever arachnoid plane appeared favorable, dissection was carried out without debulking, and nearly always the tumor was pushed gradually by the underlying brain pulsations and edema so that the tumor gets delivered en bloc. The main advantages of ‘en bloc’ removal appear to be lesser bleeding and shorter operative time. The limited dural opening cannot be overemphasized to avoid herniation of the edematous brain being pushed out by the tumor. Also if tumor cannot be freed of its attachment in the initial phase of surgery internal debulking becomes unavoidable.
+Of the total 35 large meningiomas (>5 cm) operated by us in 2 years, 8 patients had en bloc removal while the rest had initial debulking. The mean blood loss in en bloc removal was around 400 ml, with no patient having new neurological deficit, new onset seizures, or postoperative hematomas.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1879_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1879_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3c3fdb45919bda80e355b4176f1bf345eb6a7328
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1879_en.txt
@@ -0,0 +1,6 @@
+A 61-year-old African American male with past medical history of hypertension and schizophrenia presented to the emergency room following 2 episodes of syncope.
+He reported 3 month history of progressive neck mass. Physical examination revealed a temperature of 37.7 degrees, blood pressure of 130/87 mmHg, pulse of 92 bpm, and respiratory rate of 17 bpm. There was extremely large left sided neck mass extending into the left axilla and multiple palpable left and right cervical lymph nodes. The lungs were clear to auscultation, and there was a 2/6 systolic ejection murmur heard best at the bases. The abdomen was soft and nontender, without palpable organomegaly. There was a 5x2 cm right gluteal non-tender, non-mobile mass with central ulceration and also a 2x2 cm spherical mass at the left upper back with small central ulceration. There was 2+ pitting edema of the lower extremities bilaterally. There was differential swelling of left upper extremity. Electrocardiogram showed normal sinus rhythm, left axis deviation, low voltage and mild t wave inversion in V2–V4 .
+Initial CT scan of the abdomen and pelvis showed diffuse metastatic disease of the visualized lower chest, abdomen and pelvis including superficial soft tissues, left kidney, and probable right kidney. There was diffuse confluent adenopathy and massive right inguinal lymphadenopathy, along with pronounced diffuse anasarca. There are multiple renal masses. There are solid masses arising off of the lateral aspect of the left kidney involving the upper, middle and lower lobe . The left kidney mass was described as an exophytic lesion. There was a mass along the anterior aspect of the heart that measures approximately 5 cm but incompletely visualized. CT head was negative.
+Transthoracic echocardiogram revealed a large mass measuring 4.8 cm x 3.0 cm extending from the apex to the mid RV cavity, and extending into the RV outflow tract stopping just short of the pulmonic valve . There was deformation of the RV free wall suggesting invasion of the myocardial wall and a malignant growth. There was mild RV enlargement, with normal function of the segments not involved in mass. There RA was mildly dilated with no mass seen, and there was no evidence of thrombus in the IVC. There was a small pericardial effusion without echocardiographic evidence of tamponade. A dedicated CT of the thorax revealed a mildly enlarged heart, and a filling defect in the RV measuring 6 cm extending to the apex and suspicious for malignancy .
+A core biopsy of the right superficial gluteal mass revealed a tumor arranged in solid nests having abundant eosinophilic cytoplasm, central nucleus and conspicuous nucleoli, with areas of coagulative tumor necrosis, and individual tumor cell exhibiting high-grade atypia with pleomorphism .
+On immunohistochemistry, the tumor cells expressed pacytokeratin, PAX 8, vimentin and CD 10 (weakly). The tumor cells are negative for S 100, Melan-A and RCC. Immunostains for CD 117 and CK 7 were performed, however were uninterpretable due to tissue depletion. Morphology and immunohistochemical profile favor a metastatic poorly differentiated carcinoma of likely renal origin, with a possibility of an unclassified RCC. Oncology was consulted and they suggested a diffuse metastatic malignancy of primary renal origin with poor prognosis. Oncology advised that the patient should follow up in outpatient cancer clinic. Due to extent and burden of metastasis, patient and family members agreed to conservative management and patient was placed in hospice and comfort care with no further aggressive management. He was discharged from the hospital to hospice and to follow-up with the cancer clinic, although there were no records that he kept the appointments and he was lost to follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1892_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1892_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a098967abd2d3ce40881311b86c52f154009be7a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1892_en.txt
@@ -0,0 +1,3 @@
+An 11-year-old male referred to the outpatient Department of Otorhinolaryngology with a complaint of throat irritation and hoarseness of voice over the past 3 months. He had no history of breathing difficulty, dysphagia, upper respiratory tract contamination, voice misuse, tobacco use, and previous radiation presentation. Moreover, there was no family history of head and neck malignancy or any hereditary variation from the norm related to the improvement of laryngeal carcinoma in youth.His past medical history was unremarkable. Indirect laryngoscopy revealed a growth in the left vocal cord. Fiberoptic nasopharyngolaryngoscopy showed an irregular growth in the left vocal cord with impaired cord mobility . There was no supraglottic and subglottic extension of the growth and swollen lymph node in neck. Computed tomography (CT) scan and magnetic resonance imaging (MRI) of the neck showed enhancement in the left vocal cord; moreover, other parts of the neck were within normal limit .
+Furthermore, no invasion or extralaryngeal spread to laryngeal cartilages was observed in this case report. In addition, thoracic CT scan was not indicative of distant metastasis. A biopsy was done under general anesthesia and histopathological examination showed moderately differentiated non-keratinizing squamous cell carcinoma .
+It was inferred that the child had stage 1 glottic cancer (i.e., T1N0M0). Given the early stage of this disease, the patient was subjected to radiotherapy. After the fulfillment of radiotherapy, larynx was again inspected with no proof of lesion after 3 months . The patient did not require tracheostomy due to the treatment of laryngeal carcinoma and satisfactory laryngotracheal airway.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1895_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1895_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..05a7466a1d4b3d9f96fda021155474bbfc6eb96c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1895_en.txt
@@ -0,0 +1,3 @@
+A 50-year-old otherwise healthy lady presented with complains of mild headache and diplopia for 8 weeks duration. On examination, she had the right lateral rectus palsy with diminished right corneal reflex. Radiology showed lesion extending from the cerebellopontine angle to the middle cranial fossa straddling across the petrous apex with its erosion [-]. There were mild ventriculomegaly and early papilledema for which a ventriculoperitoneal shunt was placed. Her headache improved and diplopia disappeared, though the sixth nerve paresis was apparent on examination.
+The patient was offered surgery. However, she opted for upfront GKRS with presumptive diagnosis of trigeminal schwannoma. As the lesion was close to the brainstem, total dose of 25 Gy was administered. The patient was regularly followed up and showed no symptoms for a decade. Sequential MRI showed no increase in size or change in character of lesion [-]. However, in the past 6 months, she presented with features of pseudobulbar palsy (severe ataxia, difficulty in swallowing, change in voice, and spasticity) and the radiology showed significant increase in size of the lesion with brainstem compression and heterogeneous contrast enhancement [-].
+She was operated through the right temporal craniotomy and interdural approach (by senior author PS). The tumor was grayish, fleshy with mild vascularity with a plane from the fifth nerve fascicles. Through the expanded Meckel’s cave, the component from posterior fossa was excised. Histopathology confirmed chondrosarcoma Grade II . Tumor cells were positive for S-100 and vimentin . The patient improved clinically and doing well at 8-month follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1905_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1905_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a6f63612f11f9dc116d014e7f6d5118ed3fbd826
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1905_en.txt
@@ -0,0 +1,4 @@
+A 4-day-old baby girl was referred from a paediatric tertiary care hospital for the genetic evaluation of bilateral asymmetric ectrodactyly. She is the second child of a non-consanguineous couple; a 25-year-old father and 23-year-old mother. The baby was delivered normally at term following an uncomplicated pregnancy. The birth weight was 2.5 kg and there were no post-natal complications. She had ectrodactyly involving three limbs, with the absence of the third digit on the left hand and the second and third digits on the right hand. The right thumb was clinically normal, but the fourth and fifth digits were malformed. The right foot had fixed clubfoot deformity with only 2 toes . There was no facial dysmorphism or facial clefts. Radiographs of the upper limbs showed complete absence of the metacarpal bone and the phalanges of the third digit in the left hand and absent metacarpals and phalanges of two digits on the right hand . During a subsequent evaluation of the proband at the pediatric clinic, right tibial hemimelia was documented in the patient’s medical records by the attending clinician, but the radiological images of the leg were not available for inclusion in this article. Cardiovascular, respiratory and abdominal examination showed no abnormalities. Ultrasonography of the abdomen, brain and bilateral hips were normal.
+The mother also had bilateral ectrodactyly involving both hands, with the absence of the third digit on the right hand and two digits on the left hand. She had bi-phalangeal fifth digit on the left hand . She had not previously been investigated for this condition and was otherwise healthy without any remarkable events in the medical and obstetrics history. The first child of the couple who was aged 2 ½ years old at the time of consultation had normal growth and development with no congenital anomalies. There were no other family members or close relatives affected with similar limb deformities or other congenital anomalies.
+Peripheral venous blood samples were obtained from the baby and the mother with informed written consent. Genomic DNA was extracted from the blood samples and quantitative polymerase chain reaction (qPCR) was performed to identify rearrangements of the BHLHA9 gene (Chr17:1173858–1,174,565, hg19)(Ref Seq BHLHA9:NM_001164405). The RPPH1 gene (NR_002312) was used as the gene of reference. The qPCR results showed a BHLHA9/RPPH1 ratio of 1.46 in the baby and 1.50 in the mother confirming the BHLHA9 gene duplication. The unaffected sibling was not available for genetic assessment of her BHLHA9 status. Genetic counseling was offered to the family.
+At the time of reporting, the baby was 10 months of age. Her body weight was 7.95 kg (25th centile), length was 72 cm (above 50th centile) and head circumference was 44 cm (between 25th and 50th centile). She had age-appropriate developmental milestones. Hearing and visual assessments were normal. Repeat ultrasonography of the brain and the abdomen showed no abnormalities. 2D-echocardiography showed a structurally and functionally normal heart. She is currently being followed up at the pediatric tertiary care hospital and awaiting reconstructive surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1923_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1923_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..3647a7e140b19f5a34427f788083f30470dbc405
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1923_en.txt
@@ -0,0 +1,3 @@
+A 31-year-old man was admitted to our department because of acute abdominal pain, nausea, vomiting and anxiety of ten hours duration. On physical examination severe abdominal tenderness was marked, localized to the right lower abdomen aggravated on walking and coughing. His temperature was 37.8 degrees celcius and his pulse rate 92 bpm. Laboratory investigation disclosed a white blood count of 16,800/mm3, neutrofils 72% with left shift and elevated erythrocyte sedimentation rate (ESR) and C reactive protein (CRP).
+All other hematological and biochemical parameters were within normal range. Clinical presentation and laboratory findings suggested acute appendicitis and laparotomy was performed. Through a right paramedian subumbilical incision the right iliac fossa was explored and a grossly inflamed omental mass was revealed and resected. .
+A small amount of fluid was seen. The appendix was macroscopically normal and no other cause of acute abdomen was identified. The pathology of the surgical specimen reported primary omentitis. The patient made an uneventful recovery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1924_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1924_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c456c7c7f84b5d1843203728a00c969ff628dec6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1924_en.txt
@@ -0,0 +1,3 @@
+A 48-year-old man presented to the orthopedic oncology outpatient department with multiple large soft-tissue swellings over the dorsum of hands, extensor aspects of his elbows, knees, and feet . The swellings were also present over his heels overlying the Achilles tendons. The swellings started when the patient was 26 years of age and gradually kept on increasing in size to their present-day form. These swellings varied in size from 2 cm × 2 cm of few swellings over the dorsum of hands to 12 cm × 10 cm over the dorsum of feet. On examination, these swellings were firm, non-tender, mobile, and few swellings had developed overlying skin changes in the form of reddish-yellow discoloration and stretched-out appearance. The family history was unremarkable. Blood investigations (hemogram, serum electrolytes, liver enzymes, renal function, and blood glucose) and chest radiographs which the patient was carrying were completely normal. A dermatology consult was sought and based on the clinical history and appearance of the swellings; a provisional diagnosis of Multiple Xanthomas was considered. The lipid profile of the patient was got done and it revealed very high serum cholesterol and serum LDL (Low-density lipoproteins) levels. His lipid profile was as follows: Total cholesterol: 476 mg/dL; low-density lipoprotein (LDL): 361 mg/dL; triglyceride (TG): 103 mg/dL; very LDL (VLDL): 24 mg/dL; and high-density lipoprotein (HDL): 50 mg/dL. The lipid profile derangement pattern was suggestive of Type IIa FH.
+Since, the patient had extremely large swellings at certain regions, due to which he experienced trouble in kneeling and walking, a surgical plan to excise the symptomatic swellings – over the elbow, over the patellar region, and over the heel was made. The excised swellings were sent for histopathological examination. The gross cut surface of the swellings was reported to be firm with yellowish to orangish nodular appearance. On microscopy, all soft-tissue swellings had a similar morphological appearance consisting of nodules composed of sheets of foamy histiocytes, numerous cholesterol clefts, and giant cells in dermis and subcutis . The final histopathological report was consistent with a diagnosis of xanthomas. The patient recovered uneventfully following the surgery.
+Since the patient was diagnosed with hypercholesterolemia, the patient was started on lipid-lowering medications including high dose statins with niacin. He also underwent a cardiac evaluation to see for systemic manifestations of hypercholesterolemia including atherosclerosis and coronary artery disease. The patient was strongly positive for exercise-induced ischemia on treadmill exercise stress test and subsequently started on appropriate cardiac medications. At the last follow-up with us, the patient reported improvement in his lipid profile and a generalized global reduction of the size of the remaining xanthomas, with no development of any new lesions.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_192_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_192_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..887f23347f914c7e25dbb63e0f217c20f0f0e32b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_192_en.txt
@@ -0,0 +1 @@
+A 49-year-old female presented with progressive weakness of both lower extremities of 2 years duration (i.e., bed-ridden). She was originally misdiagnosed with multiple sclerosis (MS). On examination, she exhibited a severe spastic paraparesis with hyperactive reflexes/bilateral Babinski signs. The thoracic MRI demonstrated a focal intramedullary lesion with an exophytic component at the T6 level with a mixed T2 signal intensity [Figure 1]. Utilizing an operating microscope, the patient underwent a laminectomy and midline myelotomy resulting in gross- total tumor excision [Figure 2]. The lesion proved to be a mature teratoma [Figure 3]. On the 10-day postoperative, MRI confirmed complete tumor resection [Figure 4]. Ten months later, her right lower extremity strength had dramatically improved, but left lower paresis remained unchanged.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1945_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1945_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..652ad79c64b6968d48e762942b0763583a3d1ae4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1945_en.txt
@@ -0,0 +1,3 @@
+A 45-year-old man previously injured by a chest shotgun was referred to our Institution for a retained bullet in the left ventricle. The patient’s medical history included hypertension, diabetes, and thyroid dysfunction.
+One month before the admission, the patient underwent an emergency cardiorrhaphy through a left thoracotomy. At that time, the patient was in a war zone, and the previous emergent operation was performed by a general surgeon with the aim to stop the bleeding. At the time of hospitalization, the patient was in stable clinical conditions with sporadic atypical chest pains and rate-dependant left bundle branch block (LBBB). At presentation, the physical examination did not showed pathological signs, except for a left thoracic wound. Blood tests, including markers of cardiac injury, were all within normal limits. Transthoracic echocardiography showed the bullet retained within the left ventricular chamber localized into the posterior wall underneath the posterior mitral leaflet without signs of valve dysfunction or systolic dysfunction . Chest X-ray and angio-computed tomography (CT) scan confirmed the presence of the missile in the left ventricle wedged within the tendineal chordae underneath the posterior mitral leaflet .
+Preoperative workup included a coronary angiogram showing unobstructed coronary arteries. After multidisciplinary discussion at the Heart Team, we decided to proceed with the surgical removal of the RCM. The operation was performed through median sternotomy with routine cardiopulmonary bypass. After aortic cross-clamping and cardioplegia delivery, the left atrium was opened, the posterior mitral leaflet was incised just above the RCM, and the bullet was removed . The edges were then sutured to re-establish continuity of P2 with a 4/0 braided suture. Posterior ring annuloplasty was then performed using a flexible Gore-tex band. The post-operative course was uneventful and the patient was discharged on the seventh post-operative day. Echocardiography performed at discharge did not revealed any residual mitral regurgitation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1951_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1951_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ab4d4e4d2e1c15b9488d192fc4960f42a16af52
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1951_en.txt
@@ -0,0 +1,8 @@
+A 37-year-old woman was admitted to our hospital in 2010 with complaints of headache, amenorrhea and acromegalic features. Her headache and amenorrhea had begun about one year ago. Past medical history was not significant and she had no prior history of diabetes, hypertension, hyperlipidemia, cardiac or pulmonary problems.
+Physical examination has revealed typical acromegalic features in her face and extremities. Her vital signs were in normal ranges and neurologic examination showed intact function of cranial nerves.
+Laboratory studies showed normal white blood cells, serum blood glucose and renal and liver function tests. Serum endocrinological testing revealed markedly elevated levels of IGF-1 and low levels of Follicle Stimulating Hormone (FSH) and Luteinizing Hormone (LH). Other endocrinological tests were within normal limits. On Oral Glucose Tolerance Test (OGTT), the serum Growth Hormone (GH) level has not suppressed in response to induced hyperglycemia.
+Skull X-ray examination demonstrated a slightly enlarged sella turcica. Computerized tomography revealed a pituitary mass without extra-sellar extension. Following clinical diagnosis, the tumor was completely excised via trans-nasal endoscopic approach. No residual tumor was found on post-operative MRI images. Histologically, the tumor was diagnosed as a pituitary adenoma with GH positive cells. The serum IGF1 levels gradually decreased to the normal range during the first year after surgery. The patient was symptom free for three and a half years when she returned with complaint of visual impairment. Perimetry test revealed visual field defect of bitemporal hemianopia.
+On her brain MRI, there was a mass in the sellar and supra-sellar region. In the sellar part, tumor extended to the right cavernous sinus (Knosp grade III) and also a supra-sellar extention to third ventricle floor and anteriorly to sub-frontal area was obvious. On coronal images with contrast injection, there was a slight peri-tumoral edema and the border of tumor adjunctive to brain paranchyma showed fair enhancement . On coronal view, there was very interesting radiologic appearance. Supra-sellar mass had grown independently into the remaining sellar part .
+Endocrinological studies revealed markedly elevated basal level of serum growth hormone. No autoimmune disease was found clinically or by serologic studies.
+Following local recurrence had been evident, surgical operation was performed via trans-nasal endoscopic approach. Dural adhesions from previous surgery were exposed. The tumor was removed by suction and curettage. After complete removal, operation cavity was checked by angled lenses. Vascular and neural structures were completely preserved.
+Surgical specimen fixation was done with 10% formalin and paraffin embedding and H&E staining was performed for histological examination. Immunohistochemistry with peroxidase method using antibodies against Prolactin, GH, LH, FSH, Thyroid Stimulating Hormone (TSH), Adrenocorticotropic Hormone (ACTH), P53, Ki67, Cluster of Differentiation 3 (CD3) and Cluster of Differentiation 20 (CD20) antigens was also performed. Histopathological examination of the surgical specimens revealed sheets and clusters of monomorphic cells with round to oval nuclei and eosinophilic cytoplasms invading brain tissue in irregular fashion. There was scattered dense intra-tumoral lymphoid follicle formation more prominent upon invasive parts. Some lymphoid follicles had germinal centers, too . An immunoperoxidase panel for anterior pituitary hormones showed sparsely granular immunoreactivity for GH and negative results for other pituitary hormones. CD3 and CD20 immunostaining was positive in 40% and 60% of infiltrating lymphoid cells, respectively. Additional staining for P53 was negative and Ki67 index was negligible (positive in < 0.8% of tumor cells).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1963_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1963_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4e3409d4df6266f05bef29d47c7f1811cbce1caa
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1963_en.txt
@@ -0,0 +1 @@
+A 62-year-old Asian man consulted a doctor because of asthmatoid wheeze, anarthria, purpura and gait disturbance. He has no history of hypertension. He pointed out proteinuria for the first time two months ago before the consultation. He was diagnosed with a cerebral hemorrhage following a computerized tomography scan . His laboratory findings revealed that his serum creatinine concentration was 0.66 mg/dl, his serum IgE concentration was 18230 IU/ml (normal: <170 IU/ml), and his eosinophil count was 18900/μl. His urinary analysis revealed 1.61 g/gCr of proteinuria. Coagulation tests revealed a prolonged activated partial thromboplastin time at 61.2 seconds and a prothrombin time of 25.5 seconds. In addition, FV activity alone severely decreased to 4.4% of normal, and an FV inhibitor was present at a titer of 2.5 BU/ml, suggesting the presence of antibody-mediated circulating inhibitors specific for FV . The patient was diagnosed with a cerebral hemorrhage, eosinophilia, hyper IgE syndrome and acquired FV inhibitors. Steroid therapy with prednisolone (1 mg/kg) for the treatment of purpura and acquired FV inhibitors was administered. Treatment with steroid led to the improvement of his clinical symptoms including purpura, normalization of the coagulation tests, and disappearance of eosinophilia. To confirm the diagnosis of proteinuria, we performed a renal biopsy. Fine granular depositions were observed at the subepithelial layer in the glomerulus upon IgG fluorescent staining . Spike formations were partially observed at the subepithelial layer upon Periodic acid-methenamine-silver (PAM) staining . An impaired lamina rara layer and endothelial cell swelling and detachment were observed with high-density deposits at the lamina rara externa upon electron microscopic analysis . We determined that the patient had developed MN with glomerular endothelial cell damage. After the administration of steroid therapy, the proteinuria improved gradually.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1967_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1967_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7d435fe6a96740302bcd0d360eb322964ecffbd8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1967_en.txt
@@ -0,0 +1,5 @@
+A 57-year-old Caucasian male with history of Crohn’s disease, colon cancer, and bilateral deep vein thrombosis (DVT) was referred to the Plastic Surgery Clinic from a dermatologist for a chronic, nonhealing skin lesion over the right lateral tibia, present for the past 13 years. The lesion was previously diagnosed as biopsy-proven pyoderma gangrenosum, being refractory to multiple treatment options, and passing through phases of waxing and waning severity. He is currently taking Humira, which has helped debulk the lesions. Past surgical history includes hydrocele excision, right ventral hernia repair with mesh, left groin lipoma excision, inferior vena cava (IVC) filter, colon resection, splenectomy, cholecystectomy, and leg DVT removal.
+Examination of the lesion revealed an irregularly shaped, raised, fungating, exophytic lesion with no bleeding or infection. The entire lesion measures 12.0 cm × 12.0 cm × 1 cm as shown in Fig. . Other skin changes seen on physical examination include bilateral hyperpigmentation of lower extremities, consistent with evidence of venous stasis. His Crohn’s disease is currently being managed, and on examination the abdomen was soft, nontender, with normoactive bowel sounds in all four quadrants and no evidence of organomegaly.
+The patient has no history of tobacco use or recreational drug use. He quit drinking alcohol 30 years ago.
+A punch biopsy of the right lateral tibia was performed four years prior, revealing lobular vascular proliferation within the dermis with associated hemosiderin and spongiosis of the epidermis consistent with stasis dermatitis. More recently, at the time of presentation, punch biopsies of the same area revealed invasive squamous cell carcinoma of verrucous type.
+An extremity venous limited ultrasound performed the month prior showed new partial compressibility of the proximal femoral vein and partial compressibility of the popliteal vein stable from 2019, unable to distinguish between acute nonocclusive thrombus within the proximal femoral vein versus manifestations of chronic DVT. X-ray of the right tibia/fibula, also performed the month prior, showed no acute osseus injury or aggressive osseous destruction of the tibia/fibula. Positron emission tomography/computed tomography from the patient's skull base to thigh performed month of presentation showed a large, intensely hypermetabolic lesion along the skin of the right calf, measuring up to 105 mm, with no clear delineation between the two suspected process, pyoderma gangrenosum and squamous cell carcinoma. Imaging findings displayed hypermetabolic, enlarged right inguinal and external iliac lymph nodes, noted to be a non-specific finding in this context. It was noted that chronic wounds or metastasis may display this pattern, size, and degree of uptake. No evidence of distant metastasis was found.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1973_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1973_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a6a12b82859837f519b2bfdbc9fa00cc8df2a912
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1973_en.txt
@@ -0,0 +1,6 @@
+A 54-year-old woman with a 10-year history of a reversible bulge in her right sacrococcygeal region presented to our outpatient clinic.
+The bulge disappeared in the prone position and appeared when standing. In addition, she complained of long-term constipation. There was no regional or abdominal pain, no nausea and vomiting, and no abdominal distention in her course of disease. In the past ten years, she had not received any relevant examination or treatment. Noticing that the bulge was increasing in size gradually, she came to seek treatment and then was admitted to our inpatient ward.
+The patient denied a history of chronic diseases or infectious diseases. She had a history of caesarean section 17 years ago but no trauma or blood transfusion. She also had no known drug or food allergies.
+A bulge in the right sacrococcygeal region was revealed upon standing, which was approximately 8 cm × 8 cm in size and soft in palpation with no tenderness . In the prone position, the bulge returned spontaneously but relapsed when performing the Valsalva manoeuvre. The abdomen was flat, with an old surgical scar in the hypogastric zone.
+Laboratory examinations performed in the ward included routine blood tests and biochemistry examinations. All results were within normal limits.
+Doppler ultrasound detected a bulge in the bowel when there was an increase in abdominal pressure, which returned to the abdominal cavity after loosening. Computed tomography confirmed the Doppler ultrasound finding of rectal herniation and displayed an abnormality in the structure of the tissues between the midline of the sacrococcygeal region and the right gluteus muscle .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1988_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1988_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d53843802f278299fd5d811264173933b80eac74
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1988_en.txt
@@ -0,0 +1 @@
+A 3-month-old male Chinchilla cat weighing 0.8 kg was admitted for pain in the right hindlimb. Radiographs revealed an oblique diaphyseal fracture of the right femur. After closed reduction, two Kirschner (K)-wires of 1.5 mm diameter were inserted in a normograde fashion. The inserted K-wires were removed 1 month after the surgery. Several days after removing the implants, the patient was presented with a fracture of the distal metaphysis of the right tibia after falling from a low height. Surgical repair was performed in the same way using two K-wires 1.6 mm in diameter. After the second operation, as additional fractures occurred owing to unknown reasons or suspected slipping events, several additional surgeries were carried out inserting K-wires into intact long bones to aid stress distribution on those bones. K-wires with a diameter of 1.2 to 2.0 mm were used and applied in a normograde fashion after closed reduction .Blood tests were performed to identify other diseases that could cause pathological fractures. Complete blood count revealed no particular abnormality. Serum total calcium, serum total phosphorus, ionised calcium, parathyroid hormone and 25-hydroxy vitamin D levels were all normal . As blood urea nitrogen and creatinine levels were within the reference intervals and renal ultrasonography confirmed no specific findings, secondary renal hyperparathyroidism was deemed improbable. Trabecular bone mineral density was measured from the 12th thoracic vertebra and the fourth lumbar vertebra using CT (Hi Speed QX/I; GE Medical). Relatively low trabecular bone mineral density was confirmed in the patient (219.8 Hounsfield units [HU] at the 12th thoracic vertebra and 169.46 HU at the fourth lumbar vertebra), compared with normal cats of a similar age. Bone biopsy was performed from the patient’s humerus during surgery and the sample was submitted for histopathological examination. Irregular and thin cortical bone with increased diameter of Haversian canals and replicated cement lines was identified . Based on these results, OI was tentatively diagnosed.Radiography was performed for follow-up or when the patient showed clinical signs. Follow-up radiographs were taken for 2 years. The patient showed spinous process fractures on several thoracic vertebrae 3 months after the first operation. After 5 months, the patient showed fractures on the ribs. As alignment was unchanged, no additional surgery was performed. Seven months later, a pelvic fracture not disrupting the pelvic cavity was revealed. The patient showed a fracture of the proximal ulna which had the K-wire inserted, luxation of thoracic vertebrae 4–5, changes in the morphology of the thoracic cavity and a fracture of the canine tooth of the right mandible, implying dentinogenesis imperfecta 1 year after surgery. Loosening of an inserted pin often occurred and irritated the adjacent joint and soft tissues, which then required cutting of the pin and/or re-insertion. The last radiographs taken 2 years postoperatively suggested repeated fractures and bone unions . Follow-up complete blood count and serum chemistry, except parathyroid hormone and 25-hydroxy vitamin D, were performed regularly but failed to reveal any abnormalities. During the 3-year follow-up period, although the patient often showed lameness or ataxia due to fractures and required medical management using tramadol (Tridol 2 mg/kg q12h; Yuhan Corporation) and/or meloxicam (Metacam 0.05 mg/kg q24h; Boehringer Ingelheim), it was able to walk until it died due to undetermined reasons.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2067_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2067_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6b395e4a9484739383273b23100ec5ae91e65766
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2067_en.txt
@@ -0,0 +1,5 @@
+A 66-year-old man was admitted to the clinic of a primary care doctor complaining of a sudden deterioration in right hypochondoralgia persisting for 2 weeks. A computed tomography (CT) scan revealed a right adrenal hemorrhage and an abnormal tumor in the upper lobe of his left lung. He was subsequently referred to our hospital for further examination and treatment.
+His past medical history and family history were unremarkable. He was a current smoker with a history of 46 pack-years. An enhanced CT scan showed a massive shadow in the left lung S1 + 2 progressing to S6 beyond the lung lobe, with a maximum diameter of about 42 mm , and a right adrenal hematoma with no active bleeding . The laboratory data revealed a slight elevation in carcinoembryonic antigen (CEA, 5.6 ng/mL) and neuron-specific enolase (NSE, 18.52 ng/mL). The patient had mild anemia (hemoglobin, 10.3 g/dL).
+A diagnosis of the pulmonary lesion using a bronchoscopic trans-bronchial lung biopsy showed no evidence of malignancy; therefore, a CT-guided percutaneous needle biopsy was performed. The pathological examination showed a non-small cell lung cancer (NSCLC) that was suspected to be a pleomorphic carcinoma. The adrenal lesion was diagnosed as a nonfunctional tumor based on endocrine examinations and adrenal medulla scintigraphy (123I-MIBG). 18-Fluorodeoxyglucose positron emission tomography (FDG-PET) showed the accumulation of FDG not only in the left lung nodule (SUVmax, 17.0) but also in the right adrenal one (SUVmax, 4.1) . Together, these results suggested a diagnosis of NSCLC and adrenal metastasis, and the clinical stage was classified as cT2bN0M1b, stage IV (TNM classification 7th edition).
+Because there was a risk of rebleeding from adrenal metastasis, we performed a right adrenalectomy. We considered that a complete resection of the primary lung cancer would be possible since the adrenal metastasis was an oligometastasis. A pathological analysis of the lung tumor demonstrated areas of atypical cells with eosinophilic cytoplasms as well as sarcomatous component, with extensive necrosis . Immunohistochemistry revealed that the tumor cells were positive for cytokeratin AE1/3, CAM5.2, CK7, and p63 (partial) but negative for 34βE12, CK20, TTF-1, calretinin, and D2-40. The adrenal tumor was similar in pathologic and immunohistochemical analyses . Thus, the final diagnosis was pleomorphic carcinoma of the lung with an adrenal metastasis, pT2bN0M1b, stage IV (TNM classification 7th edition).
+The patient received chemotherapy as stage IV NSCLC (60 mg/m2 of cisplatin on day 1 and 40 mg/m2 of TS-1 twice a day on days 1 to 14, repeated every 4 weeks). After two courses, he decided to quit the intravenous chemotherapy because of adverse events, general malaise, and anorexia. We suggested to receive oral chemotherapy, but he refused to take TS-1 because he feared adverse events. Consequently, he began taking UFT (600 mg/day) and continued this treatment for 2 years. He has survived without any recurrences for 6 years since the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2072_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2072_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ac3d5dd4a160e7f0a212e51bb24880fcd030418e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2072_en.txt
@@ -0,0 +1,6 @@
+A 63-year-old female (149 cm, 57 kg) was scheduled for elective laparoscopic distal gastrectomy under general anesthesia for gastric cancer. Her prior medical history included cerebral infarction and cervical spondylosis, controlled with medication. When she was 37 years old, she was diagnosed with Isaacs’ syndrome. Whole-body stiffness worsened, and double filtration plasmapheresis (DFPP) was performed four times per year to treat the symptoms.
+The patient had previously received a surgical arteriovenous shunt in the left forearm, a subcutaneously fixed superficial artery, and an arteriovenous graft in the upper left arm; however, all had occluded within 1 year. Additionally, she had received a thrombectomy of the right femoral vein. As her blood vessels were easily occluded due to frequent vasospasms, a temporary cervical catheter had been used when providing DFPP treatment. The patient orally received tacrolimus (3 mg/day) to suppress the symptoms of Isaacs’ syndrome; dantrolene (150 mg/day), carbamazepine (600 mg/day), and gabapentin (900 mg/day) to relieve the muscle symptoms; dabigatran etexilate methanesulfonate (320 mg/day) as an anticoagulant; cilostazol (150 mg/day) to prevent cerebral infarction; and nicorandil (10 mg/day) as a vasodilator to suppress vasospasms.
+The results of preoperative examinations were not remarkable except hemoglobin of 10.8 g/dL. The patient had myokymia of the bilateral upper extremities, neuromyotonia of the bilateral thumb, and left ptosis. We classified her physical status as American Society of Anesthesiologists physical status III. She was admitted to the hospital a month prior to the operation to receive DFPP four times.
+When she arrived at the operating room, she was hemodynamically stable and treated with dantrolene (50 mg), carbamazepine (200 mg), gabapentin (300 mg), and nicorandil (5 mg) as premedications. We performed preoperative monitoring, including standard monitoring, neuromuscular monitor (TOF-Watch®), and electroencephalogram using the Bispectral Index monitor.
+General anesthesia was induced with 100 μg fentanyl, target-controlled infusion of 2.5 μg/mL propofol, and 50 mg lidocaine after pre-oxygenation with 100% oxygen. After induction, we confirmed that T4/T1 was 100% using the TOF; we then administered 20 mg rocuronium. The time to get a TOF ratio of 0% was 4 min, and endotracheal intubation was carefully performed without complications. Anesthesia was maintained with oxygen, air, propofol (TCI concentration, 2.3 μg/mL), remifentanil (0.15–0.3 μg/kg/min), and intermittent intravenous administration of fentanyl. We also used the minimum amount of muscle relaxant. Rocuronium (10 mg) was administered when the TOF ratio increased to 50%. The total dose of rocuronium was 90 mg. Surgery proceeded uneventfully. For postoperative analgesia, infiltration anesthesia was performed at the rectus sheath with levobupivacaine (0.25%, 20 mL) and an intravenous fentanyl pump (0.5 μg/kg/h) started 1 h before the end of surgery. At the end of the procedure, we confirmed that the TOF ratio had recovered to > 90%. The residual neuromuscular block was antagonized using sugammadex (2 mg/kg), and propofol and remifentanil were discontinued. Shortly afterward, the TOF ratio recovered completely and spontaneous respiration resumed. The patient followed our commands and showed spontaneous breathing, and tracheal extubation was performed. The total operative time was 225 min and the anesthetic duration was 355 min. Subsequent to confirming stable vital signs and neuromuscular symptoms after extubation, the patient was moved to an intensive care unit.
+After transfer, she complained about abdominal pain, so the infusion rate of fentanyl was increased to 1.0 μg/kg/h, and dexmedetomidine (0.4 μg/kg/h) was added to control pain. She was discharged to the general ward the day after surgery; however, the abdominal pain worsened because myokymia frequently occurs in the rectus abdominis muscle. The patient complained about severe pain (numerical rating scale, 8/10), so the infusion rate of fentanyl was increased to 2.0 μg/kg/h, which was effective for controlling pain. Afterward, she often experienced vomiting 8 days after surgery. The clinical course seemed to originate from postoperative pyloric stenosis. She received gastric bougie procedures two times after the surgery. The symptoms of Isaacs’ syndrome were stable after the postoperative pain was relieved, and she was discharged on postoperative day 66.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2123_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2123_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e61001c6cc13f3f6ede857b69c00ddfff9646225
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2123_en.txt
@@ -0,0 +1,8 @@
+A 76 year old ‘never smoker’ female with no past medical history was diagnosed with locally advanced NSCLC during investigations for a community-acquired lower respiratory tract infection. The Medical Research Council (MRC) Dyspnoea Score was 3 and there was a dry cough. Computed tomography (CT) of the chest demonstrated a 4.5 cm (anterior-posterior) × 4.1 cm (craniocaudal) left lung upper lobe mass with abutment of the mediastinal pleura and distal atelectasis and pneumonitis .
+An 8 mm ipsilateral lymph node was visible at station 10. Multiple sub-centimetre lung nodules were noted throughout the right lung. Histological and immunohistochemical assessment of core biopsies from the primary lesion via bronchoscopy favoured the adenocarcinoma subtype of NSCLC (see Table ). The molecular analysis revealed ALK fusion protein overexpression along with ALK rearrangement. This result is in keeping with an ALK rearranged adenocarcinoma. The main lesion had an SUVmax of 16 on 18fluorodeoxyglucose positron emission topography-CT (PET-CT) imaging and no other lesions were avid. Following a review of the imaging at the multidisciplinary meeting (MDM), staging was offered at T2 N0 M0 (TNM 8 ), and in light of the patient’s fitness, radical treatment was recommended.
+During the assessment period for a primary lobectomy, the patient developed symptomatic atrial fibrillation. She underwent a successful direct current (DC) cardioversion and was discharged on edoxaban. Three weeks later the patient was noted to be in atrial fibrillation once more during an inpatient admission for the management of chest sepsis, for which she was discharged on digoxin. She was electively admitted to the Cardiology ward 6 weeks later for a second DC cardioversion procedure. Under conscious sedation, the patient received one synchronised shock of 120 J delivered via anterior-posterior paddles ie one placed at the left parasternal edge, one at the corresponding position on the patient’s back. One week post-procedure the patient attended the Emergency Department complaining of dysarthria and left-sided hemiparesis. CT and magnetic resonance imaging (MRI) of the brain confirmed the presence of a dense right-sided middle cerebral artery territory infarction (see Fig. ). The patient was in sinus rhythm, transthoracic echocardiography was unremarkable and mild bilateral carotid atheroma only was noted on ultrasonography (< 50% stenosis), suggestive for a stroke secondary to a delayed cardiogenic embolus related to atrial fibrillation, despite anticoagulation.
+Five days later, haemorrhagic transformation of the stoke was detected on MRI following clinical deterioration. A 3.5 cm intracerebral haematoma was identified within the right basal ganglia, causing effacement of the right lateral ventricle frontal horn, which was managed conservatively. The clinical condition stabilised and both her speech and weakness improved with rehabilitation from the department of Stroke Medicine.
+As the patient’s ECOG PS recovered to 2 and her breathlessness resolved, work-up for radical treatment resumed, given her ongoing determination to gain control over the cancer. Updated cross-sectional imaging demonstrated complete regression of the left upper lobe lesion and a reduction of the previously documented mediastinal lymph node. Remaining atelectasis had a maximum standard uptake value (SUVmax) 2.7 on repeat PET-CT imaging (8 months since first PET). A review of the patient’s medications was undertaken searching for possible effects on FDG uptake, which was negative. The merits and risks of radical radiotherapy versus active surveillance were explored with the patient who elected to proceed with the latter.
+Clinical review after 6 months of active surveillance, dry cough and mild dyspnoea were reported by the patient. Corresponding with the imaging findings, thoracic imaging with CT showed increased patchy parenchymal changes at the site of the previous left upper lobe lesion without associated hilar or mediastinal lymphadenopathy. Repeat PET-CT imaging demonstrated increased uptake (SUVmax 10.2) in a sub-pleural 4 cm mass in keeping with local relapse (see Fig. ), and no additional sites of disease.
+As the pulmonary function tests (FEV1 90% predicted; TLCO 80% predicted) were favourable and physical fitness had stabilised (ECOG PS 2) the patient was consented for a course of radical thoracic radiotherapy without chemotherapy. She completed 55 Gy in 20 fractions planned with the intensity modulated radiotherapy technique and delivered as 6 MV arc therapy, with daily online cone beam-CT image guidance, treating Monday to Friday for 4 weeks . Target volumes were subject to peer review . Tumour shrinkage was noted during routine offline imaging review.
+There were no acute toxicities during routine clinical assessments on treatment, or at 6 weeks post-radiotherapy. On clinical review 4 months after treatment completion the patient was more frail and had continued respiratory symptoms. Around this time, the first radiological follow-up scan demonstrated radiation pneumonitis focally in left upper lobe. At 1 year the patient returned to ECOG PS 1 and the imaging demonstrated stable disease locally and no evidence of distant relapse. At 18 months post-radiotherapy there was radiologic progression in the lungs with new pulmonary nodules and effusion and new bone metastases correlating with new symptoms of dyspnoea, cough and back pain. Owing to poor performance status, she was not considered fit for systemic therapy including ALK-targeted therapy and was managed with multi-disciplinary best supportive care until her death 5 months later.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2136_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2136_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a0464d4e985b6de235d750bdda1eda8ffd979309
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2136_en.txt
@@ -0,0 +1,3 @@
+A 31-year-old woman with complaints of mild dyspnoea on exertion over the last several years was referred to our institution for liver dysfunction and cirrhosis. She had a significant medical history of congenital atrial stand-still and atrial septal defect (ASD) at birth. She had undergone no interventions immediately after the birth and ASD patch closure and EP implantation at the age of 6 years. Her generator was exchanged at the ages of 17 and 23 years. Although the EP generator was extracted and replaced by a transvenous endocardial pacemaker (ventricular sensing and pacing) at the age of 30 years, EP leads had been abandoned after the transvenous endocardial pacemaker implantation. The patient had no relevant family history.
+At initial presentation, her blood pressure was 131/80 mmHg, pulse rate was 60 beats per minute (b.p.m.), and her oxygen saturation was 98% at rest. Physical examination was normal, save for mild peripheral oedema. An electrocardiogram showed a ventricular pacing rhythm with a heart rate of 60 b.p.m. Blood investigations revealed thrombocytopenia with a platelet count of 98 000/µL (reference range 158 000–348 000/µL); mild liver dysfunction; and an elevated B-type natriuretic peptide level of 41.9 pg/mL (reference range <18.4 pg/mL). Coagulation capacity was within the normal range. Antibody titres related to autoimmune disease, hepatitis viruses, and human immunodeficiency virus were negative. Tumour markers and interferon-gamma release assay results were negative. Chest radiography revealed bilateral enlargement of the pulmonary artery with cardiomegaly, EP leads with the loop placed on the anterior surface of the heart, and the endocardial pacemaker . Computed tomography (CT) scan of the thorax showed calcified EP leads on the anterior surface of the heart; CT scan of the abdomen revealed surface nodularity of the liver suggesting cirrhosis and mild ascites, with no evidence of spontaneous portosystemic shunts other than the splenorenal shunt . Transthoracic echocardiography demonstrated diffusely reduced left ventricular wall motion with an ejection fraction of 49%, bi-atrial enlargement, moderate mitral regurgitation due to left atrial enlargement, and dilatation of the inferior vena cava. There was no evidence of ventricular septal diastolic shudder, respiration-related ventricular septal shift, intracardiac shunt including residual ASD, or pericardial effusion. On pulsed-wave tissue Doppler imaging, the lateral and medial velocities of the mitral annulus in early diastole (e′) were 16.5 cm/s and 9.5 cm/s, respectively. The tricuspid annular plane systolic excursion was 10.9 mm and the tricuspid annular velocity in systole (s′) was 6.6 cm/s. Coronary angiography revealed no evidence of coronary stenosis. Right heart catheterization (RHC) showed a right atrial pressure of 14 mmHg, pulmonary artery pressure of 36/16 mmHg, mean pulmonary artery pressure of 24 mmHg, pulmonary capillary wedge pressure of 18 mmHg, cardiac index of 2.48 L/min/m2, pulmonary artery saturation of 78%, and waveforms similar to those of constrictive pericarditis (CP) . These results suggested that she had developed cardiac strangulation by the EP leads with haemodynamics similar to those of CP, leading to congestive hepatopathy with cirrhosis. Upon arriving at this diagnosis, complete EP lead removal and mitral valve repair were successfully performed .
+After surgical removal, her dyspnoea on exertion was improved. Further, RHC 1 year after surgery showed a right atrial pressure of 6 mmHg, pulmonary artery pressure of 19/12 mmHg, mean pulmonary artery pressure of 15 mmHg, pulmonary capillary wedge pressure of 13 mmHg, cardiac index of 3.46 L/min/m2, and pulmonary artery saturation of 80%. The waveforms of RHC after surgery also changed compared with those before surgery . The medication administered immediately after surgery included a beta-blocker, angiotensin-converting enzyme inhibitor, mineralocorticoid receptor antagonist, loop diuretic, and vitamin K antagonist. However, all medication has since been stopped because of pregnancy. The patient has shown no worsening of heart failure or other unanticipated events until the present time.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2159_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2159_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ceadab2b3823816931fbebf19f476d4e98b9f252
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2159_en.txt
@@ -0,0 +1,7 @@
+A 61-year-old male presented to orthopedic OPD with complaint of pus discharge from a sinus on his left shoulder tip since 2 years and pain in left shoulder region since 2 months.
+Initially, patient was treated outside as a case of soft tissue abscess over shoulder tip for which incision and drainage were done, and antibiotics were given. Later, he developed a discharging sinus. Pus was whitish in color, sticky in nature, and non-foul smelling. He consulted several local practitioners who gave him antibiotics. But there was no change in the amount and color of pus from the sinus.
+Later, patient developed pain in left shoulder just after getting up from bed. Pain was continuous and not relieved by painkillers. There is no history of trauma and swelling in the neck.
+Local examination revealed a single sinus at left shoulder tip. No signs of inflammation were present . The margins of the opening of the sinus were inverted, and no granulation tissue was observed at its mouth. Tenderness at lateral end clavicle was present. On pressing, the sinus minimal thick purulent discharge was seen. Sinus was thick walled and fixed to underlying bone. On probing, hard bony structure was felt in the depth of the wound. No cervical or axillary lymphadenopathy was present.
+Laboratory tests showed hemoglobin - 14.4 g/dl, total leucocyte count of - 10500/cumm, neutrophils - 62%, lymphocytes - 30% with erythrocyte sedimentation rate - 35 mm/h. On X-ray, lung fields were clear. Culture revealed coagulase-negative staphylococcus and Acinetobacter calcoacetcus baumanni complex sensitive to a combination of amoxycillin clavulanic acid and amikacin. Anteroposterior radiographs of left shoulder with clavicle revealed pathological fracture of the lateral end of clavicle and sequestrum with periosteal reaction at lateral end clavicle. Acomioclavicular joint appeared to be normal .
+A clinicoradiological diagnosis of chronic pyogenic osteomyeltis of clavicle with discharging sinus was made. Patient was put on injectable antibiotics. Sequestrectomy with sinus tract excision was done . Histopathology showed chronic necrotizing granulomatous inflammation, suggestive of the tubercular osteomyelitis . Patient was started on a multidrug antitubercular therapy. The wound healed with the primary intention.
+There is terminal restriction of all range of movements at shoulder after 1 year of follow-up. .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2163_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2163_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..51aa8bc6d6f0156bfff3d556e5ddbf903e05009f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2163_en.txt
@@ -0,0 +1,8 @@
+A 64-year-old man who came to our emergency department complaining of left shoulder pain.
+He had mild left shoulder trauma due to accidental falling from the standing position while walking 3 h ago.
+His past medical history included atrial fibrillation treated with aspirin enteric-coated tablets (Bayer SPA), metoprolol succinate sustained-release tablets (AstraZeneca AB), and chronic atrophic gastritis.
+The patient denied a history of smoking, alcohol consumption, drug intake, and a family history of pathological fracture or osteoporosis.
+Physical examination demonstrated swelling of the left shoulder, localized tenderness, percussion pain on the proximal humerus, and limited shoulder motion. The muscular tone of the upper limb was normal with no hypoesthesia. Physiological reflexes were present without pathological reflexes.
+In contrast, routine laboratory evaluation on admission, with the exception of anemia, was unremarkable. Hematopoiesis accounted for 40%, the ratio of granulocytes to erythrocytes was approximately 2:1, and megakaryocytes were 2-7/high power field. Multifocal plasmacytoid cell aggregation was also observed. Immunochemistry showed CD38 (+), kappa (+), lambda (+); MPO (+), CD61 (+) and CK (-) .
+Initial X-ray films of the left shoulder were obtained, which showed only a comminuted fracture and degenerative changes in the upper left humerus . Magnetic resonance imaging (MRI) was then performed and showed an abnormal signal intensity of the proximal humerus associated with a comminuted fracture, and multiple soft tissue masses around the fracture, ranging from 4.8 cm to 3.9 cm, which presented as hypointensity and isointensity, as well as hybrid hyperintensity on T1-weighted (T1-W) and T2-W images, respectively. The left humerus, glenoid, and clavicle had multiple sheet-like hyperintensity on T2-W images . A neoplastic lesion with radiological characteristics was highly suspected.
+Further laboratory tests and imaging examinations were performed. Computed tomography (CT) scans and X-ray examinations revealed multiple areas of reduced bone density throughout the body. In addition, high 18-F-fluorodeoxyglucose metabolism was observed in several ribs on bone scans, and in the fifth lumbar vertebra (L5), and left proximal humerus .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2166_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2166_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..820e8ddb27764d5f3dcd01f72b364d4e7fee0bfb
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2166_en.txt
@@ -0,0 +1,5 @@
+A 35-year-old G2P0010 Cameroonian student at 39-weeks pregnancy was referred to the surgical unit of the Yaounde Gynaeco-Obstetrics and Paediatric Hospital for the management of a strangulated umbilical hernia. She had a sudden onset of localized umbilical pain three hours prior to consultation. The pain was of moderate intensity, crampy in character, aggravated by walking, without any change in bowel movement and no vomiting. An abdominal ultrasound scan revealed a parietal defect of the umbilicus measuring 55 mm in diameter with a poorly vascularised hypoechoic mass (doppler scan) measuring 50 × 30 × 37 mm, 29.6 ml in volume. In addition, the foetus was viable with a normal biophysical score and a good concordance between clinical and sonographic dating of gestational age. Hence, she was referred for surgical management of a strangulated umbilical hernia in a term pregnancy.
+An episode of severe malaria during her previous pregnancy was at the origin of a spontaneous abortion at 10 weeks of gestation. Her current pregnancy was being followed at the Efoulan District hospital in Yaounde where she had attended six antenatal clinics. A urine dipstick at 24 weeks of gestation revealed a proteinuria of 600 mg/l coupled with an increase blood pressure to 152/98 mmHg and the development of lower limb oedema. She was diagnosed with pre-ecclampsia and placed on alphamethyldopa 250 mg twice daily. A second trimester ultrasound revealed the presence of two anterior and posterior interstitial myomatous nuclei, of 51 mm and 73 mm long axis respectively.
+On physical examination, the patient was in severe pain (visual analogue scale of 9/10 cm) with a temperature of 38.1 °C, pulse rate of 112 beats per minutes, respiratory rate of 22 breaths per minutes and blood pressure of 170/118 mmHg. Abdominal examination showed a gravid uterus with a uterine fundal height of 38 cm. There was a tender, non-reducible umbilical swelling , with no cough impulse. There was no sign of peritoneal irritation. She had no costovertebral angle tenderness. Bowel sounds were present and normal. Her digital rectal examination was unremarkable. The foetus had a longitudinal lie, cephalic presentation, right-occipito anterior position and a fetal heart rate of 140 beats per minute. On vaginal examination, the cervix was posterior, non-effaced and closed. She had a bilateral pitting lower limb oedema extending to both knees. In view of this clinical picture, we thought of a strangulated umbilical hernia. All of these on a probable background of severe pre-eclampsia. The laboratory panel requested on admission is illustrated in Table .
+A multidisciplinary team involving general surgeons, obstetricians and anaesthesiologists decided on a two-in one intervention wherby an emergency ceaseraean section with indication severe pre-ecclampsia, and a herniorraphy with indication strangulated umbilical hernia will be carried out within the same operation. Preoperative management consisted of placing two peripheral venous lines of large bore needle with infusion of 1000 ml of normal saline, parenteral administration of an analgesic (paracetamol 1 g), an antihypertensive drug (nicardipine 2 mg bolus) and anticonvulsant (magnesium sulphate 5 g intravenously followed by 4 g intramuscularly in each gluteus muscles). A Pfannenstiel incision performed five hours after admission permitted the extraction of a life female baby who weighed 3300 g at birth with an APGAR score of 8 and 10 at the first and fifth minutes respectively. Intraoperative findings of an anterior and posterior sub-serosal leiomyomas both measuring about 50 mm ; anterior fibroid had an axis pointing to the umbilical ring, with irregular contours and a heterogeneous center, strongly suggestive of aseptic necrobiosis. In addition, the uterus also had several interstitial myomas. The uterine adnexae and the appendix were macroscopically normal. The herniated omentum was not necrosed. No intestines necrosis was observed. Both sub-serosal leiomyomas were surgically excised and sent for histo-pathological evaluation. A separate arciform infra-umbilical incision permitted repair of the umbilical hernia.
+Histopathological analysis of the leiomyoma samples was consistent with red degeneration (aseptic necrobiosis) of the excised uterine fibroid . The postoperative outcome was uneventful for both the mother and the baby, with the former resuming progressive oral feeding on the first postoperative day. She was discharged five days later in a good clinical condition. Her follow-up at six weeks postoperatively was uneventful.. The six-month postoperative course was also normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2180_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2180_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0fa58605839203e3641f14e4b05eaa0526271c18
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2180_en.txt
@@ -0,0 +1,7 @@
+A 25-year-old male presented to our department with two episodes of gross hematuria. Personal and family medical history were negative of any underlying diseases. Ultrasound revealed lobulated paracalyceal cystic – like lesions in the parenchyma of the right kidney with no dilation of its pelvicalyceal system .
+Contrast enhanced computed tomography in the arterial phase demonstrated dilated upper lobe interlobar artery of the right kidney and early enhancement of a variceal venous structure which drained in the right renal vein, findings indicative of renal arteriovenous fistula . There was no history of trauma or medical procedure, so the RAVF was considered as non -traumatic. Fistulous site was measured approximately 12 mm.
+The procedure was conducted in the cath lab (Siemens Artis Zee) under aseptic conditions and local anesthesia. Patient was in supine position and vital signs were monitored throughout the procedure. Under ultrasound guidance puncture of the right common femoral artery was performed and a 5F vascular sheath was introduced. A pre – shaped 5F Cobra catheter (Merit Medical) was advanced. Then, a 6 F × 45 cm Ansel guiding sheath (Cook Medical) was advanced into the proximal right renal artery. DSA revealed an enlarged interlobar renal artery and early opacification of an enlarged draining vein and inferior vena cava (IVC), findings indicative of type I RAVF .
+Next, under ultrasound guidance, puncture of the right common femoral vein was performed and a 5F vascular sheath was introduced. A pre—shaped 5F Simmons catheter (Merit Medical) was advanced into the right renal vein and selective catheterization of the dilated vein was performed with the help of a hydrophilic guidewire (Terumo). Super – selective catheterization of the venous pouch adjacent to the feeding artery was achieved by a 2,7F microcatheter (Progreat, Terumo).
+Then, a Hyperform 7 × 15 mm balloon (Medtronic) was advanced into the feeding artery across the site of the fistula. Selective angiogram with the balloon inflated showed no opacification of the fistula and the accurate site of the communication was documented and type I RAVF was confirmed. A 2,6 F microcatheter (Asahi Intecc) was advanced at the venous pouch at the site of the fistula and multiple electrically detachable metallic coils (Optima/OptiMAX/BALT) were simultaneously deployed through the transarterial and transvenous microcatheter into the fistula initially with the balloon inflated . In particular, there were used three coils 18 × 20 mm, one 14 × 47 mm, one 13 × 43 mm, one 12 × 40 mm, two 10 × 30 mm, one 10 × 17 mm and one 10 × 13 mm. Balloon inflation prevents coil migration and protrusion of the coils into the feeding artery.
+The final result was total occlusion of the fistula with preservation of feeding artery and the renal parenchyma .
+There were no minor or major complications. Patient was discharged the following day in good condition, with the instruction of a new contrast enhanced computed tomography after 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2242_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2242_en.txt
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index 0000000000000000000000000000000000000000..681c471fae77d84d75ec21efd6035000a1594be5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2242_en.txt
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+A 31-year-old Japanese woman who presented with upper abdominal pain was admitted to a local hospital. She had a history of mycoplasma pneumonia in childhood and a family history of diabetes mellitus of her father. Four days before admission, she had a fever over 37 degrees and received an antipyretic agent at the local clinic, while flu testing results were negative. On admission to the local hospital, serum amylase was elevated to 370 IU/L, and abdominal computed tomography (CT) scanning showed pancreatic swelling and mild ascites . She was diagnosed with acute pancreatitis (grade 1) and treated with ulinastatin. The morning after admission, her fasting serum glucose, insulin and C-peptide level were within normal ranges: 101 mg/dL, 2.2 μIU/L and 0.8 ng/mL, respectively. At 4 days after admission, she complained of nausea and low back pain, and fell to consciousness disturbance (Japan Coma Scale II-10: drowsiness) with hyperglycemia (861 mg/dL) and metabolic acidosis. She was diagnosed with diabetic ketoacidosis and transferred to our hospital.
+This patient’s clinical course in our hospital is presented in Fig. . On admission to our hospital, she showed confusion (Japan Coma Scale I-2) and the upper abdominal symptom of nausea. Laboratory findings showed metabolic acidosis (pH, HCO3, and the anion gap in arterial blood were 7.07, 2.7 mmol/L, and 27.7 mmol/L, respectively), hyperketonemia (serum total ketone bodies 13,179 μmol/L) and hyperglycemia (612 mg/dL). Hemoglobin A1c (5.7%) was within the normal range, and anti-GAD and anti-IA-2 antibodies were undetectable. In addition, neither her serum C-peptide after a glucagon test nor 24-h urinary C-peptide excretion was detectable. These findings met the criteria for FT1D with diabetic ketoacidosis, and the patient was immediately given intravenous insulin infusion therapy. Human leukocyte antigen (HLA) typing indicated DRB1*0401-DQB1*0301, and DRB1*1302-DQB10604 class II gene.
+Although serum amylase (1800 U/L, Fig. ), lipase and trypsin (320 U/L and 3040 ng/mL respectively) were elevated, reexamination with CT scanning showed amelioration of the pancreatic swelling and magnetic resonance cholangiopancreatography (MRCP) imaging depicted no abnormalities, even in the pancreas (data not shown). On the second day in our hospital, her symptoms showed improvement, and the serum glucose level had fallen below 200 mg/dL. However, on the 3rd hospital day, electrocardiography (ECG) depicted ST-segment elevation in V3-V6 without typical cardiac symptoms but serum creatinine kinase (CK) (830 U/L, Fig. ), CK-MB and troponin I (49 U/L and 11.99 ng/mL respectively) were elevated. Coronary angiography showed no abnormal findings. Left ventriculography (LVG) showed apical wall hypokinesis, while no other abnormal findings, including takotsubo cardiomyopathy, were detected. On the 4th hospital day, abnormal ECG findings showed improvement and serum myocardial necrosis markers had normalized. On the 8th hospital day, contrast-enhanced cardiac magnetic resonance imaging (MRI) indicated late gadolinium enhancement (LGE) in the apical wall . She was diagnosed with acute myocarditis based on the guidelines for diagnosis of myocarditis . It should be noted that no abnormality was observed in echocardiogram examination and that serum CK level was 156 U/L at the previous hospital. On the 28th hospital day, follow-up cardiac MRI showed no LGE in the apical wall.
+Because some viral infections are thought to cause FT1D, viral antibodies were measured at the time of admission and 4 weeks later: we tested for adenovirus, influenza A and B, echovirus 3, 7, 11, 12, coxsackie virus types A2, A4, A5, A6 A9, A16, B1, B2, B3, B4, B5, B6, parainfluenza virus 1, 2, 3, respiratory syncytial virus, Epstein-Barr virus, measles virus, mumps virus, herpes simplex virus, rubella virus, cytomegalovirus, and parvovirus. None of these tests revealed significantly elevated antibody titers. She was discharged on the 35th hospital day with intensive insulin treatment without medication for cardiovascular disorders or pancreatitis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2260_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2260_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..43a54c4457478526788ca4cb06d0c69ba87dcd7d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2260_en.txt
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+A 53-year-old Caucasian male represented to hospital with a 2-week history of acute New York Heart Association Class IV dyspnoea, reduced exercise tolerance, and intermittent chest pain. Of note, he had multiple hospital attendances in the preceding 8 weeks, for similar symptoms attributed to recurrent viral pericarditis in the context of a recent viral illness. He had been managed with non-steroidal anti-inflammatories, colchicine, and 4 weeks of prednisolone for this. His medical history included asthma with infrequent exacerbations, allergic rhinitis, hypertension, hypercholesterolaemia, obesity, and treated obstructive sleep apnoea. There was no history of recent surgery, travel, ill contacts, or active dental infection.
+On examination, he was afebrile, normoxic, and normotensive, but was tachycardic (heart rate 112 beats/min) and tachypnoeic (respiratory rate 24). Cardiorespiratory examination revealed soft dual heart sounds and decreased breath sounds at bilateral lung bases, but no pulsus paradoxus. Jugular venous pressure was not elevated. Oral cavity examination noted multiple previous fillings, but overall dental health was adequate with no over gingival inflammation or dental abscesses or decay.
+Electrocardiogram demonstrated sinus tachycardia with no diffuse changes or electrical alternans. Blood investigations revealed normal white cell count [7.32 × 109/L (reference range: 4–11 × 109/L)] but elevated C-reactive protein [CRP; 106 mg/L (reference range: 0–8 mg/L)]. Chest X-ray, N-terminal pro-B-type natriuretic peptide (NTproBNP), and autoimmune screens were unremarkable.
+Initial transthoracic echocardiogram (TTE) revealed mild left ventricular (LV) dysfunction with a large (2.4 cm) asymmetric pericardial effusion containing organized echogenic material adjacent to the right ventricle (RV). There was associated diastolic collapse and significant tricuspid and mitral inflow variation (62 and 27%, respectively). Inferior vena cava (IVC) was dilated and fixed ( and ).
+Urgent pericardiocentesis was performed. A total of 150 mL of blood-stained fluid was drained with symptom relief ( and ). Pericardial fluid biochemistry revealed lactate dehydrogenase (LD) 3584 U/L (reference range <300 U/L); fluid/serum LD ratio 12 (reference range <0.6); cholesterol concentration 1.7 mmol/L (reference range <1.2 mmol/L). Cultures were sent for testing. A pigtail catheter was placed for further drainage.
+The catheter was removed 48 h later due to clinical improvement, minimal output (total 240 mL drained), and improved inflammatory markers (CRP 95 mg/L, 79 mg/L, 53 mg/L 1, 2, and 4 days post-drainage). Notably, purulent debris in the catheter was observed before removal.
+Repeat TTE demonstrated only a small residual effusion (1.3 cm). Concerningly, however, the RV free wall now appeared akinetic and adherent, with ventricular interdependence and a minimally collapsing dilated IVC.
+Unexpectedly, pericardial fluid cultured gram-positive bacillus 48 h post-drainage. Intravenous (i.v.) vancomycin 2 g 12 hourly was initially commenced and changed to targeted i.v. benzylpenicillin 1.8 g 4 hourly on the identification of A. meyeri 96 h later. Fungal and acid-fast bacilli cultures were negative. No malignant cells were identified. Extensive workup with serial urine and blood cultures were negative. Orthopantomogram (OPG) demonstrated previous dental restoration and some caries disease, but no periapical lucence, abscess, or periodontal ligament widening.
+Repeat TTE, however, demonstrated increasing pericardial effusion (1.8 cm) and worsening tricuspid and mitral inflow variation (35 and 36%, respectively) ( and and , ). Further characterization with cardiac magnetic resonance (CMR) imaging confirmed 2.6 cm pericardial effusion adjacent to the RV free wall, with hyperenhancement of the involved markedly thickened pericardium on late gadolinium acquisitions. Free breathing acquisitions demonstrated diastolic septal flattening during expiration consistent with constriction, and there was a mild reduction of LV- and RV end-diastolic volumes and mild biventricular dysfunction ( and and , and ). There was no evidence of pulmonary infection. He was referred for consideration of surgical source control. Owing to concerns regarding optimal antibiotic duration prior to surgery, his case was also discussed at a multidisciplinary meeting involving Cardiology, Cardiothoracic Surgery, and Infectious Diseases specialists. He was initially deemed suitable for outpatient surgical management. However, clinical deterioration with the development of significant exertional dyspnoea and escalating inflammatory markers despite maximal appropriate antibiotic therapy necessitated semi-urgent inpatient surgery.
+Median sternotomy was performed revealing significant collection overlying RV, which was adhered to the thickened pericardium . Samples were taken for histopathology and microbiology. The pericardium was incised and a 100–200 mL frank pus was drained, before thorough washing. The sternum was protected from contamination throughout. Pericardium was then resected over the RV whilst preserving the phrenic nerve, around to the LV anterior surface. The right pleura was opened to allow drainage of potential effusions prior to right pleural, pericardium, and mediastinal drain insertions before sternal closure. The drains were removed on Day 5 post-pericardiectomy.
+Histopathology confirmed organizing fibrinous pericarditis, with reactive stromal and endothelial cells but no malignant cells. There was no bacterial growth on prolonged aerobic and anaerobic incubation. Day 6 post-operative TTE demonstrated a small pericardial space with no effusion and a preserved LV function ( and and , S and ).
+The patient was discharged 10 days post-pericardiectomy, with complete symptom resolution. He completed 6 weeks of i.v. benzylpenicillin antibiotic therapy and was reviewed in the Cardiology, Cardiothoracic Surgery, and Infectious Diseases outpatient clinics prior to de-escalation to oral antibiotics. He has since completed 7 of planned 12 months of oral amoxicillin 1 g thrice daily. The patient reports no further episodes of chest discomfort or dyspnoea and is satisfied with his physical recovery. He has, however, experienced low mood as a result of his recurrent hospitalizations and surgery and is currently receiving care from his primary care physician to address this.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2270_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2270_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..50e548b83fe5077dfab7f576c731441a3697248c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2270_en.txt
@@ -0,0 +1,5 @@
+A 43-year-old Chinese Han woman with a history of GD was referred to our department for recurrent cough, expectoration for 2 months, and hemoptysis accompanied by fever for 1 week. Physical examination of the neck showed a slightly enlarged and homogenous thyroid gland, and a bilateral lung examination by auscultation was unremarkable. Her medical history was significant only for GD, which had developed 5 years previously and was treated with PTU. She had no history of other cardiovascular or cerebrovascular risk factors; allergic diseases including asthma, allergic rhinitis, or urticarial; and psychosocial disorders and no family history of autoimmune diseases. PTU was initially started at 300 mg/day and decreased to 100 mg/day once the euthyroid status was obtained.
+In the fourth year of treatment, the patient started nonsteroidal anti-inflammatory drug (NSAID) treatment for arthralgia. In the fifth year of treatment, she developed recurrent cough and expectoration accompanied by malaise and asthenia but denied any experience of a rash, weight loss, or myalgia. After 2 months of ineffective treatment with antibiotics, the patient developed hemoptysis and fever, with a peak temperature of 37.9°C. Chest CT showed diffuse alveolar infiltrates, and pneumonia was considered. Moxifloxacin was then added to treat the bacterial infection. Two weeks later, however, the patient still had fever, cough, and hemoptysis. Repeat CT scan showed much more severe lesions with diffuse, bilateral, predominantly lower lobe nodular infiltrates and ground-glass opacity . A diffuse segmental hemorrhage was noted on bronchoscopy with a needlepoint hemorrhage and partial fusion in the submembrane along the left main bronchus spreading to the opening of the left upper lobe .
+Examination of the bronchial lavage fluid revealed 98% macrophages with iron staining positive for siderophages, and negative culture findings. Laboratory examinations revealed normal free triiodothyronine (2.18 pg/mL, normal range [NR] = 2 - 4.4), free thyroxine (0.98 ng/dL, NR = 0.93 - 1.7), and thyroid stimulating hormone (1.05 uIU/mL, NR = 0.27 - 4.2); low thyroglobulin (0.5 ng/mL, NR = 1.4 - 7.8); significantly elevated thyroglobulin antibody (> 4000 IU/mL, NR = 0 - 115) and antithyroid peroxidase antibody (256.4 IU/mL, NR = 0 - 34); gradually increased erythrocyte sedimentation rate (ESR; 80 - 112 mm/h, NR = 0 - 20); and slightly increased C-reactive protein (CRP; 39 mg/L, NR = 0 - 8). Enzyme-linked immunosorbent assays were positive for MPO-ANCA and proteinase 3 (PR3)-ANCA, while immunofluorescent assays were positive for p-ANCA and c-ANCA. The complete blood cell count indicated slight anemia, with a decrease in hemoglobin (HGB) from 123 g/L to 89 g/L (NR = 113 - 151). Coagulation study revealed a slightly elevated D-dimer (1.11 mg/L, NR < 0.55).
+Liver and kidney functions were normal. Antinuclear antibody, anti-extractable nuclear antigen, and anti-double-stranded DNA were not detected. Pulmonary function test items were normal. Abdominal ultrasonography and cerebral magnetic resonance imaging were unremarkable. Thyroid ultrasonography disclosed a diffusely enlarged thyroid gland with hypervascularity indicative of GD. Based on these findings, this patient was diagnosed with PTU-induced ANCA-positive pulmonary vasculitis with DAH. The PTU was discontinued promptly, and an intravenous injection of methylprednisolone (80 mg/day) was initiated. Three days later, the steroid dose was changed to 40 mg/day. One week later, the therapy was changed to oral prednisolone, which was then tapered over next 12 weeks. There was significant improvement in respiratory symptoms and fever 1 week after the start of prednisolone treatment and PTU withdrawal. Within days, antithyroid antibody titers and ESR decreased markedly.
+Approximately 1 month after our observation, the serum was tested negative for ANCA, and ESR and HGB level were normal. In addition, chest CT indicated restoration of the lungs; it showed rapid improvement in the pulmonary pathology with an almost complete recovery in the parenchyma that was subsequently confirmed with bronchoscopy . After 6 months of follow-up, the patient was asymptomatic at 3 months of follow-up with a negative ANCA. Whole blood and thyroid function tests revealed normal ESR, CRP, and D-dimer levels. The steroid dose was tapered. At the 6-month follow-up, steroids were discontinued, and the ANCA remained negative. The patient’s condition remains stable.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2319_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2319_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..936ddc348139aabd8fd8f5da21578b3214b54826
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2319_en.txt
@@ -0,0 +1 @@
+A 49-year-old single man (rural worker), born and raised in Laranjal Paulista-SP, was admitted to our Emergency Room at the Botucatu Medical School University hospital with 3 months history of bilateral occipital headache. Along with a history of active smoking and previous use of alcohol, the patient reported a personal history of mild occipitotemporal injury 3 months ago. On physical examination, left dysdiadochokinesia and three palpable cervical lymph nodes were noted on the left side; one of them with increased dimensions. The patient was submitted to computed tomography (CT) in a 16-row multidetector scanner, which revealed, after iodinated contrast infusion, a nodular hypodense lesion with ring enhancement and associated perilesional edema in the left cerebellar hemisphere . In light of these findings, hypothetic diagnoses of cerebellar abscess and neoplasy (primary or metastatic) were made. Radiological workup was initiated to investigate the eventual primary neoplastic site. Chest radiography showed reticular opacities, perihilar and poorly defined in the right hemithorax. The CT in a 16-row multidetector scanner and high-resolution chest protocol were done, showing pulmonary nodules in the right, some of them with excavated wall, sometimes thin and smooth, sometimes asymmetrical, and occasionally associated with perilesional ground-glass opacities. Magnetic resonance imaging (MRI) scans of the brain revealed similar finding found on CT of the anterior skull, in T1-weighted sequences , showed peripheral hyperintense rim surrounding a hypointense center and ring enhancement after intravenous infusion of paramagnetic contrast . The T2-weigthted sequences and fluid-attenuated inversion recovery (FLAIR) [Figure and ] showed perilesional edema in the left cerebellar hemisphere and peripheral hypointense in the center of the respective lesion. The diffusion-weighted (DWI) sequences and apparent diffusion coefficient (ADC), respectively, showed hyperintense and hypointense lesions with restricted diffusion of water molecules [Figure and ]. The proton spectroscopy curves for MR of cerebellar lesions showed an increase in lactate and lipids peaks and reduction of N-acetyl-aspartate (NAA) peak, without increase in choline peak . Fine needle aspiration of the lymph node was performed, and cytological analysis revealed a nonspecific reactive lymphadenopathy. Microsurgery biopsy of cerebellar lesion was performed, and the histological analysis concluded that it was paracoccidioidomycosis without neoplasia signals .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2325_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2325_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..547f9cd2cb06e4a3cea6b271685750c5e88df7a0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2325_en.txt
@@ -0,0 +1,4 @@
+The patient was an 84-year-old man who was admitted to the emergency room with a 24-h history of acute colicky abdominal pain. He denied other signs or symptoms. The relevant surgical history included old appendectomy and inguinal hernioplasty. The patient's medical history includes coronary artery disease and atherosclerosis, despite an otherwise healthy status. The patient was hemodynamically stable and in good general condition. Abdominal palpation led to pain in the left lower abdominal quadrant with no signs of peritoneal irritation. Abdominal computed tomography (CT) revealed small-bowel loops with multiple air-fluid levels and dilated stomach with a large air-fluid level . Laboratory tests showed no significant alterations.
+Decompression with a nasogastric tube was performed, and 1250 mL of light yellow fluid was evacuated. However, the symptoms persisted and he was admitted to the surgery department for further diagnostic testing, observation, and treatment. Despite stable vital signs, the patient experienced mild residual pain during palpation without abdominal distension. The patient stated that he periodically experienced mild abdominal pain for most of his adult life. Examination with an oral water-soluble contrast revealed small-bowel obstruction which remained unresolved over several hours of observation, leading to the suspicion of adhesive small-bowel obstruction . After receiving information regarding diagnostic laparoscopy and the potential for further surgical treatment based on intraoperative evaluation, the patient provided consent to the procedure.
+Laparoscopy revealed multiple diverticula in the proximal small intestine with distinctly dilated jejunal loops. Given the extent of the disease and the high iatrogenic injury risk, the procedure was converted to open surgery. A midline laparotomy was performed, and chronic rotation of the mesentery (volvulus) was observed. Derotation of the small intestinal loops was performed. Further examination revealed extensive diverticulosis in the proximal 2-m section of the jejunum starting approximately 20 cm from Treitz's ligament . Chronic fibrous adhesions and strictures were also observed in the mesentery and the small intestine. The affected small bowel was resected to prevent recurrent volvulus and other complications, such as diverticulitis, perforation, and bleeding. Following the resection of the jejunal segment with multiple large diverticula, side-to-side entero–entero anastomosis was performed. No diverticula were observed in the remaining bowel.
+The postoperative period was uneventful, and the patient was discharged from the hospital on postoperative day 6. The histopathologic evaluation of the resected material confirmed substantial jejunal diverticulosis with chronic fibrosis, adhesions, and strictures.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2369_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2369_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7df258f809e2470afa41f91f4e245a40e2e6c427
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2369_en.txt
@@ -0,0 +1,3 @@
+A 29-year-old primigravida Caucasian female with a past medical history significant for short stature, tobacco use, and poorly controlled pregestational type 2 diabetes mellitus (DM) presented to clinic for routine antenatal care. She was first diagnosed with diabetes mellitus at age 22 and managed with metformin prior to pregnancy with a history of poor glycemic control. She was transitioned to glyburide 5 mg twice daily by her obstetrician and subsequently increased to 10 mg twice daily secondary to continued elevated blood glucose levels (fasting ranged from 78 to 113 mg/dl and 2-hour post prandial ranged from 97 to 332 mg/dl). At 13 and 3/7 weeks of pregnancy, the patient was admitted for tighter blood glucose management, initiation of insulin, and a dietician consult to achieve improved control of glucose levels. A baseline hemoglobin A1c was obtained on admission and noted to be high at 8%. Previous maternal hemoglobin A1c levels were not reported. Antenatal fetal ultrasound at 22 weeks was notable for severe sacral agenesis, bilateral renal pelvis dilatation, single umbilical artery, and findings suggestive of pulmonary hypoplasia. The patient was referred to a tertiary care fetal and neonatal medicine center in the USA for further evaluation, and fetal magnetic resonance imaging (MRI) was recommended for confirmatory testing. Fetal MRI at 29 weeks gestation showed absence of the lower two-thirds of the spine with corresponding spinal cord abnormality compatible with type 1 caudal regression syndrome with noted horseshoe kidneys . No fetal cardiac anomaly was detected. Fetal anomalies were likely secondary to poorly controlled diabetes during early pregnancy. There was no significant family history.
+The mother was counseled extensively by maternal fetal medicine and neonatology that the infant’s prognosis was extremely guarded given the severe spinal cord anomaly and possible pulmonary hypoplasia with substantial risk of intrauterine fetal demise (IUFD), perinatal death, or paraplegia/quadriplegia in a surviving infant. The mother was offered additional confirmatory genetic testing, which she declined. After extensive counseling and discussion of options, which included termination of pregnancy, early induction of labor for provision of comfort care, or continuation of pregnancy to term, the mother opted to continue the pregnancy. She chose to pursue a plan for induction of labor at term (~ 39 weeks) with goal of respiratory resuscitation of the infant and admission to the neonatal intensive care unit (NICU) for stabilization if the infant was viable. She was followed closely throughout the remainder of her pregnancy by maternal–fetal medicine (MFM) and the fetal neonatal medicine center. She continued to return for regular obstetric care for the next 10 weeks with close attention to fetal growth and glucose control. On return obstetric follow up at 37 weeks gestation, the patient’s glucose log showed improved glycemic control with fasting glucose levels < 90 mg/dL and 2-hour postprandial values typically < 120 mg/dL. She was seen by her obstetrician at 39 and 0/7 weeks, at which time there was normal fetal movement and offered induction of labor. She chose to schedule an induction of labor at 39 and 3/7 weeks. Unfortunately, when she presented to labor and delivery for her scheduled induction, antenatal ultrasound showed low amniotic fluid index (AFI) and absent fetal heart tones consistent with intrauterine fetal demise. Labor was medically induced with subsequent vaginal delivery of a stillborn male. Evaluation of the newborn demonstrated normal facies and upper extremities, with normal chest to 2 cm below nipple line and bony spine palpable to approximately the lower two-thirds. No further bony spine was palpable. Feet and legs were present but very small, as was the abdomen, and a left club foot deformity was noted. The baby was small for gestational age with a birth weight of 2070 g, which is less than the first percentile with a Z score of − 3.3 according to the Fenton growth chart. Postnatal cytogenetics confirmed a normal male 46 XY karyotype.
+The family declined autopsy, so a minimally invasive autopsy was performed. Postmortem MRI confirmed findings of severe caudal agenesis and abrupt cord termination . Several skeletal abnormalities were visualized on the corresponding CT autopsy . The infant was in a frog-like position with flexion and abduction at the hips and flexion at the knees. Bilateral iliac wings were hypoplastic and closely approximated at midline secondary to sacral agenesis. Other deformities included a single umbilical artery, horseshoe kidneys , a left talipes equinovarus deformity, and eight bilateral thoracic ribs .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2393_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2393_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..08d8634234039e11d4b95ecc930f565e2ef90fe4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2393_en.txt
@@ -0,0 +1,5 @@
+This patient was a 20-year-old woman with an Angle Class II malocclusion and a severe vertical growth pattern with lip protrusion. Her chief concerns were her retrognathic mandible, difficulty with lip closure, and two missing maxillary first molars.
+The patient underwent extraction of two maxillary first molars because of deep cavities 1 year ago.
+The patient denied any family history of present illness.
+Pre-treatment facial photographs showed a symmetrical face, a severe convex profile, protrusion of upper and lower lips, and hyperactivity of the mentalis muscle. The oral examination showed an Angle Class II division 1 malocclusion with mandibular retrusion and two missing maxillary first molars . Model analysis showed 5 mm crowding in the lower arch, and a large overjet of 6 mm. No temporomandibular joint (TMJ) disorder symptoms or signs were observed in the clinical examination or the questionnaire survey. But there was TMJ click during her teenager.
+Cephalometric analysis presented a skeletal Class II malocclusion (SNA, 81.2; SNB, 70.2; ANB, 11), a high mandibular plane angle (MP-SN, 45), retroclined maxillary incisors (U1-SN, 97.2), and proclined mandibular incisors (L1-MP, 108.9) . Cone-beam computed tomography (CBCT) showed two missing maxillary first molars and four impacted third molars. There was erosion and flattening of the TMJ condyles bilaterally, and the joint spaces between the condyles and the glenoid fossae were small .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2394_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2394_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dfb9a1b1bc6c5ddb1a4cd99dccd3114a421240cf
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2394_en.txt
@@ -0,0 +1,7 @@
+A 14-year-old boy attended a local hospital for ankylosing spondylitis. Chest radiography showed an enhanced circular-density shadow near the left mediastinum, which intersected with the mediastinum at an obtuse angle; the base was close to the mediastinum, the outer edge clear and smooth, and the mass density even. A benign lesion was considered. Because of the mediastinal occupation, the patient visited our department of chest surgery for further treatment.
+The patient had no previous symptoms.
+The patient had no major illness before, and mandatory spondylitis was discovered this time because of his left hip pain.
+The patient had no previous symptoms.
+The results of the physical examination were normal.
+Blood analysis and the blood biochemistries, as well as urine analysis, were all normal. Electrocardiogram and arterial blood gas were also normal.
+Enhanced chest CT suggested irregular soft tissue density above the left aortic arch with a clear boundary, about 5.5 cm × 3.2 cm × 2.8 cm in size .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2426_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2426_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0168d2a371b34dfc90c827a393076afc321ca015
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2426_en.txt
@@ -0,0 +1,5 @@
+A 38-year-old Sri Lankan female presented with sudden onset severe right side headache and vomiting. At the same time she developed right-sided complete ptosis and ophthlamoplegia. The headache and vomiting lasted for one day, but the ptosis and ophthalmoplegia persisted. She did not have a history of diabetes, hypertension, dyslipidemia or any connective tissue disorder.
+On examination she had complete ptosis, ophthalmoplegia and a fixed dilated pupil (5 mm) on the right side. Direct and consensual light reflexes were absent on the same side. Vision and fundoscopic examination was normal. Left eye was normal with full eye movements and light reflexes. Other cranial nerves including sensory component of the trigeminal nerve were normal. She did not have scalp tenderness or tenderness over the superficial temporal artery. Upper limbs and lower limbs were neurologically normal and she did not have any cerebellar signs. Brachial pulse was decreased on the right side compared to left side. Blood pressure on the right arm was 90/ 60 mmHg and on the left arm it was 120/ 80 mmHg. She had bruit over right subclavian and carotid arteries. Rest of the cardiovascular, respiratory and abdominal examination was normal. She did not have features of Ehlers–Danlos syndrome, Marfan syndrome or manifestations of connective tissue disorder.
+Noncontract CT brain was done soon after the admission and was normal. Cerebrospinal fluid analysis, performed on day 2 to exclude a subarachnoid heamorrhage, was normal with absent cells, normal protein level and did not reveal xanthochromia. CT cerebral angiogram done on day 4 revealed generalized caliber reduction of right ICA. MRI done on day 23 showed significantly narrowed right ICA. Dissection of the right ICA was noted in the cavernous sinus, with a false lumen of 1.5 × 1 cm, which was thrombosed . The thrombosed lumen was of intermediate signal intensity in T1, T2 and Fluid-attenuated inversion recovery (FLAIR) images and did not enhance with contrast. This was compressing the right cavernous sinus. Multiple focal T2 and FLAIR hyper intensities with partially restricted diffusion, suggestive of acute infarcts, were also seen in the right parietal lobe . Following this we performed a cerebral digital subtraction angiogram, which showed total occlusion of the right ICA from its origin . Blood supply to the right middle cerebral artery was maintained via the anterior communicating and the posterior communicating arteries. Aneurysmal dilation and stenosis were also evident at the right proximal subclavian artery . The CT angiogram also revealed aneurismal dilatation (20 × 11 mm) and stenosis of the first part of the right subclavian artery . Tapering of the distal part of the right carotid bulb at the origin of the right ICA was seen and was suggestive of right ICA dissection with thrombosis. Rest of the angiogram was normal . Florescent angiogram of the retina was normal.
+Full blood count showed neutrophil leukocytosis with low hemoglobin and normochromic normocytic anemia was seen in the blood picture . Liver function tests revealed low albumin with normal liver enzyme levels . Serum creatinine was 150 μmol/L (eGFR using MDRD = 35.8 ml/min/ 1.73m2) on admission and later came down to 100 μmol/L (eGFR using MDRD = 57.2 ml/min/73m2). Urine full report was normal and ultrasound revealed the kidney sizes to be 8.9 cm on the right and 8.7 cm on the left. Ionized calcium was 1.11 mmol/L (1.0–1.3) and phosphorus was 1.0 mmol / L (0.8–1.5). ESR was persistently high (130 mm in the first hour) and CRP was 95 mg/L, which later came down to 7 mg/L. She was negative for HIV serology and VDRL was non reactive. Mantoux test was negative and the chest x ray was normal. ANA, p-ANCA, c-ANCA and hepatitis B and C serology were negative. Fasting blood sugar, HbA1C, thyroid function tests and lipid profile were within normal range. Bilateral cervical ribs were noted in chest x-ray and in cervical x- ray.
+Takayasu arteritis was diagnosed and she was started on high dose of prednisolone. (1 mg/kg). Aspirin was also started. Because of critical cerebral artery complication neurosurgical and vascular surgical opinion was taken. As the patient did not have any further neurological events and because of limited facilities available, no surgical intervention was planned. After 2 weeks of steroids her ESR came down to 50 mm in the first hour and after one month ESR was 30 mm in the first hour. Patient’s ophthalmoplegia and ptosis remained the same and we started to tail off steroids gradually and added azathioprine as a steroid-sparing agent. The difference between right and left brachial pulses reduced and the right arm blood pressure increased. She did not have any further vascular events and a follow up angiogram was planned in six months time. Authors followed the CARE guidelines when writing this case report.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2450_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2450_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..83bd5e54199de353904d94d7ab0e0932233d67e3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2450_en.txt
@@ -0,0 +1,6 @@
+A 69-year-old Japanese man presented with pain and a polypoid mass on the lower left gingiva for which he consulted in our hospital. He had received chemoradiotherapy for SCC of the buccal mucosa 15 years prior to this consultation at the age of 54 years. At that time, he had an ulcerative lesion with a reddish and rough surface in the buccal mucosa including the corner of the mouth . The patient was a plasterer, and asbestos exposure was not apparent. He had no relevant medical history, including no history of smoking and alcohol consumption. The lesion was diagnosed as moderately differentiated SCC following a biopsy . Radiological examinations suggested a cancer metastasis in the left submandibular lymph node, and he received chemotherapy with cisplatin (total 110 mg) and 5-fluorouracil (total 2925 mg) via peripheral venous route and concomitant radiotherapy: the primary tumor and neck were irradiated at the dose of 70 Gy, performed in the hospital for 4 months. The treatment resulted in a complete clinical remission of the primary tumor and a complete remission of the neck lesion, which was pathologically confirmed as metastasis composed of nonviable SCC cells (data not shown). No recurrence was detected in subsequent years; however, he developed mandibular osteonecrosis 6 years after chemoradiotherapy and was treated with oral roxithromycin.
+On examination at the age of 69 years, his vital signs were within normal ranges. He developed Parkinson’s disease a year before this consultation, and the disease was well controlled with oral levodopa (300 mg/day) and benserazide hydrochloride (85.5 mg/day). He showed trismus; however, he had no other abnormal physical and neurological findings. On intraoral inspection, a polypoid mass measuring 10 mm in diameter was found in the left molar region of the lower gingiva . Its surface was rough and covered by a whitish pseudomembrane. Panoramic radiography showed bone resorption, exhibiting a moth-eaten appearance that involved the base of the mandible . Contrast-enhanced computed tomography revealed a soft-tissue mass lesion accompanied by extensive bone resorption of the mandible .
+A malignant tumor was suspected, and a biopsy specimen from the polypoid lesion was obtained. The polypoid mass was composed mainly of loose granulation tissue , where atypical spindle or pleomorphic cells were scattered in the fibrin-rich edematous or pale stroma together with neutrophils, lymphocytes, and capillary endothelial cells . The surface of the lesion was mostly ulcerated but partially covered by squamous epithelium with no obvious atypia; only slight nuclear enlargement and disordered basal cell polarity were noted . In the subepithelial tissue, atypical spindle cells were arranged haphazardly and exhibited large, basophilic cytoplasm and bizarre nuclei . Some of them exhibited mitotic figures, some of which were atypical . Neutrophils were frequently incorporated within their cytoplasm , some of which appeared to be degraded with missing nuclei .
+Immunohistochemistry revealed that atypical spindle cells were positive for vimentin and α-smooth muscle actin , but not for pan-cytokeratin . No epithelial markers other than p63 were detected . The spindle cells were partially positive for p63 , and most were positive for p53 . Ki-67 staining was observed in approximately half of the cells (data not shown). Furthermore, granular CD68 staining was observed in the cytoplasm . These findings were highly suggestive of a malignancy, and SCSCC and post-irradiation sarcoma were considered in the differential diagnosis, given that the patient had a history of chemoradiotherapy for treating SCC of the buccal mucosa 15 years before.
+Although the final diagnosis had not been determined, the patient was admitted to our hospital for surgery. On admission, his height and body weight were 145 cm and 45.7 kg, respectively, and vital signs were within normal range (blood pressure 127/79 mmHg, pulse 68 beats/minute, and body temperature 36.0 °C). Complete blood count showed mild anemia (red blood cells 4.07 × 1012/L, hemoglobin 128 g/L, hematocrit 36.0%, mean corpuscular volume 90.4 fL, mean corpuscular hemoglobin 31.4 pg, mean corpuscular hemoglobin concentration 348 g/L, white blood cells 5.49 × 109/L, and platelets 130 × 109/L). The biochemical test results of blood and urine were within normal ranges with the exception of a mild elevation in C-reactive protein (8.7 mg/L), which was presumably caused by the gingival tumor. He underwent hemimandibulectomy pursuant to a clinical diagnosis of a malignant tumor. The postoperative course was uneventful.
+The hemimandibulectomy specimen had a protruding tumor that exhibited an ulcerated surface and that measured 23 × 15 mm from the gingiva to buccal mucosa . The location of this tumor was not the same site of the previous tumor. On the cut surface, there was a whitish and solid lesion invading the mandibular bone . Histologically, most of the lesion was composed of conventional SCC, measured 45 × 25 × 15 mm in size, and invaded the mandibular bone extensively . The spindle cells were distributed near the SCC foci, mostly in the remaining polypoid segment . Because the atypical spindle cells were concomitant with the conventional SCC component, we finally diagnosed the lesion as SCSCC. The tumorous spindle cells frequently contained neutrophils within the cytoplasmic vacuoles , forming cell-in-cell figures. Such figures were much rarer in the conventional SCC cells. Intense staining for lysosomal-associated membrane protein 1 (LAMP-1) and cathepsin B, which are both lysosomal markers, were observed around the vacuoles containing the neutrophils . This suggested that such cell-in-cell figures may result from the phagocytosis of neutrophils rather than from emperipolesis. The patient has had no evidence of recurrence 5 years after the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2466_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2466_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..48d04cd3b3b47c141f1860f74e21cb402220be29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2466_en.txt
@@ -0,0 +1,11 @@
+A 55-year-old female patient was referred to the orofacial pain unit of the OPH clinic for showing symptoms of temporomandibular joint arthralgia and osteoarthritis, orofacial myofascial pain, and sleep bruxism. An experienced Orofacial Pain Specialist performed a comprehensive clinical history and examination following the Diagnostic Criteria for Temporomandibular Disorders (DC/TMD) protocol and the International Classification of Orofacial Pain-1 (ICOP-1) criteria. At the moment of the examination, the patient was taking 150 mg of Venlafaxine for major depressive disorder, 4 mg of Clonazepam for sleep onset insomnia, and hormone replacement therapy for menopause.
+Another major complaint of the patient was difficulty initiating and maintaining sleep. Thus, an Epworth Sleepiness Scale and Insomnia Severity Index were performed to complete the sleep evaluation. Due to the high scores presented by the patient and clinical history consistent with chronic sleep insomnia, polysomnography (PSG) was requested Even though the PSG revealed no sleep breathing disorders, the exam showed severe modifications in the patient’s sleep architecture, a mild increase in the arousal index, and low-frequency sleep bruxism. The PSG results led us to hypothesize that the patient’s sleep architecture alterations were because of the chronic consumption of benzodiazepines. Thus, the patient was derived to her treating psychiatrist to gradually diminish and eliminate the intake of Clonazepam.
+During this time, the patient successfully underwent her osteoarthritis and orofacial myofascial pain treatment. In addition, an upper oral occlusal splint was prescribed to manage low-frequency sleep bruxism.
+In order to manage sleep initiation and maintenance insomnia, the psychiatrist tapered the dosage of Clonazepam and progressively replaced it with Trazodone until a target dose of 100 mg was reached. Throughout this period, the patient did not experience any extrapyramidal symptoms.
+Almost three months later, after the end of the orofacial pain treatment, the patient returned complaining of a sudden worsening of her awake bruxism. The patient presented abrupt rhythmic involuntary muscle contractions, similar to jaw-closing and jaw-deviating dystonic-like movements affecting the right side of her masticatory muscles. (See , and ) The dystonic-like episodes were spontaneous or triggered by everyday activities such as talking, chewing, and yawning. The severity of these motor contractions tended to be exacerbated by emotional stress and nervousness produced by these uncontrollable movements. During these episodes, some typical features of oromandibular dystonia were noticed, such as some sensory tricks (gentle pressure on the inferior incisors would milden the jaw-deviating dystonia as the placement of a tongue depressor between the molars for jaw-closing dystonia), and phenomena (e.g., oromandibular dystonia overflowing the right eyelid, resulting in right blepharospasm).
+A video examination protocol suggested by Yoshida was carried out to assess the type and magnitude of involuntary movements . In addition, a complete haematological and biochemical blood examination was required and all the parameters were within normal range. Thus, both thyroid and parathyroid hormonal dysfunction were ruled out.
+Since the literature indicates that Trazodone can induce extrapyramidal symptoms and abnormal oromandibular movement disorders only start after the addition of this medication. The authors, in agreement with her treating physician, suggested performing a slow taper until complete discontinuation of Trazodone was achieved.
+A progressive dose reduction of 25 mg of Trazodone was scheduled every two weeks. In the meantime, an inferior occlusal splint was prescribed, considering that mild contact in the inferior incisor tended to ease the intensity of the dystonic-like movements.
+During the progressive discontinuation of Trazodone, the authors noticed an immediate attenuation of the dystonic symptoms. However, only achieving a partial but clear remission of them. No video protocol was recorded during the tampering of Trazodone.
+Considering that the patient’s mental health status was stable, it was decided to take a more conservative approach, only eliminating the most likely offending drug, namely, Trazodone. Consequently, the authors maintained that Venlafaxine intake was unchanged in order not to jeopardize the psychiatric treatment, and also closely monitored the evolution of the clinical symptoms. Additionally, the authors indicated the administration of 25 units of incobotulium toxin (Xeomin®, Merz, Germany) per masseter muscle, 20 units per temporalis muscle, and 15 units were applied to the inferior head of the right lateral pterygoid with electrical stimulation guidance (See anatomical landmarks in ).
+During the two-week follow-up consultation, the authors could recognize a substantial decrease in the magnitude and intensity of the oromandibular movement. Two months and seven months after the discontinuation of the offending drug and botulinum toxin application, the authors re-recorded Yoshida’s video protocol to carry out an objective before and after comparison of the treatment results. See for comparison prior to and after the treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2485_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2485_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fc8f10c303c6370bbac363bf6c79dca668069e14
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2485_en.txt
@@ -0,0 +1,7 @@
+A 45-year-old male patient, without any past medical conditions, presented with a severe burning sensation on the hallux, 2nd, 3rd digits, and dorsum of the right foot. The patient, who works in a chemical plant, was replacing a worn-out flowmeter connected to the EO tank. The patient was not wearing personal protective equipment (PPE), such as chemical-resistant clothing and shoes. According to the Material Safety Data Sheets, EO is supplied through an automatic isolation line. During the incident at 2 PM, a large amount of water mixed with EO solution spilled on his right shoe. The patient did not experience any immediate symptoms and continued working with the wet shoe until approximately 5:30 PM. He returned home around 7 PM (approximately 5 hours after the exposure) and took a shower, effectively decontaminating the region. The next morning, the patient woke up to a severe burning sensation and pain in the dorsum of the right foot and proximal area of the digits. He discovered desquamation, redness, and oozing. The patient then presented to a nearby hospital .
+The patient did not provide any specific family history and was not under treatment for any disease or condition. He reported a smoking habit (10 pack-years) with occasional social alcohol consumption.
+The patient had worked in restaurants since his mid-20s. Since 2013, he had been employed at a chemical plant for trial runs of facilities and indicator system maintenance and repair. In 2018, he started to work in production of basic petrochemicals such as surfactants and concrete hardeners. He was responsible for the EO supply from the ingredient tank to the production line, replacement of indicator systems, and facility maintenance. Typically, there is no risk of EO exposure, as it is supplied through an automatic isolated pipeline, but workers may be exposed during the replacement of indicator systems.
+The patient had stable vital signs within the normal limits and was alert. However, the patient appeared acutely ill at presentation and had subcutaneous tissue damage on the right dorsum of the foot and digits, with severe redness and dark pink dermal surfaces, serosanguineous exudates, blisters, and desquamation . The burn area was calculated to be 3.5% of the total body surface area. He did not report dyspnea and had clear breathing sounds upon auscultation.
+Hematological analyses (complete blood count, blood chemistry), urinalysis, and plain chest radiograph performed at the emergency department were all within the normal limits.
+The area was irrigated and disinfected. Topical antibiotics, silver sulfadiazine, was applied to unhealed burn wounds to protect the burn from becoming infected and the patient was followed-up in the outpatient clinic for 4 weeks. Normal skin was restored without any defects, and at the 9-month follow-up, there were no notable findings in the area other than hyperpigmentation . At a general health assessment 9 months after the incident, the patient reported reduced sensation in the right foot. After an outpatient consultation at our department of occupational and environmental health, he was referred to hematology-oncology, pulmonology, and neurology. There were no abnormal findings in the peripheral blood smear, bronchial provocation test, nerve conduction study, and electromyography. Follow-up was therefore concluded.
+For this study, we obtained approval from the Institutional Review Board (IRB) of Dankook University Hospital (IRB No. 2021-05-009).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2486_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2486_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2e6754bf61765b327aed2d834c376dd6ef4c2676
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2486_en.txt
@@ -0,0 +1,6 @@
+The present case involves a 65-year-old female with a medical history of hypertension and type 2 diabetes mellitus. In 2020, her ECG showed complete left bundle branch block (LBBB), and in January 2021 the patient experienced dizziness with no apparent cardiac cause. In October 2021, the patient was seen in the outpatient clinic because of dizziness and shortness of breath. ECG and Holter monitoring revealed a 2:1 AV-block, high-degree AV-block, and complete AV-block. A trans-thoracic echo showed normal cardiac function, except for the abnormal septal movement typically seen in LBBB. Subsequently, the patient was referred to our center for brady-pacing and due to the prospect of chronic RV pacing, she was accepted for CSP.
+Upon admission for CSP implantation in October 2021, the patient had complete AV-block with a ventricular escape rhythm of 33 beats per minute. The CSP implantation was successfully performed under local anesthesia with the device placement location being subcutaneous and left-sided. The right atrial lead was successfully positioned within the right atrial appendage. Consistent with the 2021 ESC pacing and CRT guidelines (Class IIa recommendation), the operator proceeded to insert an RV backup lead at the RV apex in the context of His-pacing.
+Thereafter, a ventriculogram was performed to visualize the His-region for CSP lead placement (Medtronic SelectSecure Model 3830 lumen less lead, Medtronic, Inc., Minneapolis, MN). His capture could be achieved at several sites, but pacing at high output only resulted in partial correction of the LBBB. After three unsuccessful attempts to correct the LBBB completely at the His, the decision was made to proceed with conversion to the LBBA. The CSP lead was then placed in the ventricular septum until sufficient (non-selective) LBBA pacing was achieved, with satisfying sense and threshold values. During pacing, specific observations were made; a modest R’ in V1 and a stimulus to LV activation time of less than 80ms. The inter-peak time measured was 24ms (interval between peak R-wave in V6 and R’ in V1) . Achievement of more selective LV capture was hindered by the challenge of reaching deeper into the septum. Following lead implantation, a fluoroscopic image revealed the fulcrum sign, demonstrating the placement of the CSP lead tip within the RV septal wall . Finally, a cardiac resynchronization therapy pulse generator (Medtronic Solara CRT-P, Medtronic, Inc., Minneapolis, MN) with the CSP lead connected to the LV port was implanted subcutaneously. The LBBA pacing threshold at implant was 0.5 V and the pacing settings were eventually programmed to 2.5 V/0.4ms for the LBBA lead.
+The day after the procedure, a chest X-ray confirmed the lead position and a threshold test was performed to ensure stable pacing values . Two months after implant, during the routine device checkup, it was discovered that the LBBA pacing threshold had increased slightly to 1.25 V.
+During the routine device follow-up at one year, it was observed that the LBBA pacing threshold had risen to 3 V, which was above the pacing output of 2.5 V. Consequently, the patient was receiving RV only pacing from the backup lead . Attempts to increase the output led to pocket stimulation, prompting a change in the pacing configuration to LVtip – RVring at 4 V/0.7ms. Subsequent follow-up two months later revealed an even higher LBBA pacing threshold. At increased pacing output, anodal capture at the lead ring was observed, and battery life expectancy decreased drastically. As a result, RV pacing was established as the default mode, and LBBA pacing was deactivated.
+Subsequently, a CMR scan (1.5T scanner, Sola, Siemens Healthineers, Erlangen, Germany) was performed to investigate the possible cause of the increasing LBBA pacing threshold. To ensure safety during the procedure, the device was programmed in the MR safe mode. The following imaging techniques were applied: cine imaging, T1 and T2 mapping, and wideband late gadolinium enhancement (LGE) imaging (to reduce cardiac implantable electronic device–induced artefacts) as presented in Fig. . The cine imaging showed a normal LVEF of 58% and normal cardiac dimensions. Proximal LV septum thickening (14 mm) was present with hypokinesia in the same area. T1 mapping demonstrated focal high T1 values in the proximal LV septum of 1263 ± 51ms (site-specific normal myocardial T1 values: 950–1050ms) indicative of myocardial fibrosis, edema or infiltration. On T2 maps, a slightly increased T2 value was present in the same area (54.6 ± 2.7ms) as compared to the site-specific normal myocardial T2 values (42–50ms), compatible with focal edema/inflammation. LGE images revealed non-ischemic patchy mid-myocardial high signal intensity in the same proximal LV septum, suggestive of focal fibrosis. Fibrosis was not limited to the insertion point of the CSP lead tip; instead, it extended in both the basal-apical and inferoseptal-inferolateral directions. The combination of findings, including basal septal thickening with mid-myocardial focal LGE and evidence of inflammation with concomitant diffuse myocardial edema is suggestive of cardiac sarcoidosis. Therefore, further lab tests and a PET-CT scan were performed. Lab results showed an increased serum angiotensin-converting enzyme (ACE), and normal soluble Interleukin2-receptor antagonist levels. PET-CT findings did not support the diagnosis of cardiac sarcoidosis (no lymphadenopathy or avid lymph nodes within the imaged region) or the presence of active myocarditis. Alternative causes for basal septal thickening with mid-wall focal LGE could be an infiltrative cardiomyopathy, systemic disease, or a hypertrophic cardiomyopathy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2503_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2503_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5a4378b879210fc1ddef804513533a26cb3e8242
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2503_en.txt
@@ -0,0 +1 @@
+A 53-year-old previously healthy woman was diagnosed with a calvarial lesion on a brain checkup and was referred to the hospital. She had not undergone cranial radiotherapy in her life. Cerebral magnetic resonance imaging (MRI) revealed an intradiploic tumor in the right parietal bone protruding into the cranial cavity. It was a lobular mass 11 × 14 × 12 mm, presented isointensity on T1- and hyperintensity on T2-weighted sequences, and was inhomogeneously enhanced with intense enhancement of the surrounding dura mater. The inner table and dura underlying the tumor appeared intact. There was no identifiable peritumoral brain edema . On computed tomography (CT), the tumor was accompanied by a well-demarcated calvarial erosion at the site of the tumor, extending more predominantly into the inner side compared to the outer side. In addition, sclerotic changes were observed in the surrounding bone . The patient was requested to undergo a tumor resection. Intraoperatively, the tumor was reflected with the surrounding bone that presented sclerotic changes and removed en bloc. The inner table compressed by the tumor was partially defective and the underlying dura mater was erosive, which was circumferentially resected and replaced by an artificial substitute . Eventually, a Simpson Grade I resection was achieved. Adhesions between the tumor and surrounding dura mater were not found in the intact underlying cerebral cortex. Microscopically, the tumor comprised cells with oval-shaped nuclei and intervening vasculature of varying sizes. There were a few mitotic figures. Immunohistochemical examination showed positive staining for epithelial membrane antigen and progesterone receptor but negative staining for CD34. These findings are consistent with those of angiomatous meningiomas. In addition, tumor invasion into the adjacent bone and dura mater was observed . At present, the patient is planning to undergo periodic MRI surveillance in every 6 months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2527_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2527_en.txt
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index 0000000000000000000000000000000000000000..c849cc75d1429f54a074773246059a45212ea94f
--- /dev/null
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@@ -0,0 +1,2 @@
+A previously healthy 64-year-old female was admitted to the First Affiliated Hospital of China Medical University (Shenyang,Liaoning Province, China) with a large retroperitoneal tumor. The patient had been experiencing right lower quadrant abdominal pain for almost three years, but she had ignored the symptoms until the abdominal pain intensified with a radiating ache in the waist. During physical examination, a large, fixed mass with a diameter of 10 cm could be felt in the right upper abdomen without obvious haphalgesia. The patient presented with normal blood pressure and no swelling in either lower extremity. General laboratory work-up results were within normal limits (Blood routine test: white blood cells, 7,000/L, hemoglobin, 11.1 g/dl; serum creatinine, 0.48 mg/dl; urine routine test: white blood cells: 9.9/µl, red blood cells:19.40/µl; neurone specific enolase: 50.20 ng/ml). The tumor was further diagnosed by following imaging studies, including computed tomography (CT) and endoscopic ultrasonography (EUS), which were performed to investigate the abdominal pain. Contrast-enhanced CT scans revealed a large (7.8 cm * 5.5 cm * 5.0 cm) irregular hypodense retroperitoneal mass with heterogeneous enhancement and invasion of the IVC, and the right ureter was compressed with proximal ureteral dilatation and hydrops . EUS revealed a hypoechoic mass outside the distal wall of the descending duodenum. EUS-guided biopsy confirmed the diagnosis of a mesenchymal tumor with low malignancy potential. Dimensional CT of the IVC was performed to investigate the relationship between the tumor and the vessel. CT revealed that the IVC was encircled by the tumor with moderate invasion . To further investigate whether the left and right renal veins had been invaded by the tumor, IVC angiography was suggested, revealing that the IVC was compressed and narrowed . The right renal vein presented with normal imaging findings and no tumor invasion. Due to the lack of essential tools, left renal vein angiography was not performed successfully. To prevent pulmonary embolism resulting from the abscission of the tumor during the operation, an IVC filter was placed prior to the surgery. According to preoperative imaging, the right kidney needed to be resected due to invasion by the tumor. Preoperative emission tomographic imaging of the kidneys indicated that the left glomerular filtration rate(GFR) was 49.8 ml/min, the right GFR was 34.8 ml/min, and the total GFR was 84.6 ml/min. Given that the retroperitoneal tumor with the IVC and adjacent viscera was resectable en bloc, the patient underwent surgical resection.
+During the operation, we found that a 6 cm segment of the IVC, the right kidney with ureter, the descending duodenum seromuscular layer and the origin of the left renal vein had been invaded by the tumor , therefore, the tumor was resected en bloc with the IVC (from the suprarenal to infrarenal segment), the right kidney with ureter, and the duodenum seromuscular layer. As the left renal vein was involved, it was ligated and resected to the proximal part of the left renal vein ahead of the genital vein drainage point. IVC reconstruction was performed with the interposition of a 20 mm diameter polytetrafluoroethylene (PTFE) prosthesis . The proximal and distal IVCs were occluded for 70 min during the operation.There was a high risk of renal insufficiency after surgery for this patient, since a single left kidney without a left vein can not provide sufficient function. After checking the specimen from the right kidney, we found that the right renal vein was not involved. Therefore, we used the resected right vein as a bridge between the reconstructed IVC and the left renal vein. After the right renal vein was trimmed, it was anastomosed between the left renal vein and the reconstructed IVC . When the vascular occlusion was lifted, left renal vein blood smoothly flowed through the interposed right vein. showed the resection of tumor carrying the kidney with ureter. Since the procedure is a little complicated, showed the drawing of the procedure to visually describe the operation steps. The patient had an uneventful recovery process with normal renal function (serum creatinine 0.71 mg/dl) after the operation, and urine routine test showed normal number of white blood cells (2.5/µl). However, follow-up CT indicated that the left vein was blocked two weeks after the operation, her renal function is still normal(serum creatinine 0.81 mg/dl). Pathological examination verified the diagnosis of leiomyosarcoma. The patient was discharged two weeks after the operation. She continues well with normal renal function (serum creatinine 0.89 mg/dl) and has no evidence of disease eight months after surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2537_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2537_en.txt
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index 0000000000000000000000000000000000000000..f2325ca542ec12fc9dc8d7b6d73ddd872552b741
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2537_en.txt
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+A 53-year-old woman presented with bilateral visual loss. She had a prior history of “IIH” by modified Dandy criteria 19 years prior but aggressive surgical treatment with lumboperitoneal shunt placement and two revisions failed to improve the vision. She had a pituitary adenoma that was resected but the vision did not improve and she presented with 3 weeks later with new-onset headache and visual loss. Her BMI was 35.44 kg/m2. Past medical history included depression, hepatitis C, hyperlipidemia, and uterine cancer post-hysterectomy. The patient was taking trazodone for anxiety and buprenorphine for chronic pain. She had allergies to penicillin, tolterodine, ondansetron, metoclopramide, and prochlorperazine. She never smoked and had no history of alcohol or drug use. The family history was non-contributory.
+At presentation she reported new headaches, transient visual obscurations, and a history of “papilledema” and “IIH” in 2003, at the age of 35. In 2003, cranial magnetic resonance imaging (MRI) was normal and lumbar puncture (LP) revealed normal CSF contents but an elevated opening pressure, which was compatible with the modified Dandy criteria for IIH. The patient had progressive visual loss that required LP shunt and had a subsequent shunt revision.
+From 2015 to 2018, she began experiencing painless peripheral vision loss, which she and her physicians attributed to “old damage from the pseudotumor cerebri”.
+The patient presented again in 2018 with progressive peripheral vision loss in both eyes. A repeat cranial MRI showed a prior stable mild Chiari I malformation but a new suprasellar pituitary adenoma . A diagnosis of compression optic neuropathy was made. Visual acuity was hand motion in the right eye (OD) and 20/60 in the left eye (OS). Automated perimetry (Humphrey visual field (HVF) 24 − 2) revealed a temporal hemianopic impairment with a superimposed inferior altitudinal field loss OS and diffuse depression OD. Repeat LP results revealed normal CSF and opening pressure. The patient had a Grade 1 pituitary adenoma removed completely via a transnasal technique, but her vision did not improve, likely due to the prior optic atrophy that was present for years prior to resection.
+In February 2020 the patient presented to the neuro-ophthalmology clinic at Houston Methodist Hospital with one-month worsening headaches and vision loss for which she was admitted. On neuro-ophthalmic examination, the visual acuity was no light perception OD and counting fingers OS. The right pupil was amaurotic. Optical coherence tomography (OCT) of the retinal nerve fiber layer and the macular ganglion cell layer showed diffuse loss OU. New subretinal and intraretinal edema was seen on OCT and ophthalmoscopy showed diffuse optic atrophy OU.
+Repeat cranial MRI showed gross total resection of the pituitary adenoma with no recurrent or residual disease. LP showed normal opening pressure and CSF content. Repeat orbital MRI with contrast however showed symmetric thin peripheral optic nerve sheath enhancement of the intra-orbital optic nerves OU . Serum MOG-Ab testing was positive at a 1:100 titer. She was treated with intravenous steroids followed by plasma exchange and rituximab. There was an improvement of subretinal fluid collection following the plasma exchange, and she continued rituximab every 6 months. In September of 2020 her VA was NLP OD and 20/400 OS but the incomplete improvement was attributed to prior optic atrophy. In August of 2021 OCT was done and her VA was stable at NLP OD and 20/400 OS. On May 3, 2022, she presented with 3 weeks of worsening vision and headaches, her VA was NLP OD and CF OS, with a right RAPD, on OCT global was 75 OD and 67 OS after being 99 OD and 84 OS and showed bilateral optic atrophy despite treatment for MOGAD likely due to the delayed treatment of MOGAD.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2548_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2548_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..307bc7a64ddd8fc35a19915b5022078c2cce4da7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2548_en.txt
@@ -0,0 +1,5 @@
+A 59-year-old female presented to the emergency department (ED) with a chief complaint of right lower extremity pain and swelling. Vital signs at triage were temperature (oral) 98.2° Fahrenheit; heart rate 83 beats per minute; respiratory rate 17 breaths per minute; pulse oximetry 99% on room air; and blood pressure of 135/78 millimeters of mercury (mm Hg). The patient had a hospital admission 40 days prior to presentation for PE and right popliteal DVT with a positive nasopharyngeal COVID-19 test. She denied a familial history of hypercoagulable states or a personal history of thromboembolic disease prior to her COVID-19 infection. In the ED, she underwent an ultrasound of the right lower extremity. The ultrasound showed the previously seen right popliteal DVT , as well as interval development of right mid-femoral DVT .
+Repeat COVID-19 nasopharyngeal swab testing was negative. Per the patient, when she was discharged previously she was unable to follow up with a hematologist/oncologist due to COVID-19-related lockdown restrictions but maintained compliance with her apixaban at five milligrams (mg) twice per day. Her international normalized ratio (INR) on presentation was 1.36 (reference range: 0.83–1.09) and her D-dimer was 2054 nanograms per milliliter (ng/mL) (0–500 ng/mL). She was admitted for anti-coagulation and started on low molecular weight heparin (LMWH) at 1 mg per kilogram. Throughout her hospital course, she was placed on warfarin with INR values ranging from 0.98 to 4.14. An echocardiogram was performed that showed a normal size, thickness, and function of the left ventricle. In addition, the right ventricle was normal in size and function. The patient was discharged with 12 mg of warfarin daily with hematology follow-up.
+The patient had been admitted approximately 40 days prior for submassive bilateral central PE with a right popliteal DVT . A detailed report of her previous admission is warranted given the patient’s previous DVT and PE findings with a positive COVID-19 nasopharyngeal swab test.
+On ED arrival during the first admission, vital signs at triage were heart rate 120 beats per minute; blood pressure of 150/109 mm Hg; respiratory rate of 22 breaths per minute; and pulse oximetry of 89% on room air. Laboratory studies revealed a 0.89 ng/mL troponin I (0.00–0.05 ng/mL) with the additional following labs: D-dimer 5397 ng/mL and INR of 1.0. The chest computed tomography angiography showed acute bilateral central PE with probable right heart strain with multiple small bilateral peripheral ground glass infiltrates suggestive of COVID-19 pneumonitis. The patient was given at the time a heparin infusion with a bolus based on actual body weight and protocols.
+She was admitted to the intensive care unit (ICU) and underwent urgent thrombolysis with thrombectomy. During the procedure, one mg per hour of alteplase was catheter directed while mechanical thrombectomy was performed. The total amount of alteplase received was 24 mg. Repeat angiography approximately 24 hours later showed significant improvement in blood flow to the right and left main as well as segmental and subsegmental pulmonary arteries with significant decrease in central clot burden but with residual central filling defects. An echocardiogram was performed during her admission. However, due to all images being suboptimal in quality, the study was technically limited with “probable normal LV systolic function…right ventricle is not well visualized.” During her hospital course, she was placed on 10 mg of apixaban twice a day for one week and transitioned to 5 mg twice a day with which she was discharged on the same schedule. The patient underwent rehabilitation, which included daily exercising. She stated she was compliant with her apixaban medication at 5 mg twice a day.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2553_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2553_en.txt
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index 0000000000000000000000000000000000000000..b70e5b61f42828be7a5e510fec25bc0df0a55ff7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2553_en.txt
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+A 50 year old male from a VL endemic village of Bihar presented to the OPD of this institute in August 2007. He had fever with weakness and pallor of about 3 months duration. The fever was associated with chills. He also complained of frequent loose motions in the last 6 months and had lost about 7 kg of weight. He had dry cough of one month duration associated with small amount of haemoptysis and oral ulceration more marked on the tongue. He also complained of frequent micturition and pain in the metatarsophalangeal joints of the big toes bilaterally alongwith some amount of generalized joint pain.
+He was a truck driver by profession and was a frequent visitor to the red light areas of metropolitan cities namely Mumbai and Kolkata. On close questioning he revealed having frequent sex with multiple commercial sex workers. He use to take alcohol, toddy and smoked 2–3 cigarettes per day. He had two small children aged 8 years & 6 years (both girls). At the time of presentation he had bradykinesia with mask facies and characteristic pill rolling tremor more marked on the right side. The arms swing was also absent on the right side while walking and his gait was festinant. There were no features of forgetfulness or dementia, history of falls or any associated autonomic disturbances. He however had micrographia with monotonous speech.
+On clinical examination he had a mouth temperature of 102°F (39°C) with a pulse rate of 120/min. His respiration rate was 20/min and his blood pressure was 110/70 mmHg in the left upper limb in supine posture. Chest and cardio vascular system examination were normal except for sinus tachycardia. His liver and spleen were palpable 2 cm and 4 cm below the respective coastal margins in the mid axillary lines. On central nervous system examination the mask facies, bradykinesia, pill rolling tremor, cogwheel rigidity and festinant gait were elicited. Bradykinesia and rigidity were asymmetric. The palmo-mental and glabellar tap reflexes were positive bilaterally. The planters were bilaterally flexor. All the above symptoms were more marked on the right side.
+The patient was subjected to various hematological and biochemical investigations along with splenic aspiration, chest x-ray postero-anterior view, ultra sonography of abdomen and computerized tomography (CT scan) of the brain. He had a hemoglobin level of 6 gm/dl along with a total count of 4000 cells/mm3. Liver and renal function tests were normal. His fasting blood sugar was 120 mg/dl and post prandial level was 160 mg/dl. His serum uric acid was 7.2 mg/dl. Western Blot for HIV1 was positive. His CD4 count was 180/μl and CD8 count was 643/μl. Splenic aspirate for Leishman Donovan bodies was 3+ according to WHO criteria. Ultra sound showed hepatosplenomegaly with features of fatty liver. CT scan of the brain and ECG were normal. ELISA and PCR for tuberculosis were negative. MRI and spinal fluid examination were also done and found normal.
+Based of the above findings a diagnosis of HIV1, VL and Parkinsonism was made. Other associations were diabetes mellitus and hyperuricaemia. He was put on diabetic diet and started on Miltefosine 50 mg capsules twice daily for 28 days after meals along with iron and folic acid supplements. He was also administered Allopurinol in the dose of 100 mg tablets twice daily. He was started on highly active antiretroviral therapy with two nucleoside reverse transcriptase inhibitors namely Zidovudine (200 mg) plus Lamivudine (150 mg) and one non nucleoside reverse transcriptase inhibitor namely Nevirapine 200 mg twice daily after food. Parkinson's disease was treated with Entecapone (100 mg), levodopa (100 mg) and Carbidopa (25 mg) combination twice daily with Triphenhexidyl (2 mg) twice daily along with Selegiline hydrochloride 5 mg twice daily. Other D2 receptor agonists like ropinirole or pramipexole were not added.
+After one month of treatment his spleen had regressed, there was no fever and no LD bodies were seen in the bone-marrow aspirate. He was continued on antiretroviral therapy (ART) and Anti-Parkinsonian therapy (entekapone, levodopa, carbidopa, triphenhexidyl and selegeline) along with allopurinol. His CD4 increased to 300/ml. He was able to walk with considerably less tremor. He, however, relapsed for visceral leishmaniasis after 3 months of therapy and was treated with Amphotericin B in the dose of 1 mg/kg body weight for 15 days in 5% dextrose intravenous infusion on alternate days. He was told to report after one month but was ultimately lost to follow up. About 6 months later, it was gathered from his relatives that he had died. VL, itself, is a disease of poorest of the poor as it mainly affects the low socio-economic group and the combination of HIV and Parkinsonism makes it more difficult for the people of poor countries likes India for proper treatment compliance and regular follow-up visits. It is hoped that possibly due to this reason the patient could not turn up and eventually he might have contracted some other AIDS related complications and lost his life. We really feel pity for his poor family.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2554_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2554_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..00093ed50851dfec25d4d7beaab9d739b73f11f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2554_en.txt
@@ -0,0 +1 @@
+A man in his early 40s with no past medical history presented with a mild headache that had persisted for two days. He was diagnosed with a SAH that corresponded to the World Federation of Neurosurgical Societies Grade I. Computed tomography angiography (CTA) revealed a bilateral VADA . We confirmed that the left VADA ruptured by hematoma localization on images. Therefore, the left VADA was surgically trapped via a left lateral suboccipital approach on admission. Fresh bleeding was found under adventitia of the left VADA, consistent with a rupture. The posterior inferior cerebellar artery (PICA) was not involved in the VADA. Therefore, we performed proximal clipping distal to the PICA. The trapping was completed without any intraoperative complications. Follow-up CTA revealed left PICA and obliteration of the left VADA on postoperative day 2 . However, on postoperative day 11, follow-up CTA revealed asymptomatic enlargement of the contralateral VADA . The perforating arteries from the distal part of the right VADA to the medulla oblongata, fetal-type posterior communicating arteries (PCOMs), and hypoplastic precommunicating segment of both the posterior cerebral arteries (P1) were revealed on digital subtraction angiography . We planned proximal clipping of the right VADA with a right superficial temporal artery (STA)–superior cerebellar artery (SCA) bypass on postoperative day 17. The right STA–SCA bypass was performed first using a subtemporal approach [ and ]. Ultrasonic pulse Doppler velocimeter intraoperatively detected a graft flow rate of 25 mL/min. Proximal clipping distal to the PICA was performed after completion of the STA–SCA bypass . Parts of the proximal VADA vessel walls were thin, indicating a high risk of rupture. Although the VADAs extended up to the vertebral junction, neither of the VADAs was a continuous lesion. We found perforating arteries in the right VADA . Ultrasonic pulse Doppler and indocyanine green imaging revealed a PICA, and the perforating arteries from the VADA were preserved. Motor and somatosensory evoked potentials and auditory brainstem response remained stable throughout the surgery. The bilateral VADA was obliterated, and the patent STA–SCA bypass flow was observed using CTA . No infarction was observed on postoperative magnetic resonance imaging. The patient had an uneventful postoperative course and was discharged about a month after rehabilitation. He received a modified Rankin scale score of 0 at both the 1-year and 6-month follow-up assessments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_256_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_256_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0ba7ff645d49c7494abd06939c9ebdb585979184
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_256_en.txt
@@ -0,0 +1,3 @@
+A 65 year-old white male began symptoms of weakness for medium efforts in March 2007. Two months later, during one week, he had 2 episodes of dark feces, associated with periumbilical pain, irradiating to the flancs and epigastric area. He denied heart burn, pyrosis, regurgitation, post-prandial fullness, nausea, vomiting, diarrhea and loss of apetite. Blood tests revealed normocytic normochromic anemia (hemoglobin = 11.1 g/dL), and upper gastrointestinal endoscopy was normal. During the next two months there was aggravation of anemia (hemoglobin = 7.2 g/dL, mean globular volume = 67.6 fL) and progressive asthenia, without evident blood loss or gastrointestinal symptoms, coming then to the Emergency Room. The patient had a past history of chronic hepatitis B, arterial hypertension, gout, dislipidemia and had removed colo-rectal polyps, with an unknown histologic diagnosis, 3 years before. He presented an alcohol consumption of 75 g of ethanol / day, was a former smoker (10 pack years), and was medicated with losartan+hydrochlorothiazide, allopurinol and simvastatin+ezetimibe. In the past 18 months the patient referred a weight loss of 15 kg.
+Physical observation, apart from descoloration of skin and mucous membranes, was unremarkable, revealing no palpable adenomegaly (including absence of Virchow node), no abdominal masses, and a normal digital rectal examination. Blood tests confirmed a blood loss / iron-deficiency anemia (serum iron = 4μg/dL, serum ferritin = 8.1 ng/dL, percent transferrin saturation = 1.06%, total iron-binding capacity = 313 mg/dL), but were otherwise normal. Chest x-Ray showed cardiomegaly and clear lungs. The upper gastroduodenal endoscopy revealed no lesions. Colonoscopy identified 3 polyps, with no signs of bleeding, in the sigmoid, descendent colon and cecum, corresponding to tubular adenomas with low-grade dysplasia which did not seem to be responsible for the clinical presentation. Since we were unable to proceed with capsule endoscopy due to difficult availability in our hospital, we decided to do an abdominal CT-scan, which showed a diffuse upper jejunal thickening with local, retrocural and peri-aortic adenomegaly, along with distension of D3 suggesting a suboclusive pattern . The day after the CT scan, the patient began with retching, so programmed surgery was antecipated. Resection of upper jejunum and regional lymph nodes, with jejuno-duodenal anastomosis, was performed. The histologic examination revealed an ulcerated, poorly diferentiated adenocarcinoma - T4N2M0 (stage III) ( and ).
+Six months after surgery, follow-up CT scan revealed evidence of local recurrence of the tumour, again with lymph node involvement. The patient was proposed for chemotherapy with six cycles of capecitabine. By the end of the second cycle the patient started vomiting and abdominal pain relieved by metochlopramide and diazepam, allowing the third cycle. Due to recurrence of symptoms and marked weight loss he then repeated the CT scan, once more revealing diffuse upper jejunal thickening with distension of D3, extensive lymph node dissemination (abdomen and thorax), and a single hepatic metastasis at segment IV. A paliative bypass was performed with successful symptomatic relieve and the patient is still alive 14 months after diagnosis.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2590_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2590_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d026f6dc2638aaf7023d345324ebe39d22e42c5c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2590_en.txt
@@ -0,0 +1,6 @@
+A previously healthy 51-year-old Hispanic female with a significant history of hypothyroidism presented with acute onset chest pain for 1 day. She described the chest pain to be pressure-like in nature, retrosternal, and radiating to her left arm and shoulder without associated shortness of breath. She reported to be sitting at rest when the pain occurred suddenly. She has been an active individual most of her life, but has had intermittent chest pain with exertion for the past 2 months. She has had to stop exercise for relief and has minimized her physical activity. The chest pain on presentation was reported to be similar in nature to the chest pain she had previously. According to the patient, she did not have any syncope, palpitations, racing of the heart, lightheadedness, anxiety, diarrhea, weight loss, or brittle hair. The reason she sought medical care this time was due to increased severity of pain.
+Two months prior to presentation, she was diagnosed with hypothyroidism with a thyroid-stimulating hormone (TSH) level of ~500 U/mL and given levothyroxine 137 mcg daily. The dose was reduced a few days after labs indicated supranormal triiodothyronine (T3) and thyroxine (T4) levels, but low TSH after starting the medication. She had most recently been on levothyroxine 100 mcg daily, which she was compliant with. She also reported taking omeprazole 20 mg daily for gastroesophageal reflux disease. She did not use oral contraceptive pills. She has never had hypercholesterolemia and had a negative fasting lipid panel from ~1 year prior to presentation. She denied any other past medical or surgical history. She does not have allergies. She was a lifelong non-smoker, did not consume alcohol, and did not use illicit drugs.
+On presentation, her vitals were normal. Her BMI was 27.3 kg/m2. The physical exam is only significant for a woman who appears in her stated age in mild distress due to chest pain. The electrocardiogram was consistent with normal sinus rhythm without any abnormalities. Troponins were elevated and trended upward from 0.080 to 0.120 to 0.222 ng/mL each 8 hours apart. TSH was nearly undetectable at <0.015 U/mL consistent with hyperthyroidism. T3 and T4 were not measured on presentation. Levothyroxine was stopped. Chest x-ray was unremarkable. Bedside 2D echocardiogram showed a normal left ventricle with EF of >60% without any regional wall motion abnormalities. The left atrium was mildly dilated, and right ventricular systolic pressure was 32 mm Hg. Non-ST elevation MI was diagnosed and patient was given atorvastatin 80 mg, heparin drip, clopidogrel 600 mg, and aspirin 324 mg. Sublingual nitroglycerin 0.4 mg was given, which improved the chest pain from a 10/10 on presentation to a 6/10. Coronary angiogram was done on the day of presentation, which showed an anomalous RCA arising from the left coronary cusp of the sinus of Valsalva, but no evidence of occlusion ( and ).
+A follow-up coronary computed tomography angiogram was done, which confirmed this finding and showed the anomalous RCA taking an inter-arterial course originating from the coronary ostium with a slit-like deformity and at least 50% luminal stenosis .
+Troponins trended downward and chest pain resolved. Due to known poor outcomes with this type of symptomatic coronary anomaly, the patient was referred to a cardiothoracic surgeon for definitive surgical correction. The patient was discharged home with levothyroxine 50 mcg daily, metoprolol 25 mg BID, and recommendation against aggressive physical activity.
+Informed consent was obtained from the patient for publication of this case report and any accompanying images.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2591_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2591_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..602eca0cfdc98c4576264bf39c636d23591f3845
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2591_en.txt
@@ -0,0 +1,2 @@
+A ten-year-old girl with a history of cystic fibrosis (CF) with gastrointestinal and pulmonary involvement, presented to her pediatrician with newly diagnosed growth retardation, fatigue and frequent headache. An arginine growth hormone-releasing hormone test confirmed growth hormone (GH) deficiency, and after further laboratory analysis, a central hypothyroidism and hypercortisolism was diagnosed. Substitutional therapy with levothyroxine and hydrocortisone was initiated, which improved the patient’s headache and fatigue. Ophthalmologic examination revealed bitemporal hemianopia. Further work-up with magnetic resonance imaging (MRI) revealed a 3 × 3 × 2.5 cm cystic space-occupying lesion in the sellar and suprasellar compartment with compression of the optic chiasm, with partial calcifications in computed tomography (CT), highly suspicious of a craniopharyngioma (CP) . Hydrocephalus was not present at the time of presentation. Due to the compression of the chiasm causing clinical hemianopia, the indication for surgical decompression was given. We weighed the possibilities of a neuroendoscopic transventricular (NET) cyst fenestration and partial tumor resection versus an endonasal endoscopic approach (EEA) or an open transcranial approach. The advantage for the transventricular neuroendoscopic approach is its minimal-invasive nature and straight-forward decompression of the cyst, which is causing compression of the optic chiasm. However, the patient presented with very small ventricles, making neuroendoscopy cumbersome, and the neuroendoscopic approach would only allow a partial tumor resection. EEA shares the advantage of being minimal-invasive. However, due to her age and the concomitant diagnosis of CF, known to be associated with hypoplasia and markedly reduced pneumatization of the paranasal sinuses, a non-pneumatized (conchal type) sphenoid was present , making the AAE more challenging . In addition, gross total resection (GTR) was not considered achievable through an EEA, due to a supra-chiasmatic tumor extension. Still, both an NET or EEA seemed superior to an open approach (e.g. subfrontal or interhemispheric) given the invasiveness and associated morbidity of such approaches, while similar to the EEA and NET approach, GTR would most probably not be achieved either [–]. We ultimately decided to perform an EEA together with our colleagues from ENT. The conchal configuration of the sphenoid sinus required meticulous drilling of squamous intrasphenoidal bone, exposure of the harder sellar bone, and a superior trans-chiasmatic sulcus extension to achieve satisfactory exposure of the suprasellar tumor cyst . Intraoperatively, crystals and cystic fluid, suspicious of CP, were drained from the cyst, and the cyst was dissected from the cavernous sinus walls, the sellar diaphragm, and the dorsum sellae without risking injury of adjacent structures. At the end of the operation, a symmetrical diaphragmal descent was achieved as indirect sign for the decompression of the optic chiasm . Postoperative MRI showed the expected near total tumor removal. While the cyst was completely drained, tumor remnants extending posteriorly to the superiorly displaced chiasm remained as expected . Postoperatively, the patient developed diabetes insipidus (DI) for which she received desmopressin under the supervision of the pediatric endocrinologists. During her inpatient stay, she recovered from her DI with stable sodium levels but required vasopressin substitution. Overall recovery was good, while the hemianopia persisted. No signs of rhinorrhea resulting from cerebrospinal fluid (CSF) fistula were noted. We were able to discharge the patient to her home 11 days after surgery. Unexpectedly, the histopathologic analysis found conspicuous areas of skin with formation of hairs and squamous epithelia, compatible with a mature teratoma . The cytokeratin staining was positive for epithelial cells consistent with the finding in a mature teratoma . These findings led to the diagnosis of a rare case of infantile mature teratoma originating from the sellar region After discussion in our interdisciplinary pediatric neuro-tumor-board, no further treatments (e.g. chemotherapy, radiation therapy) were indicated and a clinical and radiological follow up was initiated.
+At her first postoperative follow-up appointment after 6 weeks the patient was back in school, without any complaints. The hemianopia remained unchanged, and cortisol, vasopressin and thyroxin substitution was still required one year postoperatively. She was also started on growth hormone (GH) replacement therapy 6 months postoperatively. MRI follow-up one year after surgery showed stable appearances without any sign of progression .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2593_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2593_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0b97cb1287c37ba200a2772f4ad1c07e03964bd6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2593_en.txt
@@ -0,0 +1,5 @@
+A 32-year-old male presented at our institution with a history of pain over the lateral aspect of the left foot for 2 years of insidious onset. He complained of pins and needle sensation over plantar aspect of the left foot. There was no significant history of trauma. He noticed swelling behind the left knee in the past 6 months which was initially peanut shaped and gradually progressed to the present size.
+On examination, there was an oval mass of 2 × 3 × 1 cm, firm, non-pulsatile, non- fluctuant, non-transilluminating in the left popliteal fossa which was mobile in both directions. Skin over the swelling was pinchable. The patient was neurologically stable except with decreased sensation over lateral aspect (plantar region) of the left foot. Notably, the left popliteal and dorsalis pedis pulses were felt.
+Magnetic resonance imaging (MRI) of the left popliteal fossa revealed encapsulated round to oval shaped, eccentrically placed lesion seen within the intermuscular space in the posterior aspect of knee joint. Lesion shows homogenous isointense on T1 and heterogeneous hyperintense signal on T2. There are hypointense foci seen within the hyperintense area on T2 which is suggestive of fascicular sign. The sagittal image showed continuity of mass lesion with the tibia nerve displaying fat split sign, lesion measuring 2 × 3 × 1 cm (, , ).
+Under spinal anesthesia, the patient underwent neurolysis of tibial nerve and excision biopsy of tumorous lesion (, ) by incising the epineurium of tibial nerve since the tumorous lesion was eccentrically placed. As there was no disruption of tibial nerve continuity, no nerve repair was done. Gross resected specimen of tumorous mass of 2 × 3 × 1 cm and the cut specimen showing areas of hemorrhage, necrosis, and cystic spaces interspersed along the tumorous lesion (, ). Histopathological examination (×40) of the lesion showed biphasic tumor consisting of compact hypercellular Antoni A areas and myxoid hypocellular Antoni B areas and nuclear palisading around fibrillary process of Verocay bodies without any neural elements seen . Immunohistochemistry (IHC) staining of the resected lesion revealed strong positivity for S-100 staining .
+The patient was regularly followed up at timely intervals for 9 months since the excision of the lesion. The follow-up period was uneventful. The patient had improved sensation over lateral aspect (plantar region) of the left foot and without any recurrence of tumorous lesion during the follow-up period.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2598_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2598_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0c6e785ae03b67cc2c37cedfc6b5d9e47825b36c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2598_en.txt
@@ -0,0 +1,6 @@
+A 73-year-old man presented on foot and was admitted to our hospital with complaints of left lateral abdominal pain. Enhanced computed tomography (CT) revealed a left retroperitoneal hematoma and a large, ruptured Crawford type IV TAAA. The aneurysm was 80 mm in diameter. Furthermore, a tear in the left renal artery resulted from a ruptured aneurysm in the anterior wall . The CT showed a heavily calcified visceral and infrarenal aorta, and the aneurysm was localized to the visceral segment, suggesting a mycotic penetrating atherosclerotic ulcer. The patient had not taken antibiotics. The preoperative evaluation revealed renal dysfunction (serum creatine, 1.21 mg/dL; estimated glomerular filtration rate, 46 mL/min) and no other comorbidities.
+The patient’s level of consciousness suddenly deteriorated and his systolic blood pressure fell to 50 mmHg. Therefore, we performed endotracheal intubation and rushed the patient to the operating room. We chose open emergency surgery owing to uncontrollable hemorrhage, and we initially considered graft placement. A left thoracoabdominal incision is the standard approach; however, the patient’s hemodynamic status was exceedingly unstable. We expected this procedure, including arranging the operative position, to require more time than median laparotomy. Controlling the hemorrhage and stabilizing vital signs were of primary importance.
+The patient was brought to a hybrid operating room and an occlusion balloon was inserted from the right femoral artery through the abdominal aorta under the diaphragmatic level. A median abdominal incision was made and intra-abdominal bleeding was observed. Even with balloon occlusion, bleeding was difficult to control and the surgical field was difficult to secure. Heparin was not administered. During dissection of the anterior wall of the aneurysm, bleeding was observed from the perforation, and without manual hemostasis, the patient’s blood pressure decreased to an undetectable level. The position of the central balloon occlusion was guided just above the aneurysm, and the rupture tear site was closed using 7 needles with 4 − 0 nonabsorbable monofilament, reinforced by pledget stitches (Bard polytetrafluoroethylene) to secure the operative field. This allowed the release of balloon occlusion, and the systolic blood pressure increased to 80 mmHg. Dissecting the proximal site of the aneurysm was impossible owing to the likelihood of hemorrhage. We considered open and patch closure of the aneurysm rupture site under balloon occlusion; however, considering the difficulty of maintaining an operative field and the risk of occluding the left renal artery, we elected to close the perforation site only and instead perform a 2-stage graft replacement after life salvage . Intraoperative findings revealed no evidence of infectious aneurysm or pseudoaneurysm.
+Because the aneurysm remained after the first surgery, the patient’s blood pressure was strictly controlled using medication. He remained hospitalized until the second surgery, ensuring urgent treatment if the aneurysm ruptured in the interim. Hemoglobin level and hematocrit were frequently measured (more than 3 days per week) and the TAAA was evaluated by CT once weekly. Stabilization of the patient’s condition required a full month, and the second surgery was then performed. He had no cardiac dysfunction (ejection fraction: 84%) or coronary artery disease according to the preoperative examination.
+Under general anesthesia, the patient was placed in the left lateral position and a spiral skin incision was made. The aneurysm was approached by a left lateral thoracotomy through the seventh intercostal space, a diaphragm incision, and a pararectal approach. Severe adhesions were observed along the descending aorta from the celiac artery to the terminal abdominal aorta. A partial cardiopulmonary bypass was established by cannulation of the left femoral artery and vein. The descending aorta was cross-clamped under the diaphragm proximally and the left common iliac artery was controlled distally. The aneurysm was opened and the terminal aorta was clamped using an occlusion balloon. The thoracoabdominal aorta was replaced with the abdominal aorta under the celiac trunk immediately proximal to the aortic bifurcation. The superior mesenteric artery and the bilateral renal arteries were reconstructed with the interposition of a Carrel patch from small graft branches (24-mm Gelweave Coselli Thoracoabdominal Graft; Terumo Medical Corporation, Tokyo, Japan).
+Weaning from cardiopulmonary bypass and postoperative recovery were uneventful. The patient was removed from the intensive care unit on postoperative day 7. On postoperative day 12, CT revealed no anastomotic pseudoaneurysm, and the graft to the left renal artery was occluded . The patient was discharged from our hospital on postoperative day 22. A recent follow-up CT scan, 5 years postoperatively, revealed no occlusion or anastomotic pseudoaneurysm.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2601_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2601_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..53e8d08e3da26809689fc20b06a5502770394aa1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2601_en.txt
@@ -0,0 +1,6 @@
+A 34-year-old Persian woman with a history of depression and Sjögren’s syndrome, currently being treated with fluoxetine, was brought to the emergency department (ED) by paramedics, presenting with nausea, hypotension, confusion, and drowsiness. Diagnosed with depression by a psychologist 6 months earlier, she had no previous history of overdose or self-harm. Approximately 4 hours before she arrived at the ED, she had taken about 40 hydroxychloroquine (HCQ) tablets (200 mg each) and 60 azathioprine tablets (50 mg each). Her baseline electrolyte levels 80 days before the incident were normal, indicating no prior hypocalcemia or hypokalemia.
+Additionally, there were no previous instances of overdose, self-harm, or cardiac complications, further suggesting that the overdose was the cause of her current condition. She had vomited twice since the overdose. She had been under prednisolone, nonsteroidal anti-inflammatory drugs (NSAIDs, such as naproxen), and other painkillers for her pain management, but she stated that she did not overdose on these drugs. She had a family history of rheumatoid arthritis, but there was no family history of mental disorders.
+Upon arrival, her vital signs were as follows: a heart rate of 62 beats per minute, blood pressure of 70/50 mmHg, respiratory rate of 19 breaths per minute, and oxygen saturation of 97%. Her body temperature was 36.7 °C, and she weighed approximately 58 kg. Physical examination showed mydriasis with reactive pupils, a weak but normal-sounding heart, and weak pulses in both hands. She complained of lip and finger stiffness, with a positive Trousseau sign and a negative Chvostek’s sign observed. Initial electrocardiography (ECG) showed a mildly flattened T wave and prolonged QT interval (640 milliseconds). The echocardiography showed an ejection fraction (EF) of 55% and pulmonary arterial pressure (PAP) of 25 mmHg. No clonus, tremors, or signs of hyperreflexia were observed. Neurological examinations revealed weakness in her extremities and a Glasgow Coma Scale (GCS) score of 13, indicating she was confused but responsive to voices.
+Laboratory analyses of her blood and urine showed hypokalemia (potassium: 2.4 mmol/L), hypocalcemia (calcium: 7.5 mg/dL), hypoglycemia (blood glucose: 65 mg/dL), and a positive result for benzodiazepine, tramadol, buprenorphine, and morphine. She stated that she had not taken any of these substances and overdosed on azathioprine and HCQ only. Her blood gas analysis indicated metabolic acidosis with respiratory alkalosis. Complete blood count (CBC) revealed low levels of hemoglobin, red blood cells (RBC), hematocrit (HCT), total iron-binding capacity (TIBC), and iron levels. We also managed to find the patient’s last routine laboratory tests (80 days prior), in which all her findings were normal and indicated no hypocalcemia or hypokalemia before the incident. However, since there were no cardiac complications in the patient before the overdose, there was no previous ECG. She was transferred to the hospital’s poison control center owing to her initial findings . Our data, as depicted in Table , indicate that the patient’s baseline electrolyte levels, including calcium (9.6 mg/dL) and potassium (3.5 mmol/L), were within normal limits 80 days prior to the incident. She received intravenous ondansetron (8 mg), pantoprazole (40 mg), potassium chloride injection (30 mEq), and a mixture of 5% dextrose and 0.9% sodium chloride. Her blood pressure improved to an acceptable level overnight following the administration of 1000 cc each of 5% dextrose and 0.9% sodium chloride. An infusion of 100 mg of calcium gluconate, diluted in 5% dextrose, ameliorated her finger stiffness. Post potassium chloride injection, her QT interval shortened to 590 milliseconds, and the flattening of T waves improved.
+Approximately 24 hours after consuming HCQ and azathioprine, the patient reported nausea and headaches. She underwent a brain computed tomography (CT) scan and an ECG, which showed normal results . She received injections of ketorolac (30 mg), dexamethasone (8 mg), and ondansetron (2 mL) for her symptoms (nausea and headache). About 26 hours after admission, the patient chose to be discharged. She was prescribed calcium, iron, and folate supplements and was subsequently referred to therapy sessions with her psychologist.
+One week later, during follow-up, the patient had fully recovered, and her blood tests showed no significant abnormalities. Consent for the publication of this case has been obtained from the patient. We confirm that all experiments were carried out following relevant guidelines and regulations. Informed consent for participation and publication was obtained from the patient. Postrecovery, the patient’s treatment regimen for Sjögren’s syndrome was thoroughly reviewed and adjusted to minimize future risks, highlighting the importance of individualized management in complex cases. The absence of immediate preoverdose health data presents a limitation in our case, possibly obscuring a complete understanding of the patient’s baseline health status before the overdose.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2604_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2604_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c424dc3e886033b51059fd7937235cac4d2f82ad
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2604_en.txt
@@ -0,0 +1,73 @@
+A 50-year-old woman with a history of fatigue, worsening exertional dyspnoea, and
+weight increase (8 kg) in the last 3 months was referred to our
+Cardiovascular Department by her general practitioner. Clinical examination detected
+hypotension (90/60 mmHg), an holosystolic murmur best heard at the cardiac
+apex, bilateral pulmonary rales, lower extremity oedema, and macroglossia. Her past
+medical history was unremarkable except for bilateral carpal tunnel (CT) surgery
+some years before. She denied suffering from arterial hypertension, and an
+electrocardiogram (ECG) obtained 1 year earlier was reported normal (not
+available).
+The patient is a previously asymptomatic young adult without comorbidities,
+presenting with severe new-onset HF. The differential diagnosis includes
+cardiomyopathies, hypertensive, ischaemic, and valvular heart diseases. Macroglossia
+and CT syndrome suggest an infiltrative disease, while the heart murmur endorses the
+possibility of a severe valve disease precipitating acute HF. The absence of any
+cardiovascular risk factor makes the diagnosis of ischaemic heart disease
+unlikely.
+The ECG showed sinus rhythm with normal QRS voltages and Q-waves in anterior and
+inferior leads not consistent with the degree of left ventricle (LV)
+hypertrophy (max 17 mm) and normal wall motion evident at echocardiography
+.
+In addition, grade III diastolic dysfunction, reduced LV global longitudinal strain
+(GLS –14%) with an ‘apical sparing’ pattern, thickened
+mitral valve leaflets, right ventricle hypertrophy and dilated inferior vena cava
+were found (Video 1). Laboratory tests revealed high brain natriuretic peptide
+(BNP) levels (618 pg/L, normal reference value <100 pg/L) and
+persistent mild increase in troponin T (0.34 ng/mL, normal reference value
+<0.25 ng/mL). An invasive angiography excluded coronary artery
+disease. Clinical and instrumental findings rose the suspicion of CA, and the
+Gillmore’s algorithm was followed: serum λ free light chains (FLCs) returned
+pathologically increased (108 mg/dL, delta FLCs 93 mg/dL) and Perugini
+grade 1 myocardial uptake was found at diphosphonate scintigraphy . The diagnosis of
+AL-CA was confirmed through detection and typing of amyloid fibrils at Congo red
+staining and electron microscopy of abdominal fat specimen. A concomitant diagnosis
+of a smouldering micromolecular λ-type myeloma was made on the basis of
+22% clonal plasma cell in the bone marrow biopsy (BMB) without signs of
+end-organ (classic ‘calcium elevation, renal insufficiency, anemia, and bone
+abnormalities’ criteria) damage .
+The advanced heart involvement (Mayo cardiac stage III) and the micromolecular myeloma
+contraindicated ASCT as up-front therapy. Therefore, low-dose cytoreductive therapy
+with cyclophosphamide, bortezomib, and dexamethasone (CyBorD) was started, halving
+the standard dose of the proteasome inhibitor and monitoring troponin serum
+concentrations and fluid status on a daily basis. Up-titration of diuretic dose up
+to 200 mg/die of furosemide was necessary due to frequent readmissions for
+decompensated HF with haemodynamic deterioration. No other HF medications were
+started. Low cardiac index (2.5 l/min/m2) at right heart
+catheterization and severely reduced maximal oxygen consumption during exercise
+(VO2) peak (15.4 ml/kg/min, 50% predicted value) with
+impaired ventilatory efficiency at cardiopulmonary exercise test (CPET) were
+documented. After one CyBorD cycle, therapeutic strategies were collegially
+discussed in a multidisciplinary team, considering three main variables: young age,
+severe cardiac involvement with ominous prognosis, and absence of significant
+extra-cardiac involvement, which was systematically investigated. The patient was
+judged a good candidate for HTx followed by ASCT. Thus, she entered on the HTx
+waiting list within 2 months from HF diagnosis. She experienced two syncopal
+episodes without clear prodromal symptoms and received an implantable cardioverter
+defibrillator for the prevention of arrhythmic death as bridge to HTx.
+Despite fragile conditions, she succeeded in having a full course of chemotherapy
+with unexpected progressive reduction in serum values of BNP and FLCs. After 1 year
+of CyBorD therapy (6 cycles), serum FLCs normalized without residual hematological
+disease at BMB. At cardiological evaluation, the patient was in New York Heart
+Failure (NYHA) I functional class with normal BNP value (70 pg/L), lower diuretic
+dose (125 mg/die), recovered LV systolic function (GLS −20%)
+,
+increased exercise capacity (VO2 peak of 20.8 ml/kg/min,
+76% predicted value), and normalization of ventilation and carbon dioxide
+production slope at CPET . Due to significantly improved
+cardiac performance and the complete hematological response, CyBorD therapy was
+discontinued, and the patient was withdrawn from HTx waiting list and the planned
+ASCT. She underwent apheresis and cryopreservation of hematopoietic stem cells in
+case of future need of ASCT. At device interrogations, no record of ventricular
+arrhythmic events or ICD discharge was found. She remained stable in NYHA I
+functional class after >3 years from HF onset under regular cardiological and
+hematological follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2611_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2611_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..97810408c492a6b3736163d452e9e61a8cb91b4b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2611_en.txt
@@ -0,0 +1,2 @@
+Written informed consent for the publication of this article was obtained from the patient prior to submission of the manuscript.
+A 62-year-old female with a past ocular history of conjunctival melanoma in the left eye, which had been treated with topical excision and beta brachytherapy with ruthenium 10 years earlier, was referred to our department for the management of actinic keratopathy. Uncorrected distance visual acuity (UCVA) at presentation was Counting Fingers (CF) at 50 cm. The patient underwent uneventful penetrating keratoplasty, and the 1-month postoperative UCVA was CF at 1 m. Three months postoperatively she presented as an emergency to our department complaining of red painful eye and reduced visual acuity. UCVA had decreased to hand movement (HM). Slit-lamp examination revealed conjunctival injection and a diffuse corneal melting abscess infiltrating the corneal rim . Corneal scraping was performed and sent for microbiologic cultures and analysis. The patient reported professional exposure to plant material, making a fungal infection highly possible. Intensive antibiotic and antifungal therapy was introduced including voriconazole topical and per os, amphotericin B per os, topical moxifloxacine and doxycycline. Cultures confirmed fungal keratitis with Purpureocillium lilacinum (anc. Paecilomyces lilacinus), which was voriconazole-sensitive, and this treatment was subsequently pursued. Despite aggressive medical treatment, corneal melting progressed to the stage of graft perforation. We decided to proceed with a combined repeat PKP and PACK-CXL. The operation was performed under general anesthesia without any intraoperative complication. PACK-CXL was applied intraoperatively on the infected graft. A modified protocol was utilized with riboflavin instillation every 2 min for 15 min followed by UVA irradiation at 9 mW for 10 min. The irradiation zone was set from limbus to limbus to cover an area extending over the donor-recipient junction and the corneoscleral rim, as it seemed that the infection had spread to the recipient rim. PACK-CXL was repeated after placement of the new graft with the same irradiation zone and according to the same parameters for 10 min. Immediate postoperative UCVA was CF at 30 cm. The postoperative period was uneventful, and the graft remained clear thereafter. Nine months postoperatively the patient had regained a UCVA of CF at 1 m. No signs of infection or graft-related complications were noted .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2632_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2632_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b16044e3ae52eb90daa801a7281d1508f0256414
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2632_en.txt
@@ -0,0 +1,11 @@
+A 56-year-old gentleman (65 kg, 160 cm, BMI 25.4 kg/sq.m and ASA-IV E) presented to our emergency department with a two-day history of right lower abdominal pain, fever, and vomiting. His medical history was significant for long-standing type 2 diabetes mellitus (DM), hypertension, dyslipidemia, and dilated cardiomyopathy. Examination revealed tenderness in the right iliac fossa and bilateral fine basal crepitation. CT abdomen revealed acute gangrenous appendicitis, and an urgent open appendectomy was scheduled.
+We assessed him preoperatively and consulted with a cardiologist. He was admitted to the Emergency Department, and our focus was on the patient’s cardiorespiratory system and ability to tolerate a general anesthetic procedure.
+On examination, he was stable enough to verbalize his medical history. He also had a history of hospital admission for decompensated heart failure in 2019. At that time, transthoracic echocardiography (TTE) revealed a dilated left ventricle (LV), severely reduced systolic LV function (EF 18%), severe global hypokinesis of LV, and Grade 3 diastolic dysfunction. The patient was treated with anti-heart failure medications and discharged home a week later. He was prescribed aspirin, bisoprolol, ramipril, dapagliflozin, rosuvastatin, isosorbide dinitrate, and insulin.
+In this visit, he had poorly controlled DM (HbA1C 13%). Laboratory tests revealed an NT pro-BNP level of 1122 pg/mL, troponin T level of 28 ng/l, CRP level of 158 mg/l, WBC 16000/mcl. TTE revealed a moderately dilated left ventricle, severely reduced LV systolic function, biplane LVEF of approximately 25%, severe global hypokinesis of the LV, and Grade 3 diastolic dysfunction. His medications on admission included bisoprolol, rosuvastatin, and insulin.
+The patient had a revised cardiac risk index (RCRI) of 4, with 15% risk of major adverse cardiac events (MACE) and high risk for both general anesthesia and neuraxial blockade.
+He was admitted to the SICU for preoperative optimization, arterial and central venous line insertion, Pulse index Continuous Cardiac Output (PiCCO)-guided fluid resuscitation, and antibiotic prophylaxis.
+Owing to the patient’s high risk, we held a multidisciplinary team meeting. The team decided that the patient would undergo an open appendectomy with QLB combined with monitored anesthesia care (MAC). As the patient had gangrenous appendicitis, there was a further risk of deterioration.
+The patient was counselled regarding the urgent need for surgery, perioperative risk of cardiac complications, and specific anesthesia management, and written consent for anesthesia was obtained. He was brought to the operating room, and standard monitors were applied, along with an invasive arterial line monitor and supplemental oxygen administered via face mask at 5L/min. Inotropes (dobutamine and adrenaline infusions) were prepared in case he developed hemodynamic instability.
+In the left lateral decubitus position, 2 mg of midazolam and 50 µg of fentanyl were administered intravenously as anxiolytics. An ultrasound probe (curvilinear low-frequency) was placed in a transverse orientation at the midaxillary line at the L2-L4 level to visualize the three expected abdominal layers (transversus abdominis, external oblique, and internal oblique). The probe was then moved posteriorly until quadratus lumborum muscle (QLM) was confirmed. Under aseptic techniques and ultrasound guidance, the needle was inserted and advanced into the anterior aspect of the QLM. Proper positioning of the needle tip was confirmed by hydrodissection, and 20 mL of 0.33% levobupivacaine was injected into the fascia between the right QL muscle and psoas muscles .
+Surgery was performed 15 min after the block, with supplemental local infiltration and intravenous fentanyl at titrated doses of up to 50 µg. Intraoperative sedation was achieved with 2 mg of midazolam intravenously at titrated doses of up to 4 mg. A minimal dose of noradrenaline 0.03–0.05mcg/kg/min infusion was continued to maintain normal hemodynamics. An additional dose of intravenous fentanyl (50 µg) was administered to blunt the effects of deep peritoneal stimulation. The patient maintained the airway and vital signs around baseline throughout the procedure.
+The patient was transferred to the SICU for hemodynamic monitoring and organ support. The numerical rating of pain score was 0/10 at rest and 2/10 with movement at 24 h and reached a maximum of 4/10 with movement at 48 h postoperatively. His pain was managed with paracetamol, and he was discharged on the fourth day postoperatively. A summary of the clinical care pathways for our patient is shown in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2633_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2633_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ea8eb331435157481c1b466a93544a4b30fc2d51
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2633_en.txt
@@ -0,0 +1,5 @@
+A 60 years old Caucasian woman was admitted to the Emergency Department of our Hospital because of ascites and abdominalgia. Twenty years earlier she was diagnosed with breast cancer, subjected to mastectomy and then treated with several chemotherapy lines, including the inhibitor of vascular endothelial growth factor A Bevacizumab, hormonal therapy and local radiotherapy. About 5 months before the admission, she developed seizures and sudden cognitive impairment, with loss of contact: a MRI revealed cranial and cerebral metastasis. An antiepileptic drug Levetiracetam was started as well panencephalic radiotherapy was given for five days. Chemotherapy was also administered with resolution of symptoms and regression of metastasis. One month before the hospitalization, she developed lower limb deep vein thrombosis, so she started fondaparinux as anticoagulation therapy. The patient continued its oncological follow-up schedule of a stage IV breast cancer, with multiple liver, pleural, pulmonary and bone metastasis, treated with Palbociclib, anti-CDK4 and 6 antagonist and Fulvestrant, an estrogen receptor antagonist. At two follow-up visits during the 4 weeks prior to admission to the Emergency Department because of low circulating serum magnesium levels, magnesium and potassium salts supplementation was reported and then suspended due to the appearance of abdominal pain. She was sent to the Emergency department by the oncologist because of abdominalgia associated to nausea and vomiting. She has been treated with a proton pump inhibitor for at least 6 months because of heartburn, regurgitation, and symptoms related to gastroesophageal reflux disease. An abdominal ultrasound highlighted abundant ascites. She was vigilant and collaborating, without alteration on neurological exam. Her vital parameters were normal, and laboratory tests showed mild anemia (Hemoglobin 10.6 g/dl, hematocrit 32%), no renal (creatinine 0.4 mg/dL) or hepatic (GOT 21 U/L; GPT 13 U/L; total bilirubin 0.4 mg/dL, albumin 3.2 g/dL) impairment and a moderate increase in C reactive protein (63 mg/L; normal values < 5 mg/L). Plasma sodium (135 mEq/L), potassium (3.9 mEq/L), chloride (98 mEq/L), calcium (8.2 mg/dL) and phosphate (4.0 mg/dL) concentration were normal, whereas magnesium levels were at the lower limit (1.8 mg/dL). Within the normal range was also pH and bicarbonate. Coagulation was normal, except for a significant increase of d-dimer. On physical examination, she had ascites and abdominalgia without breathing impairment. She felt nausea and vomit; symptomatic therapy with metoclopramide was given and a parenteral nutrition infusion with Olimel N4 (1500 ml/day, Glucose 112,5 g, Lipids 45 g, Amino-acids 38 g, Nitrogen 6 g; sodium 21 mEq/L, potassium 16 mEq/L, Mg 2.2 mEq/L, osmolarity 760 mOsm/L) was started. She was treated parenterally with loop of Henle diuretic therapy, furosemide associated with potassium sparing diuretic canrenoate, associated to water restriction. An abundant diuretic response and the reduction of ascites was observed in the 48 hours following, with a significant weight loss and an almost complete resolution of the abdominalgia. No changes in blood pressure or heart rate were measured. She suddenly presented confused and disoriented. She was not able to attempt a simple order and she complained headache. Her blood pressure was still normal and the neurological exam did not show any focal or lateral abnormality. Ammonium blood levels were normal (37 uM/L, normal values between 10-50). An urgent cerebral tomography was performed, showing a diffuse cerebral edema (,ABC). Patient neurological condition rapidly got worse, till vigil coma, with loss of interaction ability, while her vital parameters (blood pressure, heart rate and peripheral oxygen saturation) remained normal. Treatment with intravenous desametasone (8 mg twice a day) and mannitol (mannitol 18%, 100 ml four times per day followed by 50 ml four times per day), associated with magnesium sulphate (40 mEq in saline solution 250 ml per day in 6-hour infusion period) was immediately started and continued for three days. A cerebral MRI was urgently performed showing diffuse increase in signal alteration of the periventricular, deep and sub-cortical white matter in parieto-occipital region of the two sides, as from leukoencephalopathy, also in relation to post-radiotherapy modifications. venous thrombosis of the distal segment of the transverse sinus and of part of the left sigmoid sinus .
+She continued subcutaneous Fondaparinux at anticoagulating dose (7,5 mg/die) while Palbociclib and Fulvestrant were discontinued. Anti-edema (desametasone and mannitol) treatment as well magnesium sulphate infusion were continued. Her clinical condition rapidly improved with resolution of the acute episode.
+A brain MRI was performed after 10 days, showing less but still persistent bilateral parieto-temporal-occipital vasogenic edema, partial resolution of the cerebral vein thrombosis, but evidencing the presence of few micro-haemorrhages in left temporal and parietal site .
+Patient neurological status completely recovered and after 2 weeks, she was discharged with the diagnosis of PRES.
+At a MRI brain scan, performed the following month, a reduction of the vasogenic edema but a persistent even if reduced left transverse sinus thrombosis . After a month, she was admitted to the hospital because of severe respiratory distress due to pneumonia and after three days she passed away.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2640_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2640_en.txt
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index 0000000000000000000000000000000000000000..35ae0f135d571061d2125ef253f519320788cf8a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2640_en.txt
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+A 24-year-old (gravida 0 para 0) female without experience of sexual intercourse was referred to our gynecology department with complaints of menorrhagia and vaginal discharge. Physical examination revealed multiple hyperpigmented macules on her lips, buccal mucosa, fingertips, and toes . She was diagnosed with mild anemia at 10 years of age; genetic screening for thalassemia reported no abnormalities. At 15, she underwent a laparotomy to treat an “intestinal obstruction.” Since the age of 21 years, she has experienced a prolonged menstrual period (50–60 days) and hypermenorrhea, accompanied by a clean and odorless vaginal discharge. The US examination showed an enlarged cervix with multicystic lesions, the largest of which measured 1.9 cm×3.4 cm×2.2 cm. The patient has since experienced occasional hematochezia and was referred to several medical institutions to treat abnormal uterine bleeding. At 23 years of age, she underwent gastrointestinal endoscopy, revealing chronic non-atrophic gastritis and multiple polyps in the stomach, duodenum, and rectum. The pathological diagnosis of the resected polyp specimen from the mid-ileum revealed chronic active inflammation involving the superficial mucosa . During this period, the medical imaging examination revealed a growing cervical mass. Serum gynecological tumor markers, including alpha-fetoprotein (AFP), carcinoembryonic antigen (CEA), cancer antigen (CA) 199 (CA199), CA153, and CA125, were within normal levels. The human papillomavirus screening test results for cervical secretions were negative. The patient’s father and younger brothers had similar black mucocutaneous macules, and her grandfather died of gastrointestinal bleeding. Except for her father, who was also diagnosed with leukoderma, the patient and her family denied the presence of other familial diseases.
+After admission to the inpatient department, the patient underwent magnetic resonance imaging (MRI) and multimodal US . Transrectal US revealed an enlarged, barrel-shaped cervix (6.4 cm×5.7 cm×6.0 cm) containing multilocular lesions of various sizes comprising a few solid components. The cervical lesions occupied almost the entire cervix, with the upper rim reaching the internal cervical os and the lower rim 0.7 cm above the external cervical os. No cervical myometrial echo was found. Some solid components were found in the septae between neighboring cysts, which altogether measure 4.0 cm×3.0 cm×3.3 cm; the cystic-solid echoes were encompassed by relatively larger cystic echoes. The cystic echoes, with diameters of 0.1–1.0 cm, were honeycomb-shaped with a slightly higher solid echo. The solid echo and septae showed strip-like rich blood flow signals with an arterial spectrum resistive index of 0.57. The cervical canal had a 0.4 cm separation, making the line of the cervical mucosa invisible. No abnormal echoes were observed in the anterior or posterior vaginal fornix or in the endometrium and myometrium of the uterus. No space-occupying lesions were observed in the uterine parametrium. An anechoic cyst, measuring 3.4 cm×2.3 cm×2.8 cm, was found in the left ovary. The ovarian cyst had a thin wall and was surrounded by a few short, strip-like blood flow signals. No lesions were observed in the right adnexa. The three-dimensional reconstructed view using 3D realisticVue (W10 EV3-10B, Samsung Medical, Seoul, South Korea) displayed multilocular lesions resembling the “cosmos pattern” in MRI examination, nearly occupying the whole cervix . Three-dimensional power Doppler US revealed an increased blood supply with irregular ramifications, parts of which multiplied and formed clump-like patterns. Three-dimensional tomographic US imaging of the blood flow of the cervical lesion indicated that its blood supply was located in the intercyst septae and solid components. The blood flow histograms revealed the following results: vascularization index, 4.567; flow index, 35.374; vascularization-flow index (VFI), 1.615. Using the VOCAL software (Voluson TM E10 BT19, General Electric Company, Boston, Massachusetts, the United States), the volume of the mass measured was 80.65 cm.3 Contrast-enhanced ultrasonography (CEUS) (PHILIPS EPIQ7, Philips Healthcare, Seattle, WA, the United States) using intravenous SonoVue (Bracco, Milan, Italia) revealed that solid components of the cervical mixed echo begun to develop at 7 s and peaked at 22.14 s, which gradually faded and presented a slightly increased signal in the final stage, exhibiting a “quick-up and slow-down” pattern of the time-intensity curve. CEUS also displayed a local density random walk wash-in/wash-out curve type with a wash-in slope of 1.62 dB/s, peak intensity of 19.03 dB, time from peak to 1/2 of 39.67 s, and mean transit time of 26.63 s. The cervical serous layer displayed continuous echoes of the signal, which did not increase simultaneously with the solid components of the cervical masses. The MRI revealed an enlarged cervix with multilocular space-occupying lesions of various sizes involving the entire muscular layer.
+Subsequently, a hysteroscopic biopsy revealed multiple polyp-like neoplasms in the uterine cavity and multilocular lesions in the cervix . Pathological examination of the biopsy specimen revealed LEGH and aLEGH. Whole-exome and Sanger sequencing confirmed the STK11 gene mutation in the patient and her family .
+Based on the evidence mentioned above, the patient was diagnosed with PJS and recommended undergoing laparoscopic exploration and cervicectomy according to clinical guidelines [, ]. The lesion-penetrated parts of the lower uterus, cervix, and ovarian cyst were resected and subjected to pathological examinations, revealing that the cervix and lower part of the uterus were both invaded by glandular lesions . Immunohistochemistry revealed Polyclonal Antibody to Mucin 6 (MUC6)-positivity. Simple gastric metaplasia (SGM) and LEGH in the cervix were also documented, suggesting the presence of gastric-type glandular epithelium. Alcian-blue/Periodic acid Schiff reagent (AB/PAS) staining revealed the presence of neutral mucus in the gastric-type cells.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2645_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2645_en.txt
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index 0000000000000000000000000000000000000000..0018a066a9803b6b161cefbac96376d39a2eca70
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2645_en.txt
@@ -0,0 +1 @@
+The patient was a 40-year-old female, gravida 6, para 1, with a history of cesarean section. On December 14, 2018, an ultrasound examination revealed multiple masses of medium-to-low echogenicity in the myometrium of the uterus, suggestive of leiomyomas. The largest leiomyoma in the posterior wall measured approximately 3.5 × 4.0 × 2.7 cm . On September 3, 2019, the ultrasound results confirmed an early intrauterine pregnancy. Multiple medium-to-low echogenicity lesions were observed in the myometrium, including a larger one in the posterior wall measuring approximately 5.5 × 3.5 cm. A cesarean section was performed on April 1, 2020 (36 + 4 weeks of gestation) due to premature rupture of membranes and a history of previous cesarean section. Intraoperatively, multiple leiomyoma-like masses were found in the posterior wall and bottom of the uterus, protruding into the serosal layer and not clearly into the mucosal layer. The most prominent lesion had a diameter of approximately 8.0 cm. After consulting with the patient, uterine myomectomy was withheld. One month after delivery (April 30, 2020), an ultrasound examination showed multiple heterogeneous hypoechoic masses in the uterine region, with the largest one being 8.6 × 7.7 × 7.3 cm in the posterior wall, exhibiting capsular blood flow signals. Over two months after delivery, a follow-up ultrasound examination revealed a hypoechoic mass of approximately 8.6 × 3.6 cm in the uterine cavity, displaying lacking blood flow signals. Myometrial echogenicity was homogeneous. No specific treatment was provided immediately, however, the patient reported lower abdominal distension and increased vaginal discharge. The leucorrhea test suggested vaginitis, and she was prescribed oral cefuroxime for 7 days. Over three months after delivery (July 24, 2020), a follow-up ultrasound examination showed a hypoechoic mass of approximately 6.5 × 3.4 cm in the uterine cavity, with visible blood flow signals and a resistance index (RI) of 0.44 . The patient did not report significant abdominal pain, vaginal bleeding, or discharge during regular follow-up visits. The patient experienced a slightly increased menstrual flow as compared to before, without symptoms such as dizziness or weakness. Surgical treatment was recommended, but the patient declined. Annual follow-up ultrasound examinations after delivery suggested a gradual reduction in the size of uterine leiomyomas. In the third postpartum year (May 8, 2023), the ultrasound examination revealed no noticeable leiomyoma-like echoes in the posterior wall of the uterus . During the whole treatment,the treatment principle is symptomatic management and regular follow-up under the condition of no severe complications, with surgical interventions pursued when required.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2655_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2655_en.txt
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index 0000000000000000000000000000000000000000..0c0a7f466fe20379b02ee9705255ba770ff46ab7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2655_en.txt
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+A 58-year-old woman was admitted to the hospital with fever, headache for 21 days and left limb weakness for 2 days. The patient had chronic headache (30 years) and dental caries with intermittent toothache (6 years). Twenty-one days (Jun 20) before admission, the patient had fever, swelling pain on his forehead, cough and expectoration, then she was treated in a local clinic. Subsequently, the fever and headache symptoms aggravated (the maximum body temperature reached 38 °C), accompanied by nausea, vomiting, rash, night sweats and arthralgia. The patient was transferred to Beijing Shunyi hospital (Beijing, China), and treated with cefonicid (anti-infective) and amlodipine (reduced blood press), but the fever and headache continued. 2 days (Jul 9) before admission, the patient suddenly developed left-sided limb weakness (the strength grade of left-limb was IV stage) that did not affect standing or walking.
+On Jul 11, the patient was transferred to our hospital. She exhibited somnolence, bilateral equal-sized round pupils (diameter 3 mm) and sensitivity to light. Her eyes movement in all directions were not limited, and there was no nystagmus, symmetric bilateral nasolabial folds, normal muscle strength in the four limbs (the strength grade of four limbs was V stage), and unstable ataxic movement. In addition, she had no obvious objective sensory disturbance (sensory plane) and the pathologic reflexes were not elicited. The sign of meningeal irritation (Kemig’ and Brudzinsk’ signs) and Brudzinski’s sign were positive. Laboratory test results revealed that the white blood cell counts (11.73 × 109/L), neutrophil counts (9.22 × 109/L) and high-sensitivity C-reactive protein levels (> 5.00 mg/L) were elevated, the level of procalcitonin (PCT) was < 0.1 ng/mL, and the autoimmune encephalitis antibodies (AMPAR1-Ab, AMPAR2-Ab, CASPR2-Ab, DPPX-Ab, GABABR-Ab, IgLON5–Ab, LGI1-Ab, NMDAR-Ab), paraneoplastic antibodies (anti-Amphiphysin, anti-CV2, anti-GAD65, anti-Hu, anti-PNMA2 (Ma-2/Ta), anti-Recoverin, anti-Ri, anti-SOX1, anti-Titin, anti-Tr (DNER), anti-Yo, anti-Zic4 ) and demyelinating antibodies (AQP4-Ab, GFAP-Ab, MBP-Ab, MOG-Ab) were negative. On Jul 12, a lumbar puncture was performed and the test results were shown in Table . The mNGS (MBX52313, Tianjin Genskey Medical Technology Co., Ltd, Tianjing, China) results showed that the Eubacterium brachy, P. gingivalis, Fusobacterium nucleatum and Torque teno virus 29 were detected, but the fungi and mycobacterium tuberculosis were not detected.
+The brain computerized tomography (CT) scanning indicated the new right thalamus infarct . The brain cranial-enhanced magnetic resonance imaging (MRI) showed the right lateral paraventricular and right thalamic infarct, and abnormal signal in occipital horns of bilateral lateral ventricles were increased . In addition, the brain enhanced nuclear magnetic resonance (NMR) scanning suggested that meninges were thickened and enhanced at the base of the brain, and with meningitis changes . The neck CT angiography (CTA) revealed arteriosclerotic changes, slender right vertebral artery (segment V4 with obliteration), the slender intracranial arteries with uneven thickness, the M1 segment of the left middle cerebral artery with localized moderate stenosis, and the P1 and P2 segments of the left posterior cerebral artery with localized severe stenosis .
+Based on these findings, the patient was finally diagnosed with suppurative meningoencephalitis caused by infection of oral anaerobes (CNS infection), acute cerebral infarction and intra oral abscess (gum and surrounding soft tissue infection). The patient was then given ceftriaxone (4 g, ivgtt, qd, 3days), vancomycin (0.50 g, ivgtt, q8h, 16 days). Subsequently, her symptoms, including headache and fever, alleviated. She was transferred to the Infectious Diseases department (Jul 19), then she was treated with ceftriaxone (2 g, ivgtt, q12h, 2 days) plus metronidazole (0.50 g, ivgtt, q8h, 13 days) to anti-anaerobes. On Aug 1, the patient’s pupils were equal in circle and size, but the abduction of both eyes was limited. Moreover, the left central was facial palsy and left limb was central hemiparesis, and the Kirschner’s sign was positive, the headache and fever was relieved, the white blood cell count in CSF was 888 × 106/L. On Aug 22, the patient’s headache and fever disappeared. During our following-up on Sep 8, the patient remained lucid and no fever or headache. Her left hemiparesis was better than before, and have currently received rehabilitation treatment in Beijing Fengtai Youanmen Hospital (Beijing, China).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2658_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2658_en.txt
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index 0000000000000000000000000000000000000000..a6dbaa5e4b8c98384890612ce10a390f4073453d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2658_en.txt
@@ -0,0 +1,6 @@
+A 12-year-old Caucasian boy was referred with a presumed diagnosis of right ON glioma to our hospital. Four years earlier, his local ophthalmologist had diagnosed a 'yellow-whitish, well-demarcated papillary cyst with central retinal vessel displacement' in his right eye (oculus dexter, or OD) and documented a visual acuity of 20/30 in both eyes. He was examined twice a year, and his vision remained stable. Four years later, his ophthalmologist documented 'visual acuity of 20/80 and concentric visual field reduction to the central 10° isopter in OD'. Fundoscopic variation of the lesion was not noted.
+One month later, after a severe headache, visual loss progressed and no light perception with an absolute afferent pupillary defect was present in the OD. A computed tomography (CT) scan showed right ON thickening, and the boy was referred and admitted to our center.
+At admission, the described neuro-ophthalmologic findings were confirmed, and on CT, the optic disc appeared elevated and enhanced after intravenous contrast was administered. Fundoscopy revealed a well-defined whitish mass without macroscopic calcification at the ON head, dilated and tortuous retinal vessels, and small superficial retinal hemorrhages . A complete general examination did not detect any other alterations.
+After informed consent was obtained from our patient's parents, a right transfrontal exploratory orbitotomy with canalicular unroofing was performed, and a normal chiasm, prechiasmatic and canalicular ON, and grayish infiltration in the proximal intraorbital portion were revealed. A frozen intraoperative biopsy of the tumor was diagnosed as an 'unrecognized tumoral process', and 0.8 cm of distal ON was resected. Because the eye had no light perception and the tumor was potentially malignant, the remaining ON and globe were enucleated with excision of the retrobulbar orbital fat.
+A gross examination of the eye revealed an ON with a width of 6 to 7 mm and a length of 6 mm. A sagittal section through the globe revealed a small, whitish, rounded tumor of 2 to 3 mm with a soft surface at the optic disc. No lesions of the cornea, iris, lens, or ciliary processes were detected. The tumor had areas composed of poorly differentiated neuroblastic cells with nuclear pleomorphism but no mesenchymal elements. Thus, the final histopathological diagnosis was malignant non-teratoid medulloepithelioma of the ON . There was dense granulation tissue with giant cells, but no tumor was present in the adipose tissue surrounding the ON .
+Systemic work-up was negative for any evidence of metastatic disease. In view of the significant mortality rate of this tumor, orbital exenteration was suggested, but our patient's parents declined [-]. Fifty gray of telegammatherapy (Co60) was applied in two fields. Our patient was closely followed with annual orbital CT and half-yearly echography for six years without evidence of recurrence. At present, he is 37 years old and has a disease-free survival of 25 years.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2671_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2671_en.txt
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index 0000000000000000000000000000000000000000..3c88c2add413dff07c6a14033f8a02f0b7174da2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2671_en.txt
@@ -0,0 +1,2 @@
+A previously healthy 15-year-old boy presented with acute-onset left testicular pain for 12 h. He was afebrile, denied having any dysuria or hematuria, and denied any history of previous trauma. Physical examination showed a left testicle that was diffusely enlarged without any discrete masses, On palpation, the left testis was tender and swollen. The right testis was normal. Ultrasonography shows heterogeneous enlargement of the left testis with areas of decreased echogenicity. No associated masses are identified. Testicular doppler ultrasonography shows absent blood flow. Surgical exploration was decided urgently to save the testicles.
+Upon surgical exploration, the whole testis and epididymis were diffusely enlarged and dusty dark , consequently, unilateral left orchiectomy was performed. The Microscopic sections show diffuse interstitial hemorrhage with intact seminiferous tubules and full spermatogenesis . There was no sign of thrombosis, vasculitis, tumors, tumor necrosis, or any other pathologies that could be concurrently present or lead to testicular bleeding.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2720_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2720_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..96b0d6627c2d65f4f2071ab6a25acee918500e22
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2720_en.txt
@@ -0,0 +1,4 @@
+A 40-year-old Sri Lankan female presented with exertional breathlessness (NYHA II) and weight loss for 4 weeks duration. There was no cough, hemoptysis, evening pyrexia or night sweats and no history of limb claudication. Her past history was negative for connective tissue disorders, vasculitis or tuberculosis. The family history was unremarkable. General examination did not reveal any abnormal physical signs. She had collapsing pulse and blood pressure of 110/40 mmHg in both arms. Early diastolic murmur was heard in both left and right sternal edge. The lung bases were clear and rest of the systemic examination was normal.
+Chest x-ray showed smooth dilatation of the ascending aorta and walls of it are not parallel to each other. Transthoracic and transeseophageal echocardiogram showed ascending aortic aneurysm (maximum diameter of 54 mm) with severe aortic regurgitation. Cardiac chamber dimensions were within normal limits and left ventricular ejection fraction was normal. Computed tomographic (CT) aortography confirmed the dilatation of aortic root and ascending aorta without dissection or leaking. Acute phase reactants were slightly elevated (erythrocyte sedimentation rate 50 mm 1st hour, C-reactive protein 18 mg/dL). Venereal Disease Research Laboratory test (VDRL) was non-reactive. Antinuclear antibody was negative.
+Cardiology team proceeded their further evaluation with pre-operative coronary angiogram which showed normal epicardial coronary arteries. Aortic valve and root replacement was recommended by the cardiologist. Cardiothoracic surgical team carried out the aortic valve replacement (AVR) with 19 mm bileaflet St Jude Medical mechanical valve and aortic root replacement with 30 mm Albo graft. Surgeon noted evidence of aortitis with external inflammatory adhesions during the surgery. Post-operative period was uneventful. Warfarin therapy was started while closely monitoring the INR and it was kept between 2 and 3. Histological examination of aortic wall revealed granulomatous aortitis with caseous necrosis even though it did not show acid fast bacilli (AFB) on Ziehl–Neelsen staining (ZNS).
+The final diagnosis of ascending aortic aneurysm with severe aortic regurgitation due to tuberculous aortitis was made on the basis of clinical, imaging and histological findings. She was treated with category one antituberculous therapy (ATT) consisting of 3 fixed dose combination tablets per day each containing rifampicin 150 mg, isoniazid 75 mg, pyrazinamide 400 mg and ethambutol 275 mg (RHZE). Frequent dose adjustment of warfarin was required during ATT. Continuation phase of ATT was extended for up to 10 months with rifampicin and isoniazid as in the case of disseminated tuberculosis. She made a good clinical recovery with improvement of her symptoms and follow up image showed functioning aortic prosthesis while maintaining INR in therapeutic range.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2734_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2734_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74b763e55cc382483f05beef48d794d533a46e91
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2734_en.txt
@@ -0,0 +1,3 @@
+A 25-month-old boy was referred to our outpatient clinic without complaints due to a gestational ultrasound that showed kidney cysts. The patient was already under antibiotic prophylaxis and physical examination and vital signs within normal limits. The parents reported no family history of kidney disease and/or other heredofamilial disorders. Renal ultrasound performed at 2 days of life showed bilateral hydronephrosis, mainly on the right kidney. At 5 months of age, a DTPA and a DMSA were performed. The DTPA showed strong retention of the marker in the pyelocalyceal system bilaterally, with little response to diuretic stimulus (. A1, A2), while the DMSA indicated preserved kidney function and symmetrical radiotracer distribution in kidneys with relative kidney function of 46% in the left kidney and 54% in the right kidney (. A3).
+Based on the first appointment at our clinic, the antibiotic prophylaxis was maintained and a new kidney ultrasound was requested, which showed dilation in the entire length of both ureters (10 mm on the right side and 8 mm on the left), with an abrupt stenosis in the distal region of both ureters at the bladder entrance with a caliber of only 2 mm. In addition, moderate bilateral hydronephrosis and slight thinning of the renal cortex parenchyma were also observed (. C2-C5). These findings indicated the diagnosis of bilateral megaureter secondary to stenosis caused by VUJO and vesicoureteral reflux (VUR). At 2 years and 10 months of age, DTPA and DMSA were requested. The DTPA showed obstructive pyelocalyceal and urethral stasis in both kidneys, with a scintigraphic pattern compatible with bilateral hydronephrosis secondary to stasis at the level of the VUJ with preservation of kidney function (. B1, B2). Despite the observed dilation, the parenchyma and renal cortex were preserved and the pattern of DTPA showed a slow emptying degree, while the DMSA showed that relative kidney function remained stable at 46:54 (. B3).
+Taking into account the clinical and imaging findings, non-surgical management was adopted, with clinical follow-up and serial imaging evaluation. During the first year, the patient visited the ambulatory semiannually and in the following 2 years, annually. At 7 years and 7 months, antibiotic prophylaxis was discontinued, with no history of urinary tract infections, and follow-up visits were maintained every 2 years. Kidney ultrasonography at 10 years of age showed significant improvement of all parameters with ureteral transverse diameter exhibiting a slight to moderate increase (0.9 cm) and preserved VUJ, indicating a satisfactory evolution and expected bilateral kidney development with the non-surgical approach. For the entire follow-up time, the patient stayed normotensive, with normal serum urea and creatinine levels, and without proteinuria, indicating favorable clinical evolution.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2773_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2773_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8296929690d5b2b85b44bde9ee08d1d2371ffeda
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2773_en.txt
@@ -0,0 +1,4 @@
+A 56-year-old woman of North African origin, with no medical and surgical history, was admitted to the Department of Internal Medicine for investigation of a Raynaud phenomenon evolving for 3 months, associated with inflammatory arthralgias involving the wrists, elbows, and ankles; the patient also reported pain and progressive proximal muscle weakness in her lower limbs when climbing stairs, which extended to the upper limbs. There was no rash. Neuromuscular examination revealed proximal tetraparesis, mild neck flexion, and extension weakness. Strength at the neck was 4/5; at the shoulder 3/5; at the wrist 4/5; at the hips 2/5; and at the ankle 4/5; dorsiflexion/plantar flexion was normal. Tendon reflexes were normal. A few days after her hospitalization, the patient developed slight dysphonia and dysphagia; then this symptomatology was accentuated over time.
+Nail fold capillary microscopy was normal. Blood tests showed significant levels of muscle enzymes [creatinine kinase (CK) 40,000 IU/L]. Autoimmune screening for myositis-specific and myositis-associated autoantibodies was negative. Electromyography (EMG) showed a decrement in compound muscle action potential on repetitive stimulation and clear signs of myopathy. The diagnosis of inflammatory myopathy was confirmed by muscle biopsy, which showed myositis . The patient was treated with prednisone 60 mg daily; we observed a slight improvement in muscle weakness and a significant decrease in CK serum level.
+A month later, she developed intermittent diplopia, ptosis, and mild dysarthria during the conversation. Serum acetylcholine receptor (AChR) antibodies were positive (5.59 nmol/L), and muscle-specific kinase antibodies were negative. A broader workup performed with computed tomography (CT) of the chest revealed a large anterior mediastinal mass (114 × 57 × 100 mm) , which a subsequent biopsy revealed as B1-type thymoma .
+Inflammatory myositis associated with myasthenia gravis was diagnosed. Pyridostigmine in combination with steroids was started, with significant improvements in generalized weakness, ptosis, and dysarthria. The patient underwent thymectomy as part of the additional treatment. Currently, she is on a low dose of steroids and pyridostigmine and is asymptomatic. The features of myositis have not relapsed.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2777_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2777_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b2247cfc14289917875b309bd0aecc6f63cfe104
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2777_en.txt
@@ -0,0 +1,2 @@
+A 64-year old woman presented with neurogenic claudication and a maximum walking distance of 50 m. She described a radiating pain from the gluteal region to the lateral legs on both sides with a predominance for the left side, with a symptom onset approximately 1 year ago. Physical examination revealed intact motor function and decreased deep tendon reflexes on the left side. Medical history consisted of a discectomy L5/S1 on the right side 13 years ago. MRI revealed a lumbar spinal stenosis at the level of L4/5 . Patient underwent a standard microsurgical decompression L4/5 on the left side, including an over the top undercutting to the right side. During surgery, no dural tear was noted. On the first postoperative day she was mobilised and described significant improvement of the preoperative pain.
+Two days later, during a turning movement in bed, she experienced a sudden sciatica radiating in her left leg. The intense pain was not responding to any analgesics and was only tolerated in a standing position leaning on the right leg. After frustrating attempts to stay in the horizontal position despite intravenous opioid administration, she was put under general anaesthesia for an MRI scan. The imaging revealed no hematoma or significant intraspinal compression. However, an unclear facet joint effusion L4/5 on the left side was apparent, which was not present preoperatively . The decision for exploratory revision surgery was therefore manly based on her clinical presentation as at this point the meaning of this effusion was unclear. In early stages of revision surgery cerebrospinal fluid (CSF) leakage was noted and after careful dissection, a nerve root herniation through a small lateral dural tear with entrapment in the facet joint gap was discovered . The herniated root was repositioned and the dural defect was repaired using stitches in a watertight fashion and a sealant matrix. Postoperatively the patient’s symptoms disappeared, she was mobilised after 2 days using a lumbar brace and the further clinical course was uneventful. As she did not develop any further clinical signs of potential segmental instability, fusion surgery was not deemed necessary.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2795_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2795_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06ed11a27f0d968d48995f90f4c218aeb352d7ad
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2795_en.txt
@@ -0,0 +1,9 @@
+The patient was a 22-year-old male soldier who received severe injury in the battlefield area next to the village of Krasnohorivka in the Donetsk oblast of Ukraine. On December 16, 2016, the patient received multifragmental combined with thoraco-abdominal injuries as a result of shelling from MLRS “Grad”. The wounds were detected mainly on the right side of the patient due to fragments penetrating the chest and causing hemopneumothorax ; firearm fracture of 5–7, rupture of right dome of the diaphragm, as well as ruptures of the liver’s parenchyma due to “hydrodynamic shock”. The entrance wound was detected in the region of 5–7 ribs between the anterior and the posterior right axillary lines, whereas an exit wound was not detected.
+The patient received first medical aid immediately at the place of injury from other soldiers of his team. This included superimposed aseptic dressings and painkillers. Then, the patient was subsequently evacuated by sanitary transport to the second level of medical care to get primary surgical aid. The time taken between injury and evacuation was less than 60 min; thus, the principle of the “golden hour” was achieved.
+To receive basic surgical aid, the patient was transported to the Military Medical Hospital #66 at Pokrovsk of the Donetsk oblast. At this level, the patient was diagnosed with having a penetrating thoracic wound. The blood loss was approximately 1500 ml, indicating hemorrhagic shock. The blood product transfusion of red was applied by using red blood cells and blood plasma.
+Thoracentesis was performed to eliminate the right hemopneumothorax. Taking into consideration the absence of an exit wound, it was not possible to be sure about the path of the wound channel; therefore, penetrating thoraco-abdominal injury was suspected and laparocentesis was performed. A hemorrhagic content was received at the laparocentesis; thus, laparotomy was performed. At the revision of the abdominal cavity, we detected a rapture of the right dome of the diaphragm as well as the ruptures of 3–6 segments (S3–6) of the liver. The entrance wound was detected only in chest area, whereas the exit wound was not identified neither in chest, nor in abdomen wall. Therefore, a conclusion was made that damage of the liver was in result of “hydrodynamic shock”. Considering the severity of the patient, minimal surgical treatment was applied, which included suturing of liver ruptures as well as excision of necrotic tissues and suturing of gunshot wounds of limbs. However, in an early post-operative period, a hemorrhage and bile were detected on drainage. Relaparotomy was performed and liver damage within the area of gallbladder fossa was detected. Given the doubts about the viability of the liver S3–6, the question was whether or not liver resection should be applied for possibly ischemic segments. However, the severity of the patient and principles of DC tactic were taken into consideration. Thus, cholecystectomy was performed to get access to damaged liver in the area of gallbladder fossa (coagulation and suturing), and patch of omentum was used to fill the gap in injured S3–6 of liver .
+For further treatment, the patient was transported to the Mechnikov Regional Clinical Hospital in Dnipro, where further resuscitation was continued. Antibacterial therapy was administrated as well as other symptomatic therapy and daily dressings were applied.
+Three days after the level III, the patient was transported to the ICU at the National Military Medical Clinical Center of Ukraine in Kyiv. The general condition of the patient remained severe. Drainage from the subhepatic area showed daily bile volume up to 300 ml. Such a volume of bile was caused by the intrahepatic biliary hypertension as a result of post-traumatic edema of liver parenchyma. In order to eliminate biliary hypertension (sixth day after the combat injury), the following intervention was performed: endoscopic papillosphincterotomy, endoscopic retrograde cholecystopancreatography, and stenting of the common bile duct. To provide enteral nutrition, the feeding tube was placed behind the Treitz ligament. Implementation of endoscopic decompression of the bile duct had resulted in gradual reduction of bile volume from the subhepatic drainage from up to 50 ml per day as compared to 300 ml before the decompression.
+At post-operative period, a computed tomography (CT) scan of the abdomen was performed. At CT analyses showed the liver to demonstrate zones with ischemic lesions . Considering liver CT data, a liver resection of the affected segment was planned to prevent further necrosis and abscess formation according to DC tactic. However, on the 16th day after the injury, intra-abdominal bleeding was diagnosed and urgent laparotomy was performed. At revision, erosion of the right hepatic artery was detected as a result of the chronic inflammation of the artery wall and continuous contact to the bile. Erosive defect was sutured and stable hemostasis was achieved . At revision of sutured areas of the liver, we found it to be covered with fibrin, partial failure of sutures and bile leakage were observed. Furthermore, tissue softening and color changes of liver S5–6 parenchyma were detected, indicating ischemic failure . In order to stop bile leakage and to prevent liver failure, a decision was made to perform anatomic resection of the liver S5–6 . Due to the critical status of the patient and considering DC approach, we postponed the surgery for stabilization of hemodynamics by resuscitation and transfusion of one-group packed red blood cells. At the ninth day after the liver resection, the patient was transferred to the surgery ward from ICU.
+Apart from the thoraco-abdominal injuries, the patient was also diagnosed with multiple fragmental injuries of soft tissues of the skull, chest, abdomen, as well as extremities. The most serious soft tissue injury was detected at the right lower limb, which was subsequently treated with VAC system .
+The patient was discharged from hospital in good condition on the 49th day after receiving injuries . The patient received 45 days of further rehabilitation according to military medical commission decision before continuing his return to military duties (V level).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2841_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2841_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..eb04f72a2f813060bb863201f7273f5f210c3ca1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2841_en.txt
@@ -0,0 +1,7 @@
+A 66-year-old male patient was admitted to our hospital with a 7-year history of gallbladder stones, detected during a physical examination, leading to a proposed laparoscopic cholecystectomy.
+Preoperative abdominal ultrasonography revealed multiple gallstones and cysts in the left lobe of the liver. Plain computed tomography (CT) of the chest and abdomen revealed low-density lesions in the left hepatic lobe, prompting the recommendation for an enhanced abdominal CT examination.
+The patient had no prior history of surgery but had a history of multiple chronic conditions, including hypertension, diabetes, hyperlipidemia, and atrial fibrillation. The patient consistently adhered to the medication regimen and reported satisfactory management.
+The patient denied any family history of tumors.
+The patient was alert and in good condition. No abnormal symptoms such as jaundice, nausea, vomiting, or acid reflux were noted. An abdominal examination revealed no tenderness, rebound tenderness, or muscle tension. No abnormal masses were palpable, and the Murphy's sign was negative.
+Total bilirubin, 20.6 μmol/L (reference range: 0-23 μmol/L); direct bilirubin, 7 μmol/L (reference range: 0-4 μmol/L); indirect bilirubin, 13.6 μmol/L (reference range: 0-17 μmol/L); alanine transaminase (ALT), 13 U/L (reference range: 9-50 U/L); aspartate transaminase (AST), 19 U/L (reference range: 15-40 U/L); carcinoembryonic antigen (CEA), 5.46 ng/mL (reference range: 0-5 ng/mL); alpha fetoprotein, 2.61 ng/mL (reference range: 0-20 ng/mL); carbohydrate antigen 199 (CA199), 29.88 U/mL (reference range: 0-37 U/mL). The rest of the laboratory results were normal. Pathological examination of the lesion revealed an IPNB with severe epithelial dysplasia or high-grade intraepithelial neoplasia .
+Abdominal enhanced CT arterial phase , abdominal enhanced CT venous phase , and an initial diagnosis of a cystic, solid lesion in the left lobe of the liver with dilatation of the distal intrahepatic bile ducts were made; cholangiocarpal cystadenoma was ruled out, and magnetic resonance (MR) enhancement examination was recommended. Subsequently, abdominal MR imaging (MRI) + MR cholangiopancreatography (MRCP) (enhanced) examination confirmed the presence of cystic and solid lesions in the left hepatic lobe, along with dilation of the left intrahepatic bile duct, indicative of IPNB.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2844_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2844_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c49616ac2020251427e3312295661960609191d0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2844_en.txt
@@ -0,0 +1,15 @@
+A 31-year-old male patient attended the outpatient clinic of our hospital’s reproductive medicine center with a complaint of “three years without pregnancy despite not using contraception”.
+Three years without pregnancy.
+In 2014, the patient’s wife had undergone an induced abortion, and the patient had undergone a high ligation of his left varicocele in 2018; however, sperm quality did not appear to have improved upon re-examination after the surgery.
+The patient has no history of hypertension or diabetes. Her parents were non-consanguineous and had no family history of hereditary diseases.
+In terms of appearance, the patient’s height was 165 cm, weight was 65 kg, and body mass index was 23.88 Kg/m2. Specialist examination showed that his pubic hair was distributed like an inverted triangle, his penis measured approximately 6 cm long when flaccid, the urethral opening showed no visible abnormalities, bilateral testicular volume was approximately 12 mL with a tough texture, the bilateral vas deferens and epididymis showed no observable abnormalities upon palpation, and no varicocele was found.
+Through two routine semen analyses and rapid morphology staining (Diff-Quik method), the patient was diagnosed with secondary infertility and ASS. Given the patient’s informed consent, 5 mL of his peripheral blood was collected. Our study was approved by the Ethics Committee of the Shenzhen Maternal and Child Health Care Hospital and was conducted with the patient’s informed consent.
+After three to five days of abstinence, the patient masturbated to enable sperm extraction, which was liquified in a water bath at 37℃. Analyses were conducted twice according to the WHO laboratory manual (Fifth Edition). Eosin staining was conducted to detect sperm viability and sperm morphology was determined after staining the sperm smear using a rapid staining solution (Diff-Quik method), and 200 sperms were counted. Morphological defects were divided into four categories: normal, abnormal head-neck configuration, detached heads, and headless, and the percentage of each category was calculated.
+Peripheral blood was collected and used for karyotype analysis through cell culture and Y chromosome microdeletion testing through PCR-capillary electrophoresis.
+For exome sequencing, we fragmented 1-3 μg of genomic DNA, extracted from each sample, to an average size of 180 bp with a Bioruptorsonicator (Diagenode). Paired-end sequencing libraries then were prepared using a DNA sampleprep reagent set 1 (NEBNext). Library preparation included end repair, adapter ligation and PCRenrichment, and was carried out as recommendedby Illumina protocols.
+The amplified DNA was captured use GenCap Deafness capture kit (MyGenostics GenCap Enrichment technologies). The DNA probes were designed to tile along the exon regions and the known non-exon pathogenic region of human genes. The capture experiment was conducted according to manufacturer’s protocol. The PCR product was purified using SPRI beads (Beckman Coulter) according to manufacturer’s protocol. The enrichment libraries were sequenced on Illumina HiSeq X ten sequencer for paired read 150 bp.
+After sequencing, the rawdata were saved as a FASTQ format, then followed the bioinformatics analysis,the data would be transformed to VCF format, variants were further annotated by ANNOVA Rand associated with multiple databases, such as,1000 genome, ESP6500, dbSNP , EXAC, Inhouse (MyGenostics), HGMD, and predicted by SIFT, PolyPhen-2, MutationTaster, GERP++.
+five steps using to select the potential pathogenic mutations in downstream analysis: (1) Mutation reads should be more than 5, mutation ration should be no less than 30%; (2) Removing the mutation, the frequency of which showed more than 5% in 1000 g, ESP6500 and Inhouse database; (3) If the mutations existed in InNormal database (MyGenostics), then dropped; (4) Removing the synonymous; and (5) After (1),(2),(3), if the mutations were synonymous and they were reported in HGMD, left them. When finished above jobs, the mutations which were left should be the pathogenic mutations.
+When performed under conditions of low sperm activity, neither method revealed morphologically normal sperm. High percentages of sperm with abnormal head-neck connections, detached heads, and headless sperm were observed, indicating complete teratozoospermia with oligoasthenozoospermia . Eosin staining showed that there were no normal sperms in the semen; instead, some were intact (with head and tail at an angle), most had headless, and very few had sperm heads without tails .
+Peripheral blood karyotype analysis (G banding): 46, XY; Y chromosome microdeletion: no deletion observed.
+We analyzed exons and adjacent splicing regions of genes associated with male infertility, with a focus on known pathogenic genes related to severe oligozoospermia and the patient’s clinical background. We found two heterozygous variants of the PMFBP1 gene : PMFBP1c.414+1G>T (p.?) and PMFBP1c.393del (p.C132Afs*3). The heterozygous splicing variant c.414+1G>T (p.?) of gene PMFBP1 was in intron 4 (the PMFBP1 gene contains 20 introns) and was likely to interfere with the mRNA splicing signal. This was a classical splicing variant, which may lead to loss of amino acids but might not destroy the reading frame. The heterozygous frameshift variant c.393del (p.C132Afs*3) of the PMFBP1 gene caused the replacement of cysteine by alanine at position 132, followed by a frameshift and a premature stop codon, resulting in the early termination of protein coding. The detected frameshift mutation may lead to > 10% amino acid loss, resulting in the occurrence of nonsense-mediated mRNA decay, which may be a non-functional mutation. According to the American College of Medical Genetics and Genomics Guidelines, these variants are probable pathogenic variants .
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2849_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2849_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..411e85e609a676c13a9085162b44262c96c5284e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2849_en.txt
@@ -0,0 +1 @@
+A 38-year-old woman received a tentative diagnosis of congenital cardiac disease in childhood. She is a farmer in Liaoning province (not high altitude) with no special lifestyles. She presented in our outpatient for further diagnosis. Physical examination revealed a loud murmur and cyanosis. Electrocardiogram demonstrated normal rhythm and right ventricular hypertrophy with right axis deviation. Echocardiographic study showed a severely dilated right ventricle, with a diameter of 39 mm; the left ventricle was relatively small, with a diameter of 33 mm. The arterial trunk was markedly enlarged (71–105 mm), with a type III APW measuring approximately 65 mm. A right pulmonary artery (RPA) originating from the posterior wall of the ascending aorta was also found, while the origin of the left pulmonary artery (LPA) was normal . The coronary arteries were normally positioned. Additionally, the patient had a type A IAA (distal to the left subclavian artery), an intact ventricular septum, and a large patent ductus arteriosus (PDA) with bidirectional shunts. The patient had severe pulmonary artery hypertension, approximately equal to the systemic blood pressure, and the left ventricular ejection fraction (LVEF) was nearly 53%. Computed tomography angiography with 3-dimensional reconstruction confirmed the large APW opening into the main and right pulmonary arteries, as well as type A IAA supplied by a large ductal artery . The patient refused to be hospitalized to further evaluate the possibility of surgery, and she was lost to follow-up. Although missing the opportunity to confirm above findings by surgery, a diagnose of Berry syndrome was made.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2859_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2859_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9fd5885f7fc346fba065e2b4c65b3e631a2df8c0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2859_en.txt
@@ -0,0 +1,7 @@
+A 60-year-old Saudi man with a history of diabetes, hypertension, and chronic active hepatitis B, an entrepreneur, married with seven children, who denied tobacco smoking, alcohol consumption, and illicit drug use, was initially seen at our facility and was diagnosed as having Rai stage II CLL in December 2012. His physical examination at presentation revealed a moderately built man. His respiratory and cardiovascular examination was normal. His liver was normal in size but his spleen was palpable (8 cm below the costal margin). He had generalized lymphadenopathy involving his neck, axillae, and bilateral inguinal regions; however, the lymph nodes were 1–3 cm in size. A neurological examination revealed no focal neurological deficit. His serum creatinine at presentation was 72 umol/L, and his blood urea nitrogen (BUN) was 4.3 mmol/L. The results of his liver function test were: aspartate aminotransferase (AST) 22 unit/L, alanine transaminase (ALT) 27 unit/L, total bilirubin 12.1 umol/L, albumin 3.5 g/dL, and alkaline phosphatase of 68 unit/L. His blood count at presentation showed a white blood cell (WBC) count of 28.9 × 109/L, hemoglobin (Hb) level of 13.4 g/dl, a platelet count of 106 × 109/L, and an absolute lymphocyte count (ALC) of 25.1 × 109/L . Peripheral blood flow cytometry revealed 43% of total acquired events co-expressing CD5, CD19, CD23, CD79b, and cytoplasmic CD79a, but lacking surface immunoglobulin light chains, CD10, and CD38. Bone marrow aspirate and biopsy (BMAB) showed hypercellular bone marrow with diffuse intestinal and focal paratrabecular lymphocytic infiltrate. The lymphocytes were mature, small, and positive for CD20, CD79a, PAX-5, CD5, CD23, and BCL2, but negative for cyclin D1 and CD10 . Conventional cytogenetic tests and fluorescence in situ hybridization (FISH) revealed that 27% of analyzed cells displayed rearrangement of the CCND1 gene in chromosome 11 and 15% of cells had trisomy 12, but t(11;14) (q13;q32) was not detected .
+A computed tomography (CT) scan of his neck, chest, abdomen, and pelvis showed hepatomegaly with focal hypodense liver lesions and massive splenomegaly (20.9 × 7.3 cm) . A liver biopsy showed infiltration with small lymphocytic lymphoma (SLL; Fig. ). He remained under surveillance until January 2016, when he developed anemia, thrombocytopenia, and significant constitutional symptoms. He was started on chemoimmunotherapy with fludarabine 25 mg/m2 on days 1–3, cyclophosphamide 250 mg/m2 on days 1–3, and rituximab 375 mg/m2 on day 1 (FCR) for a total of six cycles, until 27 July 2016. His blood counts normalized . And an end-of-therapy CT scan showed resolution of the liver lesions, and significantly reduced lymphadenopathy and splenomegaly.
+One month after completing FCR therapy, his leukocytosis (mostly neutrophilia) returned, with myeloid left shift. His spleen was palpable 10 cm below the costal margin. His WBC count reached 93 × 109/L, Hb 10.9 g/dl, platelet count 61 × 109/l, absolute neutrophil count 42 × 109/L, and eosinophil count 3 × 109/L. Peripheral blood blasts and basophils were 1% each . BMAB was suboptimal. Conventional cytogenetic analysis using bone marrow showed Philadelphia chromosomes in all examined cells with no other cytogenetic aberrations. FISH analysis revealed presence of the BCR-ABL fusion gene in 100% of cells examined, and quantitative reverse transcription polymerase chain reaction (RT-PCR) of peripheral blood showed a ratio of BCR-ABL/ABL of 21% .
+Since the morphologic findings of both the blood smear and the cytogenetics were compatible with chronic phase CML, he was started on first-generation tyrosine kinase inhibitor (TKI) imatinib at a dose of 400 mg daily. As a result, his complete blood count normalized and his spleen shrank. Although he achieved an appropriate hematologic response within 3 months of imatinib treatment, on 21 March 2017 he demonstrated a suboptimal molecular response with a BCR-ABL/ABL ratio of 17%. Subsequently, he was switched to 300 mg orally administered nilotinib (a second-generation TKI) twice daily. After 3 months of nilotinib treatment, the BCR-ABL/ABL ratio dropped to 0.093%.
+To screen for hepatocellular carcinoma, an abdominal CT scan was done in March 2017 and it revealed multiple hypoechoic liver lesions . Magnetic resonance imaging of his liver confirmed the presence of at least nine hepatic lesions . Positron emission tomography (PET) showed multiple metabolically active liver lesions . A liver biopsy performed in May 2017 confirmed RT to high-grade B cell lymphoma. After negative tests for c-MYC, the final pathological diagnosis was confirmed as DLBCL . Staging BMAB was morphologically negative for CLL, CML, and DLBCL. FISH analysis on BMAB was negative for CCND1 gene rearrangement, trisomy 12, and BCR-ABL oncogene.
+While awaiting c-MYC in situ hybridization he received two cycles of chemoimmunotherapy by infusion consisting of rituximab 375 mg/m2 on day 1, etoposide 50 mg/m2 on days 1–4, prednisone 60 mg/m2 on days 1–5, doxorubicin 10 mg/m2 on days 1-4, Oncovin (vincristine) 0.5 mg/m2 on days 1–4, and cyclophosphamide (R-EPOCH). He was then switched to rituximab 375 mg/m2 on day 1, cyclophosphamide 750 mg/m2 on day 1, doxorubicin 50 mg/m2 on day 1, oncovin (vincristine) 50 mg/m2 on day 1, vincristine 1.4 mg/m2 on day 1, and prednisone 100 mg days 1–5 (R-CHOP); he completed four cycles. Radiological assessment with PET/CT at the end of chemotherapy was consistent with complete metabolic response.
+A donor had been identified in preparation for allogeneic hematopoietic stem cell transplantation, in case our patient’s CML proved resistant to second-line TKI treatment. He was last seen in January 2018, 8 months after his diagnosis with DLBCL with no evidence of lymphoma and his BCR-ABL/ABL ratio dropped to 0.01%.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_286_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_286_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9f4e3c8e41a4fd1bdbee2bca1e9f377d053a32fc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_286_en.txt
@@ -0,0 +1,4 @@
+A 70-year-old man with hypertension initially presented with imbalance and dizziness and underwent magnetic resonance imaging (MRI), which demonstrated a 3.2 cm × 2.8 cm × 3.7 cm heterogeneously enhancing mass in the suprasellar region which extended to the posterior fossa resulting in mild mass effect on the midbrain and ventral pons and displacement of the optic chiasm . An endonasal endoscopic approach was used for debulking of the mass. However, unbeknown to the surgical team, the patient had been on daily intranasal oxymetazoline for years, and as a result, excessive nasal cavity bleeding was encountered. Thus, only a biopsy was obtained.
+The patient was diagnosed with EVN with ganglioid differentiation. Histopathological analysis showed a moderately hypercellular tumor marked by a proliferation of small cells with scant eosinophilic cytoplasm and generally rounded nuclei. These cells were intermixed with occasional large cells with large nuclei and prominent nucleoli resembling neurons or ganglioid cells . The tumor demonstrated diffuse positive staining with antibodies to synaptophysin (prediluted; Biogenex; Fremont, CA) and occasionally NeuN (1:800 dilution; Millipore; St. Louis, MO). Tumor cells were negative for glial fibrillary acidic protein (GFAP) (1:600 dilution; DAKO; Carpinteria, CA) and isocitrate dehydrogenase 1 (NADP+) mutation (IDH- 1 mutation). A Ki-67 (prediluted; Ventana; Indianapolis, IN) labeling index was 6–7%. FISH testing showed no evidence of 1p/19q codeletion.
+He was followed with serial imaging due to the favorable prognosis of the tumor. 1 year later, the patient’s tumor subsequently progressed and the patient developed short-term memory impairment as well as obstructive hydrocephalus. A right modified orbitozygomatic craniotomy and placement of a left-sided external ventricular drain was performed. Most of the tumor in the interpeduncular cistern was resected with some residual tumor in the third ventricle that did not descend. The patient had third nerve palsy postoperatively; otherwise, he was doing well. Weaning him from the external ventricular drain was difficult due to persistent obstruction at the foramen of Monro. The patient then underwent a left frontal trans-sulcal transtubular transventricular debulking of the intraventricular tumor near the foramen of Monro with septum pellucidotomy. He was successfully weaned from his ventriculostomy.
+At the 6 weeks postoperative follow-up, the third nerve palsy resolved. His short-term memory and balance were significantly improved. He underwent radiation therapy with a dose of 5400 cGy in 27 fractions 5 months following surgery to treat his residual tumor. His last follow-up was at 1 year after surgery, and he continued to improve. MRI showed a slight decrease in the size of the residual tumor as compared to his preradiation MRI.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2875_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2875_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2af4a592e2045d55f8a88e8bf466c9d2b8b89c8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2875_en.txt
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+At the time of her DBS implantation, the patient was a 57-year-old Caucasian female who had presented with a several year history of debilitating, treatment resistant blepharospasm. Prior treatments with Botox® injections had not provided relief. After a discussion with the patient about the risks and benefits of surgical intervention, she was amenable to undergoing bilateral GPi DBS electrode placement. Planning and implantation was performed through our center’s standardized protocols, and the target was selected under direct visualization (17 mm lateral to the third ventricle wall, 5 mm below the AC PC on the left, and 3.5 mm below the AC PC).
+The patient was followed for 7 years at the time of writing this report. During this period, she had returned for stimulation parameter manipulation 26 times . Her initial settings were a monopolar configuration with 3.1 V, 130 Hz, and 120 µs on the left electrode and 3.0 V, 130 Hz, and 130 µs on the right. Her maximal settings throughout her follow-up period were 8.1 V, 130 Hz, and 260 µs on the left and 8.0 V, 130 Hz, and 260 µs on the right. Her present settings are 7.0 V, 155 Hz, and 130 µs on the left and 6.7 V, 150 Hz, and 120 µs on the right.
+The first phase of her programming was targeted toward symptom control. Pulse width and voltage were gradually increased to help control her symptoms while minimizing side effects. This was achieved after about 1 year when she reported that it was “the best (I’ve) felt in a long time.” On sequential visits, there were attempts to decrease the charge density delivered to the patient by decreasing either the voltage, pulse width, or both without allowing for the re-emergence of her blepharospasm.
+Throughout her follow-up, the patient also continued to receive Botox® injections and speech therapy. These synergistic interventions allowed for further decreases in delivered charge density.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2876_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2876_en.txt
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index 0000000000000000000000000000000000000000..83e36a02a625087ea452586154a5cc8696048a8a
--- /dev/null
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+A 76-year-old man of Caucasian ethnicity was hospitalized for syncope 2 years before index hospitalization. Comorbidities included liver cirrhosis (Child-Pugh A) due to non-alcoholic fatty liver disease, type-2 diabetes, hypertension, and suspected Alzheimer-type dementia. Etiologically unclear transitory ischemic attacks had been diagnosed before. Holter electrocardiogram (ECG) showed a first-degree atrioventricular block and three episodes of bradycardia with minimal cardiac frequencies of 37bpm that were deemed unlikely as a cause for syncope. Schellong test revealed a hypodynamic cardiac response, that is, his heart rate stayed at 50bpm after change from supine to upright position. Hypoglycemia (under insulin therapy) was not detected prior, during or after hospitalization. A concomitant AKI (AKIN 2, maximum creatinine: 297μmol/L) was regarded as pre-renal, and syncope was attributed to arterial hypotension and hypovolemia. Following intravenous rehydration, he was discharged with spironolactone 150mg/day and propranolol 100mg/day for liver cirrhosis, donepezil 10mg/day for suspected dementia, amlodipine 10mg/day, and insulin subcutaneous injection (average: 50IU/day).
+At index hospitalization, he (body mass index: 35.2) was admitted with nausea and vomiting for 3 days, as well as dizziness due to a presumed hepatic encephalopathy. On admission, vital parameters including blood pressure (150/80mmHg), heart rate (62bpm), and temperature and physical examination including cardiopulmonary state were unrevealing. Specifically, ascites and peripheral edema were absent. He was oriented to person, place, and time. Physical reactions were slowed though. Compared to baseline values prior to hospitalization (serum creatinine: 139μmol/L, estimated glomerular filtration rate
+: 43.2μmol/L/1.73m2), serum creatinine was elevated on admission (Table ). Glutamate-oxaloacetate transaminase (0.64), gamma-glutamyltransferase (2.46), and international normalized ratio (1.13) were slightly elevated; serum albumin (31g/L) was decreased. Other laboratory values including inflammation parameters (leukocyte count, C-reactive protein), total serum protein, bilirubin, glutamate-pyruvate transaminase, and alkaline phosphatase were within normal range. Partial respiratory insufficiency and metabolic acidosis (pH: 7.326, oxygen partial pressure: 55.8mmHg, carbon dioxide partial pressure: 29.0mmHg, bicarbonate: 14.7mmol/L, base excess: -9.7) were found on admission. His urine test showed microalbuminuria (<300mg/day), microscopic hematuria, and leukocyturia consistent with urinary tract infection. Concomitant medication largely remained unchanged since discharge 2 years ago. ECG showing sinus rhythm and the known first-degree atrioventricular block was without change since the last ambulatory cardiology check 1 year before. During hospitalization, he was bed-bound. Gastroscopy proved helicobacter-negative gastritis. An intravenous fluid challenge using sterile saline was performed for suspected, however clinically inapparent, hypovolemia. Despite fluid challenge, oliguria suddenly developed shortly after admission, serum creatinine remained high (Table ). A pre- and post-renal cause of AKI was excluded. Myocardial infarction as a possible cause of hemodynamic instability was ruled out in repeat laboratory and ECG examinations. Echocardiography showed a normal systolic left-ventricular function, yet left-ventricular hypertrophy and diastolic dysfunction accompanied by a mild mitral regurgitation and an enlarged left atrium. Nephrotoxins and/or nephrotoxic medications were not applied. Euglycemia was verified during the whole index hospitalization. Kidney sonography revealed normal-sized kidneys with a centralized arterial perfusion (Figure ), and an increased renal resistive index (1.0 on both sides) reflecting a diastolic no-flow condition. Of importance, a bradycardia (less than 50bpm) was present during ultrasound. Propranolol was discontinued at once, thereafter urine output improved (Table ). In a Holter ECG 3 days following propranolol cessation, an intermittent third-degree atrioventricular block with pauses for less than 3 seconds was found (Figure ). He was subjected to pacemaker insertion on day 11 after admission. Thereafter, renal function in terms of urine output and serum creatinine remained stable. Beta-blocker therapy was reinstituted. By discharge to a rehabilitation facility 14 days after pacemaker insertion, renal function in terms of serum creatinine further improved (Table ), body weight remained constant in comparison to admission, and peripheral edema was absent.
+At discharge, spironolactone 50mg daily, propranolol 25mg thrice daily, amlodipine (5mg daily), donezepil (10mg daily), and antidiabetic medication including sitagliptin and insulin were maintained. Ramipril (5mg daily), torasemide (20mg daily), acetylsalicylic acid (100mg daily), simvastatin (20mg daily), and pantoprazole (20mg daily) were prescribed.
+Renal recovery continued after discharge, the prehospitalization level of creatinine was reached within 1 month following discharge.During the 4 months following discharge, amlodipine and ramipril were discontinued. Otherwise, medication has not changed. Syncope has not occurred again. His overall condition improved considerably. He was not bed-bound; he was alert and he could walk short distances with walking aid. Symptoms consistent with hepatic encephalopathy or progressive dementia were not present. Four weeks after discharge, his mini-mental state examination yielded 22 (out of 30) points. A neurologic reassessment was recommended regarding the ongoing donepezil treatment. At 4-months follow-up, sonography of his kidneys showed persistent renal resistive index of 1.0 on both sides (Figure ).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2887_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2887_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..8daa8d22d5aac9c252a7e1d29ed7579ee34295e4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2887_en.txt
@@ -0,0 +1,2 @@
+In March 2018, an 85-year-old man with no medical history was admitted after a 6-month history of worsening pain and swelling in the right wrist. Magnetic resonance imaging showed a large region of tenosynovitis from the distal forearm to the palm, and a biopsy of the synovial membrane was performed. Histological testing showed granulomatous inflammation. After nine weeks of culture on Ogawa medium (Kyokuto Pharmaceutical Industrial CO., Japan), smooth non-pigmented colonies were observed. The colony was positive for Ziehl Neelsen stain, suggesting acid fast bacilli. Initial testing with AccuProbe (Hologic, Marlborough, MA) was positive for MAC, with a value of 197,546 relative light units (RLU). COBAS TaqMan MTB/MAI (Roche Diagnostics, Switzerland), another real-time PCR test, was positive for M. intracellulare as well. However, further identification of the isolate using matrix-assisted laser desorption ionization–time of flight mass spectrometry (MALDI-TOF MS; MALDI Biotyper Version 2.0, Bruker Daltonics, US) suggested that the isolate was M. marseillense, with a score of 2.023 indicating a probable species identification. Because of this discordance, the rpoB and hsp65 regions were sequenced [, ]. In the Basic Logical Alignment Search Tool (BLAST) analysis, both sequences showed a 99.7% (E value, 0.0) and 100.0% (E value, 0.0) alignment respectively with those of Mycobacterium marseillense (GenBank accession number CP023147.1).
+Drug susceptibility testing was performed by a broth microdilution test, BrothMIC NTM (Kyokuto Pharmaceutical Industrial Co., Japan). Based on the breakpoints proposed by the Clinical and Laboratory Standards Institute , the isolate was sensitive to clarithromycin and amikacin. Subsequently, clarithromycin, ethambutol and rifampicin were initiated, and symptoms subsided gradually over the following month. Rifampicin was discontinued due to neutropenia after 2 months. Unfortunately, the patient died from an unrelated cause six months after the initiation of treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2963_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2963_en.txt
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index 0000000000000000000000000000000000000000..972a3d34243bf08fe767951a6da8f5f23f104cf4
--- /dev/null
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+A 22-year-old female was referred to our out-patient clinic for follow-up on her asymptomatic mitral valve prolapse (MVP), which was discovered incidentally when she was 6 years old. She had never previously experienced dyspnea, chest pain or syncope. Physical examination revealed a grade 3/6 systolic murmur at the upper left sternal border. Her electrocardiogram showed sinus rhythm with left anterior fascicular block and T wave inversion in leads I and aVL. All laboratory tests, including cardiac troponin, N-terminal pro-B-type natriuretic peptide (NT-pro BNP) and autoantibodies, were unremarkable.
+In addition to the anterior mitral leaflet prolapse (A2) with moderate mitral regurgitation and a mildly dilated left ventricle (left ventricular end-diastolic diameter: 56 mm) with a preserved ejection fraction , transthoracic echocardiogram revealed a retrograde blood flow from an extremely dilated left coronary artery (LCA) . Coronary angiography also revealed an enormously dilated and tortuous right coronary artery (RCA) originating from the right coronary cusp, with many collateral vessels filling the LCA (Additional file: Video 3), but failed to locate the orifice of LCA. Further coronary computed tomography angiography confirmed the diagnosis of ALCAPA .
+Given her high risk of left ventricular dysfunction, heart failure and malignant ventricular dysrhythmias, surgical correction was scheduled. Intraoperatively, her coronary arteries were found to be extremely dilated, the left ventricle and mitral annulus were mildly dilated, and anterior mitral leaflet appeared apparently thickened with rolled edges. More importantly, a chordae tendineae connecting the anterior leaflet (A2) was ruptured and markedly shortened . Therefore, reimplantation of the LCA into the aorta and concomitant mitral valve replacement were performed. The patient recovered uneventfully and was discharged from the hospital 2 weeks later. Three months following surgery, an echocardiogram revealed that her left ventricle had returned to normal (left ventricular end-diastolic diameter: 47 mm).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2975_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2975_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e5636092d4e07775825ed337c82071d513f6dec8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2975_en.txt
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+A 36-year-old female patient presented in the emergency department with sudden-onset palpitations that had started 2 h before. She had been suffering from comparable self-limiting episodes since the age of 24 years and was found to have a structurally normal heart on an earlier cardiology examination including transthoracic echocardiography. As the episodes were generally self-terminating within 10 min, she never took any medication to prevent recurrences. She had no other relevant medical history. Physical examination showed no abnormalities other than a regular tachycardia at 190 b.p.m., and blood pressure was 137/78 mmHg. The ECG on presentation in the emergency ward is presented in .
+The ECG on presentation showed a regular narrow QRS tachycardia with a ventricular rate of 192 b.p.m. The presence of a retrograde p-wave in or at the end of the QRS-complex is the hallmark of typical slow/fast AVNRT. Other tachycardias that should be considered in the differential diagnosis are orthodromic atrioventricular reentrant tachycardia (AVRT) over an accessory pathway, focal atrial tachycardia, and atrial flutter. In orthodromic AVRT, the retrograde p-waves are typically identified later (80–120 ms) after the end of the QRS-complex as the atria are only activated retrogradely over the accessory pathway after the ventricular myocardium has been depolarized. In focal atrial tachycardia, the p-waves are not retrograde and typically present not after, but just before the QRS-complex, with a PR-interval depending on antegrade conduction properties. In atrial flutter, flutter waves with a typical sawtooth pattern can be regarded as the main hallmark of common clockwise isthmus-dependent atrial flutter.
+When confronted with patients with haemodynamically stable narrow QRS tachycardia, vagal manoeuvres can be used as a first-line attempt to achieve reconversion to sinus rhythm. In patients with AVNRT and AVRT, carotid sinus massage and Valsalva manoeuvres are often used successfully to terminate the tachycardia by slowing conduction over the atrioventricular (AV) node, which is a critical part of the circuit.
+In 2015, it was shown that the modified Valsalva manoeuvre, combining Valsalva with a postural modification (leg elevation and supine positioning at the end), was more efficient in terminating episodes of supraventricular tachycardia than the standard Valsalva manoeuvre (43% vs. 17% restoration of sinus rhythm, P < 0.0001). Therefore, this method is currently recommended as a first-line over other vagal manoeuvres to achieve sinus rhythm in the acute phase.
+When vagal manoeuvres fail to restore sinus rhythm, intravenous adenosine can be administered as second-line therapy. Although adenosine blocks AV nodal conduction and therefore is mainly used to terminate AVNRT and AVRT, it may also terminate some forms of focal atrial tachycardia that are based on triggered activity. When adenosine fails to terminate AVNRT, or when there is rapid recurrence after cardioversion, intravenous administration of calcium channel blockers (verapamil/diltiazem) or beta-blockers may be used to restore sinus rhythm.
+In patients with recurrent symptomatic episodes of AVNRT, there is a good and clear indication for catheter ablation, which can be performed with a high success rate (97%) and a very low risk of complications. By avoiding ablation in the mid-septal area and the roof of the coronary sinus, targeting the inferior nodal extensions of the AV node for ablation, the risk of periprocedural AV block can be reduced to a minimum. Special consideration should be given to older patients with a baseline first-degree atrioventricular block, as the risk of iatrogenic AV block after ablation has been reported to be considerably higher in this group.
+Our patient consented to an ablation procedure which was performed under general anaesthesia with propofol and mechanical ventilation, as is the standard in our centre. After obtaining bilateral femoral venous access, three diagnostic catheters and one ablation catheter were positioned intracardially according to the positions shown in . The procedure was performed under X-ray fluoroscopic guidance without the use of a three-dimensional (3D) mapping system, as is usually the case for such procedures. With incremental atrial pacing, a clear jump from antegrade conduction over the fast pathway to the slow pathway was observed, with initiation of typical slow/fast AVNRT, as represented by the intracardiac recordings in .
+Ablation was then performed in the slow pathway region, corresponding to the rightward inferior extension of the AV node. Before ablation, a 3D reconstruction of right atrial anatomy was performed using 3D rotational angiography, as part of a study protocol on the anatomical evaluation of Koch’s triangle in patients with AVNRT. A oesophageal temperature probe was used as part of this study protocol to improve image integration accuracy; not to monitor temperature as there is no oesophageal temperature rise during ablation in the slow pathway region. Using dedicated software, the position of the ablation catheter could be projected on the 3D model during ablation, demonstrating the site of successful slow pathway ablation .
+During ablation in this region, accelerated nodal rhythm occurred indicating heating of the rightward inferior nodal extension, as is typically seen during successful radiofrequency applications in this region. The ablation power was increased from 25 to 40 W at the site of accelerated nodal rhythm and the application was continued for 90 s. After the first RF application, there was complete elimination of 1:1 antegrade slow pathway conduction, as can be seen in , and tachycardia was non-inducible during a waiting period of 30 min. The different chronological steps of the procedure are illustrated in the .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2986_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2986_en.txt
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index 0000000000000000000000000000000000000000..9d9c7839e01eb8834eb588073e504faaee9db2d8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2986_en.txt
@@ -0,0 +1,5 @@
+We report the case of a 46- year-old woman with falsely elevated FT4. She had no family history of thyroid disease and suffered from hypertension and dyslipidaemia. She was an active smoker and was having peri-menopausal symptoms. No other relevant medical conditions were present. She was first presented with a serum thyrotropin (TSH) level of 20.95 µUI/mL (0.5 - 5) and a serum free thyroxin (FT4) level of 7.7 pg/mL (8 - 18). The analysis was performed on Siemens Healthcare Reagents Kit in Advia centaur platform. Thyroid peroxidase and thyroglobulin auto-antibodies levels were positive; a thyroid ultrasound showed no goiter. The patient was diagnosed with clinical autoimmune hypothyroidism and was treated with 75 micrograms of levothyroxine daily. She was discharged from the endocrinologist to her primary care physician. Annual thyroid function tests were carried out and the results were within normal range, so the dose of levothyroxine remained unchanged.
+Eight years after she was first diagnosed with hypothyroidism, she showed a FT4 level of 51.7 pg/mL (8 - 18), a free triiodothyronine (FT3) level of 2.8 pg/mL (2.3 - 4.2) and a TSH level of 7.393 µUI/mL (0.5 - 5) in one of the annual routine thyroid tests performed by her primary care physician. The results were confirmed by a repeated test three weeks later. On the basis of these results, her primary care physician recommended a reduction in the dose of levothyroxine from 75 micrograms to 50 micrograms and referred the patient to the endocrinologist for further assessment. On examination, the patient had a body mass index of 35 kg/m2, no palpable goiter, a blood pressure of 129/88 mmHg and a heart rate of 98 bpm. She had recently increased her weight, to the extent of 7 kilograms in 6 month and she did not indicate tremor, palpitations, sweating, insomnia, diarrhoea or any other features of hyperthyroidism, in spite of the very high FT4 levels. She also denied having headaches or visual field problems that could have been caused by a TSH-producing pituitary adenoma. The test results in the past and the absence of family history of thyroid problems made the diagnosis of thyroid hormone resistance unlikely. Furthermore, the normal level of FT3 in the presence of high levels of FT4 pointed to the possibility of interference in the FT4 quantification.
+With the suspicion of interference in the FT4 quantification, the laboratory chemist was contacted and a second FT4 test, in a specimen collected 20 days after the previous one, was analyzed in parallel in two different platforms. Blood specimens were collected from the patient between 8 - 10 hours AM after overnight fasting and 24 hours after the last dose of levothyroxine. Sera of patient were left at room temperature 20 minutes, followed by centrifugation at 3000g for 15 minutes. The sera were then analyzed or immediately stored at -70°C for seven days. First, an Advia centaur platform with a Siemens Healthcare Reagents Kit (Method 1) was used with quality control material freeze-dried and human based “Immunoassay Plus Control” from Biorad and a within-run CV < 5% and inter-run CV < 8%. Second an alternative immunoassay platform Cobas e 411 with Roche Diagnostics Corporation (Indianapolis) Reagent kit (Method 2) was used with quality control material human based and freeze-dried Precinorm U from Roche Corporation and an intra-assay CV < 8.11% and an inter-assay CV < 11.2%. The TSH coefficient of variation intra-assay and inter-assay in Advia Centaur Platform were < 2.8% and < 4.28%, respectively. Both Roche Cobas “e” and Advia Centaur are competitive one-step immunoassay for FT4 quantification but differ in reagents labeling. In Advia Centaur, the labeling is an analogue of T4 hormone, labelled with acrydinium-ester, which compete with the patient’s FT4 for a little quantity of polyclonal rabbit antibody bound to a solid phase. However, in Roche, the labeling is a polyclonal sheep antibody (immunometric one-step assay) labelled with sulfonyl-Rhutenium; the solid phase bound T4 analogue and the patient’s FT4 patient hormone compete for a little quantity of polyclonal sheep antibody labeled with suffonyl-Rhutenium. The results obtained by both methods are shown in . After confirming an under-treated hypothyroidism, the dose of levothyroxine was increased to the initial of 75 micrograms.
+Autoantibodies anti-T4 presence was confirmed using PEG precipitation and dilution methods, following an in house protocol based in the radioactivity measurement of the precipitant after addition of Polyethylene glycol solution 20% w/v in water to the serum patient and serum negative control previously incubated with I-125 radiolabeled -Thyroxine in the same run. Serum patient was found to be positive with a percentage of 77.4% of fixation (positive if higher than 10%). Control negative serum showed a percentage of 5% of fixation. Auto-antibodies anti-T3 were negative following the same in house protocol. The patient sample was PEG-precipitated in order to confirm the autoantibodies anti-T4 interference in FT4 Advia Centaur assay with a validated in-house protocol in an Advia centaur platform. We selected a patient control specimen with a very low FT4 concentration like Blank and another patient control specimen with very high FT4 concentration. To compare both, the matrix effect by PEG in Advia centaur acrydinium-ester label and the behaviour of a sample in the same patient range after PEG precipitation. The antibody interference gave a very discordant result before and after PEG precipitation in the patient’s problem specimen. No relevant disagreement was found in the control specimens before and after PEG precipitation.
+To further evaluate the antibody interference, we performed a double-dilution test in order to confirm the T4-autoantibodies interference in the Advia centaur platform. We did this by using a very low FT4 level pool from hypothyroid patients as a zero diluent and patient´s control specimens without FT4 test interference as well as a very high FT4 level. All of them were analyzed at the same run. The patient sample showed a non-linear increase in the FT4 level due to the decreasing title of high avidity interfering T4-autoantibodies after double-dilution test . Finally, total T4 and T3 levels were also analyzed in Advia centaur platform in order to detect interference in total thyroid hormones. No relevant discordance was detected after the total T4 and total T3 quantification in Advia centaur platform respect the FT4 and FT3 hormones in the same platform and patient’ specimen. The total T4 level was 67.9 µg/dL (4.5 - 10.9) and the total T3 was 1.43 ng/mL (0.6 - 1.81). PEG precipitation and dilution tests were performed . Patient specimen showed a very low PEG precipitated recovery, which accounted for the PEG eliminated interference probably owing to the antiT4-autoantibodies. We speculate that the high title and high avidity patient index anti T4 autoantibodies were quenching the T4 coated paramagnetic solid phase beads, displacing the low title monoclonal mouse anti T4 from the binding site in the T4 molecule. After washing the monoclonal acrydinium labeled mouse, antiT4-antibodies were discarded and no signal was detected in the competitive assay, which explained the high Total T4 concentration observed in the patient sample in the Advia centaur platform total T4 assay.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3001_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3001_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f31c6c872675857fe4608515e0dfe4d9c7f3a2a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3001_en.txt
@@ -0,0 +1,5 @@
+8-year-old boy with no personal or family history of interest, who presented to the paediatric emergency department with abnormal ocular movements of a year's duration. The family reported that the boy had about 5-6 episodes a day of about 5-10 seconds duration consisting of horizontal conjugate ocular movements with rapid jerks and slight associated miosis, without associated head or limb movements. They did not associate it with fixation of the gaze, position or movements of the head. The patient could not self-provoke the episodes, but could identify their onset. They were of sudden onset and cessation, some of them gave the impression of disconnection from the environment or loss of consciousness, they did not refer to a postictal period or headache. They always occurred in the waking state and never during sleep. The parents had observed a higher frequency of episodes on days of greater stress and physical fatigue, without being able to identify other triggers. They also did not associate ataxia, tinnitus, autonomic symptoms or hearing loss. They denied a history of head trauma and consumption of drugs or other toxic substances. The symptoms had not changed or progressed since their onset to the day of the consultation and the neurological examination between episodes was normal.
+
+Ophthalmologic evaluation ruled out visual pathology, and the otolaryngologic evaluation ruled out pathology in that area and described a high intensity, low amplitude jerk nystagmus episode. He was hospitalized for further evaluation, with general laboratory tests (including thyroid hormones, liver function, autoimmunity profile, and vitamin D) that showed no pathological findings. Videotaping of the episodes by the family was of great help in the diagnostic orientation, and the video-electroencephalogram (VEEG) demonstrated an electro-clinical correlate of the episodes. The VEEG was performed in the waking state, recording two separate events of about 8-10 seconds duration during a total recording of 25 minutes. The background tracing was normal for his age, and coinciding with the two clinical episodes of nystagmus, epileptiform activity was recorded in the left temporal and occipital region that later generalized. After having demonstrated focal onset epileptic activity in relation to the patient's symptomatology, treatment with carbamazepine was initiated orally at an ascending dose.
+
+A brain magnetic resonance study with contrast was completed, without evidence of structural alterations or cortical development anomalies, with the final diagnosis of ictal nystagmus. He was discharged to home with a dose of carbamazepine of 13 mg/kg/day, which was then increased to 17 mg/kg/day. In outpatient follow-up in Neuropediatric consultations, 2 years after the start of treatment, good adherence and absence of side effects to treatment were noted, without new episodes.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3002_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3002_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a469112f1f327b064d5f1bb67c2c88c2cc4507d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3002_en.txt
@@ -0,0 +1,7 @@
+A 63-year-old female with poorly controlled diabetes mellitus, hypertension and dyslipidemia on oral medication presented with 3 episodes of back-to-back GTC seizures, each lasting for approximately 5 minutes, in a background of mild on-and-off headache for several months but without any weight gain, visual impairment or features of pituitary hormonal abnormalities. The seizures were associated with loss of consciousness, frothing, eye deviation and tonic and clonic movements of all four limbs followed by postictal drowsiness lasting for 2 to 3 hours. She was admitted to the A&E department and thereafter transferred to the intensive care unit, where she was managed with Levetiracetam to which she responded.
+
+The neurological examination was unremarkable except for a bitemporal quadrantanopia on the visual field assessment. Moreover, the rest of the physical exam did not elicit any features of pituitary hormonal excess or deficiency. The patient was further assessed by a consultant ophthalmologist, where bitemporal pallor and cupping in addition to bitemporal upper quadrantanopia were detected.
+
+Magnetic resonance imaging was subsequently used to detect a large pituitary tumour measuring 6.0 cm (craniocaudal) × 3.8 cm (transverse) × 4.0 cm (anteroposterior) with suprasellar extension through the third ventricle into both lateral ventricles, causing significant mass effects and impending hydrocephalus (Wilson-Hardy classification: IVC, Knosp classification: 0; Goel classification: IV). Blood investigations that were also carried out revealed normal serum electrolytes and endocrine panels.
+
+Upon stabilizing her and achieving significant glycemic and blood pressure control under the supervision of a consultant endocrinologist, she underwent neuro-navigation-guided endonasal transsphenoidal subtotal resection 2 weeks after her initial presentation. Histology revealed a null cell adenoma with a Ki-67 index of 3%. She was discharged one week after surgery, and at 3 months of follow-up, she was initiated on adjuvant radiotherapy but was well and seizure free (while on Levetiracetam) without any visual deficits. She is being closely followed up by the endocrinology team headed by a senior consultant endocrinologist and has not shown to have clinical or biochemical indicators of pituitary dysfunction. Close monitoring by MRI imaging will be performed at 3 months of completion of radiotherapy and at regular intervals thereafter to assess the growth of the residual tumour for a total cumulative period of 15 years (as per unit protocols).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3008_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3008_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a067efde31c63413a0604f3824e8daf96cbdc190
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3008_en.txt
@@ -0,0 +1,2 @@
+A 37-year-old male patient presented to a surgical emergency with the complaint of blackish skin discoloration of the Right arm over the region of the deltoid with severe pain. He had a history of intramuscular diclofenac 75 mg injection into the right deltoid one day back for generalized musculoskeletal pains. The swelling progressed rapidly throughout 24 to 30 h. Past medical and surgical history was unremarkable. There was no history of intake of steroids or any other drug that could lead to an immunocompromised state. No history of illicit drug use. On general physical examination, the patient was anxious, irritable, pale, dehydrated, febrile, and was having a toxic look. He was tachycardic with a pulse rate of 106 beats per minute, respiratory rate was 24 cycles per minute and he was also found to be hypotensive with systolic blood pressure of 90 mmHg.
+Local examination revealed a swollen right arm with blackish discoloration over the region of the right deltoid. On palpation, the whole of the right arm was extremely tender, and tense, and had extended subcutaneous emphysema. Furthermore, pallor, pulselessness, and paresthesia of the distal limb raised strong clinical suspicion of compartment syndrome. Establishing a preliminary diagnosis of gas gangrene with concomitant compartment syndrome, immediate resuscitation was given with intravenous fluids, broad-spectrum antibiotics, and strong analgesia. Vital monitoring and IOP started. Arterial blood gas analysis was performed which revealed metabolic acidosis with respiratory compensation. On blood tests, leucocyte count was 18,500 per microliter and C-reactive protein was 53 mg/dl. His creatinine was 1.7 mg/dl and urea was 95 mg/dl. Total bilirubin was 2.7 mg/dl, ALT was 160 units/l. The patient received prompt treatment with release incisions, surgical debridement, and resection of necrotic tissue. All the open wounds were copiously washed with hydrogen peroxide and normal saline. Wounds were covered with antibiotic dressings. Cultures of the fluid from necrotic tissue resulted in a positive for Staphylococcus epidermidis, clostridium perfringens, and Staphylococcus aureus. Histologic examination of the tissue removed from the right deltoid and triceps region described colliquative necrosis. After debridement, the patient was shifted to the ward and monitored for 24 h. On the next day margins of the wounds became increasingly necrosed, and the gangrene extended to anterior and posterior chest walls beyond anterior and posterior axillary lines. Re-Debridement was planned, wound margins were refreshed and the whole of the necrotic muscles involving the triceps and part of the latissimus dorsi were debrided. According to the results of culture sensitivity meropenem, 1 g 12 hourly was administrated. Minor serial detriments were performed over the subsequent days and the wounds were managed with regular dressings. The patient remained under close observation receiving intensive supportive care for almost 4 weeks. Gradual improvement was noted with the development of healthy granulation tissue. The patient was discharged in stable condition with continued outpatient wound care and follow-up in the department of plastic surgery for possible skin grafting after the establishment of healthy granulation tissue.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3009_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3009_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6c8b4ec9b6ace35541ef1deede66aa7fbae1ac06
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3009_en.txt
@@ -0,0 +1,11 @@
+Patient information: a 54-year-old patient with a history of sarcoidosis in 2004, who was treated and cured, who is consulting for diffuse abdominal pain in the form of a sensation of discomfort that develops in episodes without disorders of transit, fever or inflammatory syndrome, with a good general condition.
+
+Clinical examination: everything is normal in our patient, except for a palpable abdominal mass.
+
+Diagnostic approach: an abdominal-pelvic ultrasound was performed, revealing a thin-walled, median cystic formation with some septae with an echogenic content, measuring (148 x 141 x 60 mm). The extension assessment completed by an abdominal-pelvic tomodensitometry (TDM) was in favour of a mesenteric liquid formation with thin walls, hypodens, thin septae not taking the contrast agent, limited inside by the stomach, in front and behind by the small intestine and colon. At the end of this clinical and radiological assessment, the diagnosis of a benign cystic formation that may be compatible with a cystic lymphangioma was made. An abdominal-pelvic magnetic resonance imaging (MRI) confirmed the multicystic formation, measuring (183 x 96 x ×200 mm) without solid portion, or vegetations, developed at the expense of the mesocolon. The blood biology and the tumour markers were normal.
+
+Therapeutic intervention: a median laparotomy was performed. The intraoperative exploration showed the presence of a large intraperitoneal multicystic liquid mass, partially externalised through the median incision and developed from the left mesocolon. We performed a dissection-resection of the cyst in its entirety.
+
+The anatomic-pathological examination confirmed the diagnosis of cystic lymphangioma.
+
+Follow-up and results of therapeutic interventions: the post-operative follow-up is simple, the patient was discharged on the 4th post-operative day. After a month of follow-up, the patient is asymptomatic. The radiological control at 3 and 6 months is without particularity.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3010_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3010_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..7a5b4e393800e4dd7824e3ee973da8a7f5220de7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3010_en.txt
@@ -0,0 +1,15 @@
+A 65-year-old male patient with a history of arterial hypertension experienced a left tibial plateau fracture classified as Schatzker VI, coupled with ipsilateral leg compartment syndrome in 2014 following a fall from height. Initially managed elsewhere with leg fasciotomies and transeskeletal traction, he was transferred to our center after 2 months, presenting clear signs of malreduction of his fractures. In this scenario, the decision was made to implement a tumor resection prosthesis OSS Orthopaedic Salvage System (Zimmer Biomet, Warsaw, Indiana, USA) to correct axis deviations and significant bone deficit. The patient developed an acute periprosthetic infection, managed through surgical debridement, antibiotic therapy, and implant retention (DAIR), successfully preserving the prosthesis. The patient was discharged at 12 months, at which point severe residual stiffness in the left knee was noted.
+
+Five years later, in March 2019, the patient returned with a fistula and increased volume at the operative site, without associated trauma. Physical examination revealed a fistula on the anteromedial aspect of the proximal leg. The knee was painless, without effusion, with a range of motion from 0° to 15°. Additionally, a laterally dislocated patella was palpated.
+
+Laboratory tests showed a white blood cell count of 6900, erythrocyte sedimentation rate (ESR) of 41, and C-reactive protein (CRP) of 1.4 (normal value up to 1.0). Enterococcus faecalis was isolated from the joint fluid, sensitive to Vancomycin, Ampicillin, and Linezolid.
+
+X-rays of the left femur, knee, and leg revealed no signs of prosthesis loosening. Given the scenario of chronic periprosthetic infection, severe knee stiffness, and inveterate patellar dislocation, our team opted for a two-stage KA with IMN.
+
+In the first surgical stage, the infected tumor prosthesis, which showed no signs of loosening, was removed, resulting in a significant bone defect of approximately 31 cm (cm). Surgical cleaning was performed, and a cement spacer containing Vancomycin was placed, stabilized with a transarticular knee external fixator. Intraoperative cultures were positive for Enterococcus faecalis. After 2 months of intravenous antibiotic treatment with Ampicillin, the second surgical stage was carried out.
+
+Through a broad anterior approach, total patellectomy and removal of the cement spacer were performed, revealing a complete bone defect from the healthy distal femur to the tibia, measuring 31 cm. Subsequently, after thorough surgical cleaning and debridement, perpendicular cuts were made in the distal femur and tibial diaphysis.
+
+In this context, given the extensive bone defect, the decision was made to use a hybrid model of nail-modular prosthesis, specifically the Endo-Model Link® (Waldermar Link, Hamburg, Germany). Following progressive reaming in the femur and tibia, a trial nail-prosthesis was installed, and finally, the modular arthrodesis nail Endo-Model Link® was implanted, modified with a diaphyseal replacement module of 10 cm, proximal midsection of 10 cm with a cemented 14 mm × 13 cm femoral stem, and tibial midsections of 5 and 6 cm with a cemented 12 mm × 13 cm tibial stem (totaling 31 cm of bone replacement). Third-generation cementation was utilized. The plastic surgery team provided definitive coverage during the same surgical session using a medial fasciocutaneous advancement flap and a bipedicle fasciocutaneous advancement flap. Cultures taken during surgery were negative.
+
+The patient progressed favorably throughout the remainder of the hospitalization, completing 1 month of intravenous antibiotic treatment with Ampicillin and subsequently 3 months of oral antibiotics (Amoxicillin). After 52 months of follow-up, the patient remains in good condition, free of pain, ambulating adequately with the use of a single cane, without infection recurrence, and with radiographs indicating appropriate fusion of the arthrodesisç and a lower limb length difference of 22.1 mm.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3030_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3030_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..001ed20802a4326f64b463fc877e7380fab5ab5a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3030_en.txt
@@ -0,0 +1 @@
+This 30-year-old male patient presented with a frontal head swelling of one year duration that started after he sustained a stick injury on the frontal head one year ago, and he has an associated frontal headache for one year. There was no history of rhinosinusitis, no history of sinus surgery, and no history of radiation exposure. There was a 4 × 5 cm frontal, firm, palpable, non-tender lesion extending from the nasion to the frontal head. The neurologic examination was unremarkable; there was no sign or symptom of meningitis or a brain abscess. On a brain CT scan, there was frontal bone erosion at multiple sites with partial frontal sinus opacity, an externally growing mass, and an old frontal sinus fracture noted. An MRI was not done due to social reasons. Nasal endoscopy and ophthalmologic examination were unremarkable. We prepared him and took him to the OR after informed written consent was obtained. We put him in a supine position, intubated him, and placed him in a supine position with slight neck extension, a bicoronal skin incision, and a bifrontal craniotomy. The intraoperative finding was a soft tissue mass eroding the frontal bone and involving the frontal head galea and enlarged frontal sinuses filled with mucocele. Then, we did soft tissue mass resection from the frontal galea, mucocele exenteration, frontal sinus posterior wall or inner wall rongeoured and flattened, all frontal sinus mucosa excised, and the ostium identified and packed with muscle bilaterally. Then a pericranial pedicled flap was applied on the frontal lobe dura down to the frontal skull base. Skin closed in two layers with a drain left in the subgaleal space, the patient was stable, extubated, transferred to PACU, and then discharged on the third postoperative day with an improved headache and frontal swelling. After a month at an outpatient follow-up clinic, we found him completely improved from his headache and swelling.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3036_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3036_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ab4ab6eaf50067754944ab1ced353ca3d5098a73
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3036_en.txt
@@ -0,0 +1,11 @@
+A 34-year-old Caucasian man presented for evaluation of a five-month history of worsening exertional dyspnea, productive cough, and lower extremity swelling. He reported associated fatigue, unintentional 50 pounds weight loss, and early satiety. His past medical history was notable only for hypertension, which was controlled with hydrochlorothiazide and carvedilol. He recently started taking furosemide for lower extremity swelling.
+He is a never smoker. He has no history of recent travel or any relevant exposures. His vital signs were significant for an oxygen saturation of 92% on 2 L per minute of supplemental oxygen and mild tachycardia. Physical examination was notable for diaphoresis, pallor, diminished heart sounds, markedly decreased breath sounds over the right thorax, and 2+ pitting lower extremity edema.
+Pulmonary function tests demonstrated an intrinsic restrictive ventilatory defect with a forced vital capacity (FVC) of 4.03 L (59% of predicted) and diffusion capacity of the lung for carbon monoxide (DLCO) of 23.3 mL/min/mmHg (55% of predicted). The partial pressure of oxygen on arterial blood gas was 60 mmHg. High resolution chest computed tomography showed diffuse pulmonary nodules with upper lobe predominance and in a perilymphatic distribution; diffuse partially calcified mediastinal and hilar lymphadenopathy; moderate to large right pleural effusion; and moderate to large pericardial effusion with pericardial thickening. He subsequently underwent a transthoracic echocardiogram which demonstrated preserved left ventricular systolic function and a large circumferential pericardial effusion with evidence of mitral inflow/tricuspid inflow respiratory variation and paradoxical septal shift, concerning for early tamponade physiology. He was admitted to hospital and underwent an urgent pericardiocentesis with removal of 500 mL of serosanguinous fluid. Pericardiocentesis resulted in immediate clinical improvement. The fluid was monocyte-predominant, with negative cultures. The pericardial drain was removed after several days of minimal drainage.
+
+Thoracentesis and fiberoptic bronchoscopy with bronchoalveolar lavage (BAL), transbronchial biopsy, and endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) of the mediastinal lymph nodes were also performed. Pleural fluid analysis showed monocytic predominant transudate (53% monocytes, 38% lymphocytes) with negative cultures, cytology, and flow cytometry. Adenosine deaminase level was normal. BAL of the right middle lobe was also predominantly monocytic, with negative cultures (including acid-fast bacilli) and cytology. Transbronchial biopsies yielded two non-necrotizing granulomas, and otherwise were negative for malignancy or infection. Mediastinal lymph node fine needle aspiration from the EBUS-TBNA was non-diagnostic.
+Given the inconclusive nature of the results, the patient subsequently underwent video-assisted thoracoscopic surgery wedge biopsies of the right lung as well as pleural and pericardial biopsy. A pericardial window was attempted during the procedure but was not successful. A right chest tube was left in place with subsequent daily output of one liter or greater of transudative fluid. The pathology demonstrated lung tissue with florid non-necrotizing granulomas extending into the visceral pleura. No fungi or acid-fast bacilli were identified on culture or tissue staining. The biopsy of the pericardium showed focal fibrosis but no granulomas were seen. He was diagnosed with sarcoidosis involving the lungs, pleura, and presumably the pericardium and was started on prednisone 30 mg daily.
+
+Soon after, the patient's hospital course was complicated by re-accumulation of the pericardial effusion, and this time with cardiogenic shock, secondary to cardiac tamponade. He underwent an emergent pericardial window and mediastinal drain placement with resolution of shock but continued to have more than one liter of transudative drainage daily from both the chest and mediastinal tubes.
+Further evaluation with cardiac magnetic resonance (CMR) imaging demonstrated a significant reduction in pericardial slippage between the parietal and visceral layers of the heart as well as prominent ventricular septal bounce consistent with enhanced inter-ventricular dependence; collectively suggestive of constrictive pericarditis. Of note, there was no evidence of late gadolinium enhancement to support myocardial involvement with sarcoidosis. Confirmation of effusive-constrictive pericarditis was noted on right heart catheterization, which showed equalization of diastolic right ventricular (RV) and left ventricular (LV) pressures with evidence of a “square root sign”, and RV/LV discordance. He then underwent pericardiectomy, which on histopathologic evaluation demonstrated non-necrotizing granulomas, thus confirming pericardial involvement of sarcoidosis.
+
+The patient steadily improved clinically following his surgery and had complete resolution of the pleural effusion and lower extremity edema with diuretics. He was discharged in stable condition on 20 mg of prednisone. At one month follow-up he denied dyspnea and the echocardiogram demonstrated normal cardiac chamber size. Pulmonary function tests showed improvement with a FVC of 5.52 L (79% of predicted) and DLCO of 24.92 mL/min/mmHg (57% of predicted). Methotrexate was started as a steroid-sparing agent and prednisone was tapered off.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3044_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3044_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ec2b57dbcd9ea8b2a9326fde72e2a419187f15a4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3044_en.txt
@@ -0,0 +1,3 @@
+A 41-year-old woman diagnosed with multiple sclerosis in 2011 and treated with mirtazapine 15 mg daily and quetiapine 50 mg daily for mood disorders.
+
+In July 2021, he started treatment with DMF and reported nausea and abdominal pain as adverse effects. A week later, while taking 240 mg of DMF daily, he reported pruritus in the right upper extremity, followed by the appearance of erythematous areas with vesicles. He presented for consultation a week later, when the skin lesions had spread to the right lower extremity. He did not have fever or systemic symptoms. Treatment with DMF was discontinued and a blood test and biopsy of the lesions were performed. The blood count showed an elevation of the eosinophil count to 2,000 uL. The pathological study showed an eosinophil infiltrate at the dermis level compatible with Wells syndrome. The clinical evolution was favorable, with the resolution of the lesions and the normalization of the eosinophilia in approximately four weeks. It was not necessary to administer corticosteroids.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3062_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3062_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd787437d9c25cbcbb84b50fac309b82ad58c1df
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3062_en.txt
@@ -0,0 +1,13 @@
+88-year-old female patient with a history of Alzheimer's, admitted with worsening mental confusion 4 days ago, associated with periods of agitation, aggressiveness and inappetence. She was continuously using sertraline and quetiapine.
+
+She presented with somnolence, disorientation, and no focal deficits. A head CT scan was performed, which showed changes expected for the patient's age group, with no signs of acute changes to the method. A 6-hour EEG showed diffuse disorganization of the brain's electrical activity. A reverse transcription-polymerase chain reaction (RT-PCR) test for 2019 coronavirus disease (COVID-19) was requested at admission to the hospital, given the context of the pandemic and acute neurological change, which was positive.
+
+The patient remained under neurological surveillance, with adjustment of antipsychotics and introduction of enoxaparin as a pharmacological prophylaxis of venous thromboembolism. She underwent an MRI on the third day of admission, which showed the presence of multiple foci of heme-iron deposits with a predominance in the periphery of the brain parenchyma (suggestive of amyloid angiopathy).
+
+On the fourth day of admission, he presented a picture of dysarthria and decreased motor strength in the left hemicorpus. An emergency brain scan was performed, which showed hemorrhage in the central and parieto-occipital sulcus on the right, as well as the emergence of recent intraparenchymal hemorrhage, compromising the precentral gyrus, measuring about 3.3 x 3.4 x 2.4 cm (estimated volume of 14 ml).
+
+The patient was admitted to the neurological intensive care unit for clinical support, where heparin was discontinued and neuroprotection measures were performed. After evaluation, the neurosurgery team did not indicate surgical treatment. There were no changes in blood pressure levels and other vital signs. In the laboratory tests performed, there were no changes in coagulogram. However, there was a change in inflammatory markers (D-dimer of 1,411 ng/mL and C-reactive protein (CRP) of 3.15 mg/dL, with a reference value of less than 1 mg/dL). Ferritin and lactic dehydrogenase were within normal values.
+
+It evolved with improvement of the confusional state, but he maintained a motor deficit on the left. On the 13th day, he presented involuntary movements in the face, and a new electroencephalogram was requested, which showed epileptiform activity of variable projection in both cerebral hemispheres, predominantly in the anterior right region. In a new tomography of the skull, a greater regression of the content of subarachnoid hemorrhage in the central and parieto-occipital sulcus was observed, as well as a greater reduction of the partial attenuation/metabolisation of the intraparenchymal hematoma in the right perirrolandic region, compromising mainly the post-central gyrus, with an area of vasogenic oedema more conspicuous in the neighbouring cerebral parenchyma, remaining similar to the mass effect characterised by blurring of the sulcus between the local cortical gyruses. An anticonvulsant was initiated, with improvement of the condition, without new crises (clinical and electrographic).
+
+He is currently in the process of rehabilitation, with a left motor deficit without other neurological changes.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_307_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_307_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..9080f5912defbbb50771345f1faa93bf038a7e29
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_307_en.txt
@@ -0,0 +1,9 @@
+We report the case of a 14-year-old male sportsman (contact sport), without significant personal pathological history, who presented in the emergency room with the following symptoms: headache, dizziness, and tinnitus, and a clinical exam revealed elevated BP values (180/115 mmHg). It is worth mentioning that approximately 5 months ago elevated BP values were recorded at school but without any measures taken at that time.
+The clinical exam at the time of admission revealed extreme anxiety, warm extremities, rhythmic heart sounds, grade III systolic murmur, with interscapulovertebral and bilateral carotid irradiation, the bilateral absence of femoral pulse, BP differences between the upper and lower limbs of up to 50 mmHg (right upper limb BP 180/115 mmHg, left lower limb BP 131/91 mmHg). We found no changes in the blood parameters, and the surface electrocardiogram pointed out left ventricular hypertrophy (LVH) . The 24 h BP Holter revealed BP values >95 percentile for age and height. The abdominal ultrasound showed no blood flow in the lobar and segmentary renal arteries.
+Transthoracic echocardiography revealed a continuous curve on the Doppler interrogation of the abdominal aorta, concentric LVH, preserved systolic function of both ventricles, narrowing of the aortic isthmus, with a maximum gradient of 85 mmHg and diastolic run-off, and a severely dilated left subclavian artery .
+We performed a CTA in order to accurately assess the descending aorta, and we identified a focal narrowing of 0.7 cm diameter, multiple periscapular collateral arteries, and bilateral dilated intercostal and subclavian arteries .
+Based on the clinical and paraclinical data, we established the diagnosis of isthmic CoA and severe secondary AHT.
+In terms of AHT, we decided to initiate antihypertensive drugs (beta-blockers) before the procedure, taking into account the result of the abdominal ultrasound, which were well tolerated hemodynamically.
+The case was discussed by a multidisciplinary team and accepted for interventional treatment—implantation of covered stent under general anesthesia, with the patient ventilated with positive pressure using a laryngo-tracheal mask. The first contrast injection in the aortic arch was performed in the antero-posterior and latero-lateral projection, based on which, we identified a narrowing of the isthmic area of 7 mm, with a peak-to-peak gradient at this level of 23 mmHg, as well as a dilated left subclavian artery and multiple aorto-aortic collaterals. During the procedure, a Cheatham-platinum (CP)-covered stent of 4.5 cm was implanted on a balloon in balloon (BIB) of 20 mm × 5 cm inflated up to the burst pressure of 4 atm, which allowed the gradient reduction to 2 mmHg. The last three injections were performed in the antero-posterior and latero-lateral projection in the aortic arch, visualizing the normal position of the stent, without impairing the left subclavian artery’s emergence and without suggestive images for dissection or periaortic hematoma. These findings were also confirmed by the control native chest CT ( and ).
+The postprocedural echocardiographic assessment visualized the stent placed at the isthmic level with a maximum residual gradient of 22 mmHg and a mild persistence of the gradient in diastole along with an improvement in the pulsed color Doppler aspect of the abdominal aorta. On the 1st day after the procedure, the patient presented hypertensive episodes accompanied by severe anxiety resulting in the decision to adjust the dosage of the betablocker therapy and to associate an angiotensin-converting enzyme inhibitor, with subsequently controlled BP values.
+The clinical exam pointed out bilaterally present femoral pulses, and no BP differences between the upper and lower limbs. The 24 h BP Holter monitoring indicated the persistence of stage I AHT, and therefore, we recommended the continuation of the antihypertensive therapy. The echocardiographic examination showed findings similar to those of the immediate postprocedural evaluation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3134_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3134_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c2a85939d9e09f442f87ce79c351abc34bcc62e7
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3134_en.txt
@@ -0,0 +1,5 @@
+A 73-year-old male patient with a fever of more than 40° and difficulty in physical movement was admitted to the emergency department of our hospital. The patient had alcoholic cirrhosis of the liver. The laboratory findings revealed a strong inflammatory response, including a white blood cell count of 27200/μL, a C-reactive protein level of 12.85 mg/dL, and a high blood ammonia level of over 500 μg/dL. The tumor marker was high, with a carcinoembryonic antigen (CEA) level of 62.4 ng/mL. Computed tomography (CT) revealed a large mass near the aortic bifurcation. The tumor was initially diagnosed as unresectable sigmoid colon cancer because of iliopsoas muscle invasion and intramuscular abscess formation, left hydronephrosis due to left ureteral invasion, urinary bladder invasion, and congestive edema of the left lower leg due to invasion of the common to external iliac artery/vein. Colonoscopy revealed a circumferential lesion at 15 cm from the anal verge, and biopsy demonstrated that the tumor was a well-differentiated tubular adenocarcinoma. Genetic testing revealed that the tumor was a RAS mutated, BRAF wild type, and microsatellite stability tumor.
+
+First, a transverse colostomy was performed; then, a left nephrostomy was created for left hydronephrosis, and percutaneous drainage was performed for iliopsoas abscess, resulting in an improved inflammatory response. After 4 courses of FOLFOX + bevacizumab therapy, the tumor volume decreased, and no new lesions appeared, and the CEA level decreased to 10.1 ng/mL. Four months after the initial visit, it was determined that an R0 resection was possible via total pelvic exenteration with iliac artery reconstruction. The patient underwent left A-F bypass using an expanded polytetrafluoroethylene (e-PTFE) graft (8 mm) with ligation of the proximal common femoral artery followed by total pelvic exenteration and combined resection of the left common and external iliac artery/vein and right ureterocutaneostomy. The distal rectum was transected, and the anus was preserved; however, colorectal anastomosis was avoided. The operative time was 13 hours 39 minutes, blood loss was 3276 mL, and transfusions of red blood cells (8 units) and fresh frozen plasma (6 units) were intraoperatively performed.
+
+Pathological findings revealed that the tumor was ypT4b (bladder) N0M0, ypStage II. Treatment of left leg edema and gait rehabilitation took time, but no postoperative complications of Clavien-Dindo grade 2 or higher were observed, and the patient was discharged on the 44th day after surgery. No adjuvant chemotherapy was administered due to performance status (PS) of 2. The patient was alive 9 months after surgery and had not experienced recurrence and rebound of left leg edema.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3137_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3137_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5c41734184b00b2c91482038a7aafb86e15626c9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3137_en.txt
@@ -0,0 +1 @@
+A 68-year-old female first admitted to our hospital because of heart failure, and was finally diagnosed as an AL type of primary cardiac amyloidosis including the endomyocardial biopsy. After 3 years followed-up, she underwent a CRT device implantation for biventricular pacing following the repeated episodes of heart failure (NYHA class III) with reduced left ventricular ejection fraction of 34% and wide QRS with complete left bundle branch block of 143 ms. She kept a silent condition for 7 years after a CRT device implantation. A shortness of breath, symptoms of heart failure on physical examination, and remarkable cardiomegaly with extended cardiothoracic ratio of 74% on chest x-ray were again presented when she was 78 years old. The echocardiography showed a huge echogenic mass occupying the right atrium. Sixty-four multi-detector computed tomography (CT) showed a lobulated heterogeneously enhancing mass in the right upper lobe of liver, and a continuous tumor thrombus from the portal vein and hepatic vein to the right atrium via the inferior vena cava. Alpha-fetoprotein level was >20 000 ng/mL (reference range: 0.0 to 10.0 ng/mL), and HCC was diagnosed by a contrast enhanced CT. The continuous hypercoagulability was shown more than 6 months before the last occurrence of heart failure despite of anticoagulant therapy. She improved the symptoms of heart failure by the diuretics as a standard medical therapy. An extensive tumor thrombus with HCC was considered to have caused a hemodynamic complication in this case.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3155_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3155_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..841ada0ca6d2bd554bffe41e4d43e738f8fdd7f8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3155_en.txt
@@ -0,0 +1,3 @@
+A previously healthy 21 year old Sri Lankan female university student admitted with shortness of breath for 1 week duration. Shortness of breath was mainly on exertion, however at the time of admission it was present even at rest. She had low grade fever for the last 1 week associated with malaise and profuse sweating. Her weight and appetite have been steady throughout. She was not on any long term medication and did not take medication for minor ailments in the recent past to suggest a drug induced hypersensitivity reaction. She does not have a history of conjunctivitis, rhinitis, sinusitis or allergy to any drug or food. She took worm treatment 6 month prior. History was negative for malignancy, thromboembolic disorders and connective tissue diseases. She denied family history or other risk factors for cardiovascular disease. She is a non alcoholic, non smoker and no history of illicit drug use. She was mildly febrile and dyspnoeic at rest. There was no associated pallor or icterus. Generalized oedema or ankle oedema was absent. Physical examination was negative for malignancy, thromboembolic disorders and connective tissue diseases. She was tachycardic with regular, low volume pulse at rate of 120 beats per minute. Jugular venous pressure was elevated 5 cm above the angle of Louis with negative Kussmaul sign. Her blood pressure was 100/70 mmHg on admission. The cardiac apex was at its normal position and heart sounds were slightly muffled with gallop rhythm. There were bilateral basal fine end inspiratory crackles. Firm, non tender mild hepatomegaly with mild splenomegaly were present. Otherwise her clinical examination was normal. Her full blood count revealed absolute rise in eosinophil count of 21.6 × 103 per microliter (63.5%) with 34 leukocytes per microliter with normal platelet count, haemoglobin and red cell indices. Blood picture showed high total white cell count with severe eosinophilia with no abnormal cells. Her erythrocyte sedimentation rate was 60 mm in 1st h in the presence of normal C-reactive protein. Sinus tachycardia with wide spread ST depression was evident on electrocardiogram. Chest X-ray was normal other than the evidence of heart failure. 2D-echocardiogram showed global left ventricular hypokinesia with 40% ejection fraction and thin layer of pericardial effusion. There was no associated intra cardiac thrombus. Troponin I was elevated up to 35.4 ng/dL (< 1.0 ng/dL) and Brain natriuretic peptide was 1280.5 pg/mL. Her renal function, thyroid function, serum electrolyte, calcium, magnesium levels, lipid profile were all normal with normal liver function but elevated liver enzymes (both were at 3 times upper limit of normal). Both serum IgM and IgG were negative for Filaria, Toxoplasma and toxocara infection and stool examination was negative for parasites. Serology for Epstein-Barr virus, Cytomegalo virus and Mycoplasma were negative. Retroviral infection and tuberculosis were excluded. Her blood culture and autoimmune screen were negative. Mild hepatosplenomegaly without lymphadenopathy was detected in otherwise normal ultrasound scan. Bone marrow biopsy showed hypereosinophilia with no evidence of bone marrow infiltration by lymphoproliferative malignancy. FIP1L1–PDGFRA fusion transcript and BCR–ABL transcript were not detected. The patient declined to undergo a confirmatory endomyocardial biopsy. Coronary angiogram and other non invasive cardiac imaging were not performed due to the practical problems of getting them done as they were not freely available. Clinically detected heart failure was confirmed by 2D ECHO and biochemical markers. The presence of global left ventricular dysfunction was better explained with myocarditis than myocardial infarction as there should be multi territory ischaemia to explain it which was less likely in our patient given that she was young and did not had any cardiovascular risk factors. This would have been excluded in certainty with coronary angiogram if it was freely available to us. Peripheral blood eosinophilia pointed towards a probable cause of cardiac damage in an otherwise healthy young female without cardiovascular risk factors. Drug hypersensitivity as a cause of eosinophilia was excluded from history. Bone marrow examination confirmed the diagnosis of hypereosinophilia. Myeloproliferative hypereosinophilic syndrome can give rise to chronic eosinophilic leukaemia. The possibility of this was excluded by negative FIP1L1–PDGFRA and BCR–ABL gene transcription. Secondary causes for hypereosinophilia were excluded and the diagnosis of idiopathic hypereosinophilic syndrome and eosinophilic myocarditis was made depending on the available investigations. Normal thyroid function test, negative ANA, DsDNA, negative antibody tires of common viral infection were used to exclude other differential diagnosis. This young female was given supportive care and treatment for heart failure and monitored in the high dependency unit to observe for possible deterioration. Her blood pressure dropped to 80/60 mmHg on day four of the admission requiring inotropic support. She was treated with intravenous Noradrenaline 0.3 μg/kg/min initially through L/Internal jugular venous catheter and then it was titrated up to 0.5 μg/kg/min to maintain mean arterial pressure of 70 mmHg. As soon as the diagnosis of hypereosinophilic syndrome with eosinophilic myocarditis was made, she was started on methylprednisolone 1 g/day for 3 days and continued with prednisolone 1 mg/kg to a total dose of 50 mg. Her symptoms started responding after the 3rd dose of methylprednisolone. Clinical improvement was observed in terms of symptoms and other parameters like blood pressure and pulse rate. Noradrenaline was then tailed off gradually and stopped after 5 days of starting steroids. Eosinophil count started to drop on day 5 of steroid treatment and it was then 16.31 × 103 per microliter. Troponin level gradually normalized over the period of the next 2 weeks. She was discharged after 3 weeks of hospital stay and by this time Eosinophil count was 1.11 × 103 per microliter (7.5%) and 2D echocardiography showed ejection fraction of 50% with thin layer of pericardial effusion. Pericardial effusion completely resolved and left ventricular function became normal (EF 60%) in the follow up 2D-ECHO and eosinophil count was at just upper limit of normal (0.52 × 103 per microliter) after 2 week of discharge from the hospital.
+
+Steroid dose was started to taper off after 1 month when she was totally asymptomatic and having persistently normal eosinophil count and left ventricular function. She is now on long term maintenance dose of steroid of 5 mg daily and Steroid needs to be continued at least 6 months to 1 year. She is on regular clinic follow up with monitoring of blood counts.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_315_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_315_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5406bbef68d8f9f7864824b8195af9f421e2068e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_315_en.txt
@@ -0,0 +1,4 @@
+A 15-year-old male presented to the emergency department for evaluation of neck and chest pain. He was running at a brisk pace when he felt a sudden sharp pain in his neck followed by sustained pain in the center of his chest and neck. He reported the sensation of shortness of breath and nausea, but no dysphagia or dysphonia. There was no history of trauma to the head, neck, or chest. He was previously healthy with no prior medical problems or prior surgeries and had no history of familial or congenital medical conditions. Most notably, the patient had no family history of sudden cardiac death, aortic disease, or connective tissue disease. The patient endorsed having no known allergies and did not take any medications on a daily basis.
+On arrival, he displayed mild tachypnea with a respiratory rate of 22 breaths per minute, but otherwise had normal vital signs with a blood pressure of 128/80 millimeters of mercury, heart rate 66 beats per minute, temperature 37 degrees Celsius, with 98% oxygen saturation on room air. His airway showed no evidence of impending compromise. He appeared to be in moderate distress secondary to pain. He demonstrated respiratory splinting and held his neck and shoulders still to prevent worsening of pain. He had mild nasal flaring, but his lungs were clear to auscultation bilaterally. He had no evidence of stridor. Palpation of the chest revealed tenderness near the right sternoclavicular region of his chest. Pulses were palpable and equal in all extremities.
+A chest radiograph showed lung markings to the periphery bilaterally, no consolidations, and no opacities . The mediastinum appeared widened, which prompted a computed tomography (CT) angiogram of the chest and neck to better evaluate vascular anatomy. This revealed a pseudoaneurysm of the proximal innominate artery . There was also high attenuation blood tracking from the superior mediastinum to the descending aorta suggesting rupture of the pseudoaneurysm and formation of a mediastinal hematoma .
+The patient was taken to the operating room where he was found to have an extensive tear of the proximal innominate artery about one centimeter from its origin. The rupture was contained by the adventitia and surrounding soft tissue. The patient received an ascending aortic to innominate artery extra-anatomic bypass graft, and drains were placed to reduce the mediastinal hematoma. He was evaluated by geneticists postoperatively who suspected a connective tissue disorder. High on the differential was vEDS given his exam exhibiting flexible digits, easy bruising, and normal aortic root dimension. The patient was discharged home on postoperative day five, and nearly three weeks later, genetic testing confirmed a pathogenic COL3A1 mutation diagnostic of vEDS.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3164_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3164_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..259896aa5d7d1aaccd66a4f3df24728fcc60b11d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3164_en.txt
@@ -0,0 +1,38 @@
+A 79-year-old Caucasian man presented to the emergency room with shortness of breath, bilateral leg oedema and fatigue. His medical history was notable for arterial hypertension and degenerative valve disease, with indication of aortic valve replacement which he refused. He did not use alcohol, tobacco or illicit drugs. There was no history of recent infection, or any invasive procedure in the last year. Besides taking antihypertensive drugs, he was not on any medications. He had not been consulted by a physician in the last 3 years.
+
+On physical examination, he was afebrile, with bilateral lower extremity oedema, there was arrhythmia with a heart rate of 70/min, blood pressure was 180/80 mm Hg; there was a grade 5/6 systolic murmur at the aortic area, and a grade 4/6 holosystolic murmur at the mitral area. Respiratory examination revealed dullness to conventional percussion, decreased tactile fremitus and decreased breath sounds at the bilateral lung bases with crackles. The remainder of the exam was unremarkable.
+
+
+Investigations
+
+Standard 12-lead ECG showed atrial fibrillation with heart rate between 60–70 beats/min and left ventricular hypertrophy signs with secondary repolarisation changes.
+
+The chest X-ray showed cardiomegaly with interstitial densities and pulmonary venous congestion. Large bilateral pleural effusions were noted.
+
+The chemistry panel showed an N-terminal pro b-type natriuretic peptide level of 2000 pg/mL, increased creatinine with an estimated glomerular filtration rate of 30 mL/min/1.73 m2, high blood glucose, hyperuricaemia and hyponatraemia. The C reactive protein level was 9 g/dL (normal <5 g/dL), erythrocyte sedimentation rate was 30 mm/hour and the fibrinogen level was 300 mg/dL (normal <500 mg/dL). There was mild normochromic normocytic anaemia (haemoglobin=99 g/L) and leucocyte count was 9710/mm3 with 64% neutrophils, 7% eosinophils, 20% lymphocytes and 9% monocytes. The urinalysis was normal, with negative urine culture. Pharyngeal exudate was positive for Candida spp. and negative for Staphylococcus aureus and Streptococcus pyogenes. Further blood tests were in the normal range.
+
+Transthoracic echocardiography (TTE) showed mild left ventricle hypertrophy. Systolic function was normal with an ejection fraction estimated at about 60%. The right ventricle was mildly enlarged with normal longitudinal function. Both atria showed marked enlargement. The aortic valve was tricuspid with severe stenosis (aortic valve area 0.4 cm2) and moderate regurgitation. The mitral valve showed a mobile hyperechogenic formation with the maximum diameter of 12 mm seen in the left atrium which strongly indicated endocarditis. Doppler examination showed severe mitral regurgitation due to perforation of the mitral anterior leaflet and also moderate tricuspid regurgitation. The inferior vena cava was dilated, and the pulmonary systolic pressure was estimated at about 50 mm Hg.
+
+Transoesophageal echocardiography confirmed the presence of vegetation.
+
+Sonography of the abdominal organs was normal.
+
+Before antibiotic treatment was started, four blood cultures where taken from separate venous sites, at 30 min intervals. Each sample was placed into a pair of blood culture bottles that cultivate aerobic and anaerobic bacteria separately.
+
+Three out of four blood culture grew Gram-positive cocci in clusters. The organism grew on trypticase soy agar and was catalase-positive, oxidase-negative and coagulase-negative. It was identified as coagulase-negative Staphylococcus, and subsequently as S. warneri by the Vitek 2 GP card (BioMérieux). After 72 hours of treatment three other blood cultures were taken randomly and came out negative.
+
+
+Treatment
+
+Empirical antibiotic treatment with vancomycin 30 mg/kg/day intravenous in three doses and gentamicin 3 mg/kg/day intravenous was started. Afterwards, following the discussion with the infectious disease physician and the microbiologist, we concluded that the isolation of S. warneri was not contamination, and we established the diagnosis of S. warneri endocarditis, based on two major diagnosis criteria—echocardiography and positive blood cultures. The antibiogram revealed resistance to penicillin, tetracycline, erythromycin, clindamycin, clarithromycin, doxycycline, fosfomycin, rifampicin and susceptibility to fusidic acid, ciprofloxacin, daptomycin, gentamicin, vancomycin, levofloxacin, linezolid, moxifloxacin, norfloxacin, ofloxacin, oxacillin, pefloxacin, minocyclin and trimethoprime/sulfamethoxazole. We decided to continue treatment with oxacillin 12 g/day intravenous in four doses according to current guidelines. The patient also received medication for heart failure and was anticoagulated with acenocoumarol for his atrial fibrillation. He was consulted by a psychologist and received sleep pills, for insomnia.
+
+
+Outcome and follow-up
+
+The patient’s clinical condition improved slowly, with gradual remission of congestion, and decrease of non-specific inflammation markers, and also there was an improvement in kidney function (with a decrease of creatinine from 2.0 to 1.4 mg/dL). He was discharged after 1 month with a good clinical condition. The patient was informed again about the firm indication for mitral and aortic valve replacement, but he refused again the intervention.
+
+One month after discharge the patient had the same aspect of the TTE, with severe mitral regurgitation but with well-tolerated heart failure (New York Heart Association class II). The chemistry panel showed mild normochromic normocytic anaemia (haemoglobin 112 g/L), and a creatinine level of 1.6 mg/dL.
+
+After 3 months he was again hospitalised for decompensated heart failure (pleural effusion and fatigue). All of the five blood cultures taken this time were negative. The symptoms improved after 6 days of intravenous diuretics and the patient was discharged with the same recommendations.
+
+He is still refusing the valve surgery.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3220_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3220_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..dd4e56ad86297c30892f19f88e8ab4197cc530e9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3220_en.txt
@@ -0,0 +1,7 @@
+A 65-year-old man presented to our hospital’s clinic with a 6-month history of orthopnea and worsening dyspnea on exertion. He also described having worsening leg swelling with painless sores and cellulitis with flaky skin for the past 3 months. His past medical history was significant for chronic left leg swelling which started when he was 15 years old. No other comorbid conditions were present, and the patient had no significant travel history. His father, elder brother, and nephew had the same history of chronic massive unilateral leg swelling starting in the teenage years. All of them were diagnosed as having lymphedema praecox.
+
+During physical examination, the patient’s vital signs were blood pressure of 140/100 mm Hg, a regular pulse of 90 beats per min, oxygen saturation of 97% on room air, and a temperature of 36.7°C. The patient’s body mass index was 31.6 kg/ m2. He had jugular venous distension. The lungs were clear to auscultate, and no additional sounds were heard on cardiovascular examination. The left leg showed non-pitting edema with indurated, woody skin and lichenification, while the right leg had mild pitting edema. There were numerous verrucous folds and cobblestone-like nodules, and plaques and a painless ulcer on the left leg. The Kaposi-Stemmer sign (inability to tent the dorsal aspect of the skin at the base of the second toe) was positive. The temperature of both legs was the same.
+
+The results of the laboratory evaluation, including blood count, cardiac enzymes, D-dimer, C-reactive protein, metabolic profile, and thyroid function test were normal. Abnormal values included B-type natriuretic peptide levels of 467 pg/mL (reference range, up to 100). Blood cultures showed no organisms. Chest radiograph images showed scattered pulmonary infiltrate with prominent hilar markings, and the electrocardiogram showed a partial left bundle branch block. Echocardiography showed an ejection fraction of 20% and dilated left and right chambers. There was also global hypokinesia with a thinned left ventricle and mild mitral and tricuspid regurgitation. Doppler sonography did not show any arterial or venous clots. Computed tomography angiography showed normal coronary arteries. The patient was admitted as a working diagnosis for dilated cardiomyopathy and presumed elephantiasis of the left leg. A skin biopsy was consistent with stasis dermatitis, and a diagnosis of ENV superimposed on lymphedema praecox with congestive cardiac failure was confirmed.
+
+The patient began guideline-directed medical therapy for cardiac failure with high dose diuretics including eplerenone 25 mg once daily and furosemide 40 mg every 6 h, and intravenous amoxicillin/clavulanic acid 1.2 g 3 times daily as empirical therapy for cellulitis. His leg was treated with the help of compression stockings and inelastic multi-layer bandaging. The physiotherapist started the patient on limb decongestive therapy. After a week of guideline-directed medical therapy and physiotherapy, his swelling improved and there was a slight reduction of edema. He was prescribed oral amoxicillin 500 mg (twice per day for 7 days) and a retinoid cream. At the 1-week follow-up visit, the patient was satisfied, despite the treatment showing only a slight improvement. His shortness of breath and orthopnea had subsided. He was referred to a specialized dermatology center for further management.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3230_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3230_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b5bb1e466fd8df502f6102725273c2075bdbbb4f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3230_en.txt
@@ -0,0 +1,5 @@
+The patient was a 76-year-old woman. At the age of 70, when she was admitted to our hospital’s department of collagen medicine with polymyositis, she developed a depressive state for the first time and was subsequently treated by the department of psychiatry. She was diagnosed with major depressive disorder by diagnostic and statistical manual of mental disorders IV-TR and treated with mirtazapine 45 mg; however, her depressive state and anxiety agitation did not improve. Thereafter, she failed to respond to various drug therapies, including escitalopram, venlafaxine, vortioxetine, and augmentation with aripiprazole, and she underwent initial mECT at the age of 72. The depressive state improved immediately after mECT, but she relapsed several times, requiring mECT each time.
+
+At the age of 76, she was admitted to our hospital to undergo mECT for the fifth time because of recurrent depressive symptoms such as decreased appetite, anxiety, and agitation. After admission, vortioxetine 10 mg and olanzapine 10 mg were tapered off. Quetiapine 50 mg, suvorexant 15 mg, and trazodone 25 mg were continued. Propofol (1.0 mg/kg) was administered intravenously, and rocuronium bromide (1.0 mg/kg) was given to avoid muscle contractions. After induction of anesthesia, suxamethonium chloride (4.0–5.0 mg/kg) was administered intravenously as a muscle relaxant. The mECT was bilateral and started at 35% stimulus intensity, and effective convulsions were obtained for the first time. However, during the 8th mECT at the same intensity (35% stimulus intensity), an unexpected prolonged seizure of 966 s (over 16 minutes) occurred. The seizure was abruptly stopped with diazepam 10 mg and midazolam 2 mg. There were no tardive seizures. The patient had used a range of antidepressants in the past with poor efficacy, therefore, we considered continuing mECT could be reasonable to improve her depressive symptoms.
+
+During the ninth mECT session, the stimulation intensity was increased to 50%, which resulted in effective seizures and no prolonged seizures. Subsequently, appropriate convulsions were obtained with the same stimulation intensity, and she completed 12 sessions. Her depressive symptoms improved both subjective and objective, and she was discharged on the 45th day of hospitalization.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3245_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3245_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a1ee48222381670f1116970ef0b9ca83549858d4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3245_en.txt
@@ -0,0 +1,5 @@
+The patient, a 3-year-old female, visited the dentistry and pediatric clinics in the Uji-Tokushukai Medical Center, Uji, Japan. She had no fever, right jaw pain, mild trismus, and preauricular facial swelling around the right mandible, but had neither acne nor pustulosis. She was the only child in her family, and her family history was unremarkable. She had healthy dentition and no history of trauma or recurrent aphthous ulcer. Computed tomography (CT) revealed a hyperostotic right mandible, with osteolytic and sclerotic changes associated with periosteal reactions, which led us first to suspect bacterial osteomyelitis (BOM), although she did not have high C-reactive protein (CRP) values with normal white blood cell counts, and her blood culture was negative. Serum lactate dehydrogenase (LDH) and uric acid were within the normal ranges, while alkaline phosphatase was slightly elevated. Vitamin C levels were not examined.
+
+Physically, there was no apparent abscess or fistula at the jaw lesion. Though she received oral antibiotics (AMPC) for 1 month, her symptoms did not improve. From CT images, Langerhans’ cell histiocytosis was thought to be improbable, rather, CNO was highly likely. Consultation with otolaryngologists led to some debate about whether a biopsy of the affected mandible was required to reach a correct diagnosis, as reported by several authors; however, we chose no invasive measures. During the following 5 months, no clinical features of BOM manifested, and the follow-up of blood tests remained normal. At 6 months after the initial visit, MRI (STIR image) revealed a low-density hyperostotic right mandible. In addition, inflammation had spread to the right masseter muscle, and to the right interior and exterior wing pterygoid muscles, which was suggestive of CNO rather than BOM.
+
+Under a probable diagnosis of CNO, the patient received flurbiprofen (Froben; 3 mg/kg/day), which is a nonsteroidal anti-inflammatory drug (NSAID). During the 6 months of treatment with flurbiprofen, she was doing well; the facial swelling was ameliorated, with only occasional mild pain in the involved jaw. However, to obtain a better outcome, we then switched treatment after 12 months; the patient received a combined treatment with oral alendronate jelly (2/5 adult dose; 14 mg; 0.7 mg/kg/day), which is normally used for adults at 35 mg/day, plus flurbiprofen. This alendronate treatment was administered once per week. After 1 month of treatment with this regimen, her symptoms subsided markedly, with normalized serum CRP levels and no acceleration of the erythrocyte sedimentation rate. At the age of 4.5 years (18 months from the initial visit), the patient was almost symptom-free. Thereafter, both drugs were tapered.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3256_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3256_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..06d209719a20f7aa937f363778165b6bfc350bba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3256_en.txt
@@ -0,0 +1,6 @@
+The parents of a previously healthy 2-year-old child came to our hospital with complaints of malaise, lethargy, vomiting, loose stools, yellowing of the sclera and skin, dark urine and white stools, which have been observed in the child for 4 days. Possible contact with infectious patients, use of drugs and other potentially toxic substances was not detected. The objective status of the child during hospitalization was characterized by elevated body temperature (37.7°C), marked lethargy, icteric coloration of the skin and mucous membranes, hepatomegaly. Heart rate (HR) – 123/min., respiratory rate – 24/min., SpO2-98%. The examination revealed an increase in total bilirubin to 129.6 μmol/l, direct fraction to 116.24 μmol/l, increased levels of transaminases: ALT - 4.5 mmol/l/h, AST - 3.3 mmol/l/h. Taking into account the clinical data, viral hepatitis was suspected, an appropriate examination and symptomatic therapy were prescribed.
+
+Specific studies revealed positive titers of IgM HAV and IgM EBV (VCA), negative results of examination for markers of HBV (HBsAg), HCV (IgM+G), cytomegalovirus (IgM) and leptospirosis (PCR). An ultrasound examination revealed an increase in the size and increased echogenicity of the liver. Taking into account the detected markers, the disease was considered to be viral hepatitis A with EBV co-infection.
+
+During the first three days of inpatient treatment, the child’s condition remained stable, vital functions were within normal limits. In laboratory tests, there was a tendency to decrease the elevated levels of bilirubin and transaminases. On the fourth day of stay, a disturbance of consciousness appeared in the form of stupor (on the Glasgow coma scale (GCS) - (E3V4M5)=12b). The appearance of neurological symptoms was associated with deterioration of coagulation hemostasis indicators (Prothrombin index (PI), Activated partial thromboplastin time (APTT)), a decrease in the concentration of protein in blood serum. The worsening of the condition was considered as ALF. The treatment included antibacterial therapy (cefotaxime 50 mg/kg/day), corticosteroids (dexamethasone 0.6 mg/kg/day), parenteral nutrition, replacement therapy (fresh-frozen plasma), albumin 20%, glutargin 80 mg/day, thioctic acid 10 units/kg/day, canavit up to 5 mg/day, respiratory support (ventilation). Over the next two days, the child’s condition worsened due to ALF. Disturbances of consciousness progressed to severe coma (according to the FOUR (E0M0B0R1) scale = 1 point, without drug sedation), peripheral edema developed, hemorrhagic contents appeared through the nasogastric tube, intestinal peristalsis was suppressed, oligo-anuria developed, laboratory tests showed progression anemia, an increase in the level of indirect bilirubin, indicators of coagulation hemostasis worsened (Table 1). On the 6th day of hospital stay, the child had a cardiac arrest (asystole), which did not recover after resuscitation measures.
+
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3276_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3276_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..aa253a14ccbcba69ba3ec12aa4875068aba2fa72
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3276_en.txt
@@ -0,0 +1,21 @@
+We are presenting a full-term vital male newborn, born vaginally, with a gestational age of 38 + 6 weeks, birth weight (BW) 3,260 g, birth length (BL) 48 cm, AS 10/10, which has been referred to our Department of Neonatology for further evaluation of a midline cervical cleft along with an unidentified neck mass of unknown origin. The course of the pregnancy was complicated, with hyperstimulation syndrome as part of the IVF (in vitro fertilization) procedure which included using progesterone and myo-inositol among others (9th day after embryo transfer), but was otherwise regular.
+
+Initially, an obvious skin defect was noticed at birth as a suspected mucosal protrusion at the anterior part of the neck, with possible secretion (about 2 cm in long diameter). The described mass was firm, arising from the median cervical cleft, well separated from surrounding neck regions, without visible communication with parotid or salivary glands. At first, possible differential diagnosis included thyroglossal duct cyst, dermoid and branchial cyst, as well as some malformation of gill arches and protrusion of esophageal mucosa. Otherwise, no abnormality in physical appearance has been detected.
+
+Diagnosis and surgical management
+Otorhinolaryngologic examination demonstrated a visible tumor formation in the median line of the neck on a relatively narrow base, about 2.5 × 0.5 cm in size, moderately hard on palpation with altered skin area around the formation of an oval shape. Below the described formation, there was a smaller skin area that looked more like a mucous membrane, but without visible fistula. First it was described as a possible anomaly of gill arches or a thyroglossal anomaly, because of the specific median position.
+
+Ultrasound examination of the neck regions did not reveal pathologically altered lymph nodes. Both parotid and submandibular glands as well as the thyroid gland had regular dimensions and echogenicity, with a homogeneous structure without focal lesions. There was no dilation of the main salivary ducts. In the median line of the neck, referred to as a VI neck region (radiological region IV), there was a visible hypoechogenic skin area, with clearly limited formation of dimensions 1.2 × 1.2 × 0.9 cm without communication with the thyroid gland. Between the formation and the thyroid gland there was a small lymph node with a diameter of 0.3 cm. The formation showed no enhanced vascularization. There was no clear communication with the thyroid gland in terms of open thyroglossal ductus. The thymus was localized mediastinal with typical echogenicity without visible ectopic localizations. Other posterior neck structures have been described as within physiological limits in all regions.
+
+Surgical treatment included excision of the exophytic formation at the front of the neck in the median line. During the procedure the sinus has been shown, with a depth of 3 mm (measured with the test). No communication with other posterior structures of the neck was demonstrated.
+
+In the further clinical course, at the age of 1 year and 6 months, a re-evaluation was performed, which showed normal neck mobility, without functional limitations and the absence of any signs of respiratory or digestive difficulties, such as dyspnoea, respiratory distress, upper respiratory infections, feeding problems or persistent communication of neck structures and the digestive tract.
+
+The purpose of the second surgical act was to improve the functional and cosmetic appearance of the scar, by using of Z-plasty technique which would redirect scar tissue into better alignment within natural skin folds and lines of least skin tension, which may lengthen the already contracted scars. This was done 1 year and 8 months after the primary surgical treatment. The postoperative course passed without complications with adequate wound healing. An additional tissue sample has been taken for pathohistological analysis, which confirmed, along with the scar and adipose tissue in the dermis layer, a focal tubular formation lined with respiratory epithelium and surrounded by abundant lymphoid tissue, which was equivalent to the initial PHD findings.
+
+Long-term follow-up has been continued by otorhinolaryngologists, pediatricians and dermatologists, every 3–6 months. There was a stable clinical course, without associated complications and satisfactory cosmetic appearance of the scar, as well as full functioning of the affected region. Further follow-up is necessary because of the potential development of keloids, contractures, malignant transformation which can result with secondary respiratory and digestive problems.
+
+Pathological findings
+The observed material is a polyposis formation of 1.8 × 1 cm in size, on a peduncle of 0.4 cm in diameter. Histologically, it consists of skeletal and smooth muscle tissue fibers, individual seromucous glands, circulatory tracts, branches of the peripheral nerves and connective tissue, while on the surface, which is partially villous and eroded, there is a ciliated, pseudostratified columnar epithelium with areas of squamous epithelial metaplasia. The subepithelial layer is composed of stroma which consists of multiple glands lined with the typical ciliated, columnar epithelium.
+
+Finally, the described histological changes confirmed a mesenchymal hamartoma and are consistent with initial clinical diagnosis of the congenital midline cervical cleft (CMCC).
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3282_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3282_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c89acf2706ffbe356581f572db18424cf4157500
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3282_en.txt
@@ -0,0 +1,3 @@
+67-year-old female patient with a history of diagnosed alcaptonuria, which began with diffuse pain in the right hip four years ago, progressive, deaf, with limitation in the mobility arcs in general conditioning to claudicatio intermittens. On physical examination, the ocre pigmentation of the sclera, auricle, was noted; she presented with claudicatio intermittens, right limp, use of support orthotics, abduction 10°, adduction 5°, hip flexion 45°, extension 10°, all movements with the presence of pain. Radiologically, she presented loss of joint space in the right hip, abundant osteophytes, sclerosis in the acetabulum. Laboratory: blood count, general biochemistry and elementary urine examination with no alterations, erythrocyte sedimentation rate (ESR): 18; proteinogram, phosphate-calcium balance and parathyroid hormone (PTH) normal, normal iron profile; rheumatoid factor (FR) and anti-histocompatibility antigen (HLA) B27 negative, homogentisic acid in 24-hour urine: 1,140 mg/24 hours (reference < 10 mg/24 hours), alkaline urine test positive. In the operating theatre, with the patient under mixed blockade, a total replacement of the right hip was performed using a posterior approach, with a double-mobility G7 prosthesis (due to a history of spondyloarthropathy with lumbar ankylosis), with a Taper lock stem (Zimmer Biomet). During the procedure, the presence of dark areas in the femoral head and neck, characteristic of AHG deposits, was observed macroscopically. The procedure ended without complications, with post-operative radiological control. The macroscopic pathological examination referred to a femoral head with dark patches in bone and cartilage tissue.
+
+Follow-up was performed at two, four and eight weeks, without finding local or systemic symptomatology. At six months postoperatively, the patient presented gait without alterations, without dismetria of pelvic limbs and without referred pain. It was assessed by the modified Harris scale, obtaining a score of 82, which is defined as a good result. Subsequently, a 12-month postoperative follow-up was carried out, during which the patient showed satisfactory clinical progression with improvements in the ranges of movement. No anomalies were observed in the gait and the patient reported the absence of pain. The modified Harris hip score was recalculated, obtaining a score of 90, which is defined as an excellent result. In addition, an annual control scanometry was performed where the implant was found without data of loosening at the pelvic or femoral level, without shortening of extremities.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3292_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3292_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b6844a7dff4625b7c8dcebd82d08ccc5e8b3c387
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3292_en.txt
@@ -0,0 +1,25 @@
+A 31-year-old male was referred to a quaternary intensive care unit (ICU) for consideration for extracorporeal membrane oxygenation (ECMO) due to severe biventricular heart failure refractory to inotropic support (a cardiac index of 1.3 on noradrenaline and dobutamine infusions). He had presented with shortness of breath, extreme lethargy and abdominal pain, and was hypotensive and tachycardic.
+
+His history was significant for a diagnosis of an iron overload state after presenting with lethargy 4 months prior. At diagnosis his serum ferritin was 2541 μg/L (reference range (RR) 30–500) with a transferrin saturation (TS) of 90% (RR 10–45). Laboratory investigations revealed normal hematologic, renal, and liver function. Hepatitis serology was negative and subsequent extensive imaging revealed no evidence of malignancy. Genetic testing revealed H63D heterozygosity for the HFE gene, which is inconsistent with hereditary hemochromatosis with iron overload. While awaiting venesection he developed diabetic ketoacidosis which required admission and stabilization with an insulin infusion. His glycated hemoglobin (HbA1c) was 15% and c-peptide 0.07 nmol/L (RR 0.30–2.30). He was diagnosed with diabetes mellitus secondary to iron overload with significant beta cell insufficiency and was transitioned to twice daily premixed insulin. Given the above presentation, the decision was made to proceed to liver biopsy to investigate the extent of iron overload. A liver biopsy identified extensive intrahepatocyte iron but minimal inflammatory cell infiltrate and minimal fibrosis with a hepatic iron index of 13 (RR <2). His liver function tests were normal.
+
+Our patient, of Serbian origin, reported no family history of iron overload syndrome, endocrinopathy or cardiomyopathy. There was no history of excess alcohol intake, recreational drug use, or toxic environmental exposures.
+
+A physical examination on admission to the ICU revealed a patent airway. His respiratory rate was 15 breaths/minute, oxygen saturation 98% on 4 liters of oxygen via nasal prongs, and good air entry to bilateral lung fields but slightly reduced at the right base without crackles or wheeze. On a noradrenaline, dobutamine, and amiodarone infusion his blood pressure was 90/64 mmHg with a pulse rate of 105 beats per minute with cardiac monitoring revealing a sinus tachycardia. A cardiovascular examination was significant for a hyperdynamic apex beat with heave, a jugular venous pulse at 2–3 cm and dual heart sounds with nil murmurs. A neurological examination was significant for a Glasgow coma score of 14 (eyes 3 motor 5 verbal 6). His abdomen was soft on palpation with tenderness to the right upper and lower quadrant and no guarding. A peripheral examination was significant for a tanned complexion and the absence of peripheral edema.
+
+Laboratory investigations on admission did not account for the patient’s critical clinical state revealing normal hemoglobin concentration, platelet count, renal function and serum electrolytes. His liver function was mildly deranged with an elevated alanine transaminase (88 units/ L, RR 12–15) and bilirubin (62 umol/L RR, ≤ 23) and decreased albumin (30 g/L, RR 33–46). His C-reactive protein (CRP) and neutrophil count were mildly elevated, 9 mg/L (RR ≤ 5) and 10.27 109/L (RR 1.90–8.00) respectively, with a normal white blood cell count (12.03 109/L, RR 3.90–12.70). Antinuclear antibody and rheumatoid factor test results were negative. A high-sensitivity Troponin I test result was mildly elevated (64 ng/L, RR ≤ 26). Midstream urine and blood culture were negative.
+
+A computed tomography scan demonstrated a dilated heart with associated pleural effusions, ascites, and liver congestion. A transthoracic echocardiogram revealed normal left ventricular (LV) size with severe global systolic dysfunction with an ejection fraction of 5–10%, spontaneous echo contrast, and normal wall thickness. The right ventricular (RV) size was normal with severely reduced function. Mild to moderate mitral and pulmonary regurgitation were noted along with a trivial pericardial effusion.
+
+He had a prolonged ICU stay due to progressive multi-organ dysfunction. He was intubated and ECMO support was initiated on day 2 and biventricular assist devices (BiVAD) were inserted on day 8. An endomyocardial biopsy revealed myocyte intracytoplasmic iron deposition. This result together with the global nature of the systolic dysfunction was consistent with iron overload as a cause for the cardiomyopathy. There was no echocardiographic or histopathologic evidence to suggest myocarditis and hemodynamic instability precluded coronary angiography.
+
+Serum ferritin (SF) level was 12,361 μg/L and TS was 99% on day 2. Iron chelation therapy was commenced on day 6 with desferrioxamine, initially subcutaneously. Shortly after its commencement, increasing inotropic requirements and bilateral lung infiltrates felt to represent pulmonary edema were noted and desferrioxamine was ceased as a precaution. It was restarted on day 21 once his clinical condition had stabilized and up-titrated to a maximum dose of 4200 mg (60 mg/kg) administered via a 24-hour intravenous infusion and was subsequently well tolerated with rapid removal of iron burden. SF levels peaked on day 13 at 18,676 μg/L and TS was > 99% before decreasing to 1055 μg/L by day 59 with TS also decreasing to 65%.
+
+By the fifth week after presentation, it was considered that he may have developed diabetes insipidus on the basis of a marked unexpected increase in urine output, but because of his parlous clinical state on BiVAD it was not possible to confirm with a water deprivation test at that time. A trial of desmopressin did not result in convincing improvement.
+
+Investigation of his anterior pituitary function revealed isolated hypogonadotropic hypogonadism. Testosterone replacement was commenced with testosterone 1% gel 2.5 g topical daily with subjective improvement in energy levels and sense of wellbeing.
+
+Our patient was listed for heart transplantation and discharged home on day 69 with BiVAD in situ after progressive improvement in his physical capacity with intensive inpatient rehabilitation. Desferrioxamine was continued at home via nightly 10-hour continuous subcutaneous infusions. Our patient was readmitted on day 89 with urosepsis, which was successfully treated with antibiotic therapy. At this time, he was noted to have improved left ventricle function on an echocardiogram, estimated to be only mildly reduced on a technically difficult study. Serial outpatient echocardiograms, both resting and stress, demonstrated myocardial recovery with normal LV size and resting systolic function (visual LV ejection fraction of 55–60%) and normal RV size and low-normal systolic function. With exercise, there was good augmentation of both LV and RV function and a normal hemodynamic response. Successful BiVAD explant occurred, 141 days after initial implant with SF 163 μg/L and TS <1% 12 days prior. Left ventricular biopsy at this time demonstrated less intracytoplasmic iron deposition compared with the initial biopsy. Post BiVAD explant, desferrioxamine was ceased as a potential cause of worsening renal tubular acidosis. Cardiac magnetic resonance imaging (cMRI) completed 2 weeks post BiVAD explant demonstrated normal biventricular systolic function but a myocardial T2* time of 12.3 milliseconds (normal > 20 milliseconds) consistent with residual myocardial iron loading. A formal water deprivation test was performed and was normal, therefore desmopressin was ceased.
+
+As the patient’s history was significant for a diagnosis of hemochromatosis, JH was suspected given his age and absence of family history. Targeted gene sequencing was then performed across 39 genes and 11 promoter regions using a custom “AmpliSeq” panel (Life Technologies, Mulgrave, Victoria, Australia) and an Ion Torrent™ Personal Genome Machine™ (Life Technologies) as previously described [2]. Following alignment of the sequencing with the Human Genome version 19 (HG19), our patient’s heterozygosity for the HFE H63D was confirmed, and no other mutation were present in the HFE gene. Variant analysis identified homozygosity for a variant c.G959T (NM_213653) in exon four of the HFE2 gene (aka HJV) resulting in a p.G320V mutation (rs74315323). This DNA change was confirmed by Sanger sequencing. The G320V mutation has previously been reported in multiple cases of juvenile onset hereditary hemochromatosis [3]. No other mutations known to be associated with iron overload were identified in our patient, nor were there any other novel or rare single nucleotide polymorphisms in the coding regions of sequenced genes.
+
+At follow-up 12 months after his presentation with severe biventricular heart failure the patient has made a near-complete recovery and had returned to work. His SF level was 29 μg/L. CMRI, previously contraindicated due to the implanted ventricular assist devices, 20 months after he presented with severe biventricular heart failure, demonstrated T2* time had returned to normal in the myocardium (41 milliseconds) and liver (19 milliseconds). The study also demonstrated normal biventricular function with mild biventricular dilatation and the absence of myocardial fibrosis. He remains on insulin and testosterone replacement and 3-monthly venesections were commenced.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3307_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3307_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..daa86854878d9351649781b75edf5aeb255ce4b5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3307_en.txt
@@ -0,0 +1,3 @@
+A 68-year-old man was admitted to our hospital with dyspea and general fatigue in July 2018. He was diagnosed with acute decompensated heart failure due to ischemic cardiomyopathy. The patient had a history of severe coronary heart disease and chronic kidney disease (CKD Stage II-III). During his last hospitalization in 2017, Coronary angiography showed severe triple vessel coronary artery disease, he refuse revascularization therapy. Holter revealed paroxysmal ventricular tachycardia and frequent ventricular premature beats, so he received implantable cardioverter defibrillator (ICD) treatment. Aspirin, atorvastatin, furosemide, spirolactone, perindopril and metoprolol were taken regularly at home. On the current admission, his blood pressure and heart rate were 135/82mmHg and 75beats/min respectively. A S3 and systolic murmur were identified alone with inspiratory moist rales in the bilateral lung fields with slight edema of both lower limbs. The first laboratory values were as follows: white blood cells, 8.060/uL; hemoglobin, 14.6 g/dL; serum creatinine, 160 umol/L (estimated glomerular filtration rate 38 ml/min/1.73 m2);blood urea nitrogen 12.0 mol/L, serum sodium, 137mmol/L; serum potassium, 3.84 mmol/L; amino-terminal pro-B-type natriuretic peptide (NT-proBNP), 25,000 pg/mL; cardiac troponin 0.11 ng/mL. Electrocardiogram revealed a sinus rhythm with a heart rate of 75 beats per minutes, ventricular premature beats, non-specific ST-T changes.
+
+Chest X-ray showed cardiomegaly, left small pleural effusion and pulmonary congestion. Echocardiography demonstrated a sever left ventricular enlargement with decreased systolic function (left ventricular end-diastolic diameter, 65 mm; left ventricular ejection fraction, 28%), diffuse ventricular wall motion decrease, severe mitral regurgitation and moderate tricuspid regurgitation. The estimated pulmonary arterial pressure was 52 mmHg. The patient was diagnosed with acute decompensated heart failure caused by volume overload. In the initial treatment, intravenous loop diuretics and nesiritide were administrated as well as traditionally prescribed drugs. Because the patient was critically ill with heart failure and he was insensitive to intravenous diuretics, the patient's clinical symptoms did not improve significantly and his urine volume did not increase either. Therefore, diuretic resistance could be considered. In order to improve fluid retention and relieve his dyspnea, low-dose TLV (7.5 mg qd) was performed on day 3. The administration of TLV dramatically relieved dyspnea and increased urinary output. Cardiac rehabilitation was started gradually. Unfortunately after 3 days treatment of TLV, we observed that he became delirious and his limbs shook uncontrollably. High serum sodium 173 mmol/L was noted compared to the results of the first examination (137 mmol/L). Severe hypernatremia was diagnosed. Because no other medications were changed, we did not strictly require patient to control the fluid intake, and no other medication could cause elevation of serum sodium, we suspected a high sensitivity to the side effect of TLV. Hence, we stopped the use of TLV and encouraged patient to drink plenty of water, gastric tube was inserted orally to increase the intake of fresh water. After intensive rescue, serum sodium was restored to normal (135 mol/L) on day 10. The clinical data was as follows: white blood cells, 4, 010/uL; hemoglobin, 14.2 g/dL; serum creatinine, 104 umol/L (estimated glomerular filtration rate 62 ml/min/1.73 m2); blood urea nitrogen 10.7 mmol/L, serum sodium, 135 mmol/L; serum potassium, 4.01 mmol/L; amino-terminal pro-B-type natriuretic peptide (NT-proBNP), 3280 pg/mL; Although the patient's laboratory results and clinical symptoms improved, he still needed intravenous diuretics to maintain liquid output. But he remained insensitive to them. Later, when the patient refused continuous renal replacement therapy (CRRT), we tried again to use a lower dose of TLV (3.75 mg qd) to improve diuretic resistance. 2 days later, Serum sodium rose again (162 mmol/L). We had confirmed that hypernatremia was caused by TLV. After the suspension of TLV, his serum sodium decreased to 138 mmol/L gradually, psychiatric symptom recovered. In order to maintain the patient's urine volume, We had to give the patient a larger dose of intravenous loop diuresis and nesiritide . During this period, the patient's overall condition was stable. He was discharged on the 21st day after admission. After hospital discharge, patient eventually died of cardiac arrest due to critically ill heart failure.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3355_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3355_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..69773f513927e1aff7352209c4133a6334b78977
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3355_en.txt
@@ -0,0 +1,7 @@
+We report here a 6-year-old girl came to the outpatient department of Mogadishu Somali Turkey Hospital complaining of voice changes (deepening), extensive overweight, excessive hair growth over the body and clitoromegaly for one year. Initially, her mother was noticed that she had weight gain and her clitoris was more protruded than the normal until become elongated and enlarged associated with labial enlargement. Within one year, throughout the body, hair grew, especially chin and pubis, and bad smelling odor and revealed male characterization.
+
+On examination, her height was 1.0 m, her weight was 60 kg, and her blood pressure was 190/150 mm Hg (refractory hypertension). She had cushingoid facies, signs of virilization in the form of pustular acne, hirsutism (axillary and facial hair), and clitoromegaly. She also had an unpleasant body odor. On palpation, she had a palpable mass on the right side of her abdomen. In laboratory investigations, elevation of Dehydroepiandrosterone sulfate (DHEA-SO4) 419.03 µg/d (normal range 24.4–209.7 µg/d) indicating production of excess hormones related to adrenal tumors. Other hematological and biochemical parameters were normal.
+
+As usual in pediatric cases, in the beginning, an abdominal ultrasound (US) was performed, showing a well-defined adrenal mass with a slightly heterogeneous mix of hyper- and hypoechoic consistency with smooth margins. For further investigation and lesion characterization, computed tomography (CT) of the abdomen has done, revealing that the right adrenal fossa well-defined a 6 cm sized mass lesion with heterogeneous contrast enhancement containing hypodense necrotic areas and slightly displaces right kidney inferiorly. To bring her blood pressure back into normal range, the child was admitted to the intensive care unit two days before the operation.
+
+A diagnosis of an adrenocortical tumor was made. Correction of general condition was done. Details about the disease, plan of management, and risks were explained to the parents. After written consent and pre-anesthetic checkup, during the surgery, a Makuuchi incision was made to the patient’s abdomen. Next, the solid mass was excised by means of unilateral right adrenalectomy. Then, abdominal layers were repaired using a vicryl 1. And the mass was sent for histopathological study. Histopathological diagnosis was made using the Li-Weiss-Bisceglia criteria. The histological features of the current case are indicated. Microscopic examination revealed >75% oncocytic cells, diffuse architecture (>33% of tumor) and high nuclear grade. In addition, Ki-67 proliferation index was calculated as 15–20%. According to these findings, the case was diagnosed with oncocytic ACC. The patient was admitted, and appropriate post-operative care was given. And discharged after one week with good condition and oral medications were given. Corticosteroid drugs were started with a high dose and the dose was gradually reduced. And all the symptoms disappeared 6 months after the operation.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3356_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3356_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..03557c9c1dfd21a3634bb4a1cfd18e82f9af2f65
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3356_en.txt
@@ -0,0 +1,21 @@
+A 56-year-old male at the age of 49 years developed a cerebral stroke which resolved spontaneously within a few days leaving no permanent damage and a magnetic resonance (MR)-scan was not performed. The patient had no cardiovascular risk factors apart from family history of ischemic heart disease.
+
+Ten weeks later, the patient presented with third degree atrioventricular block (AV)-block initially thought to be associated with an acute Borrelia infection. However, the AV-block persisted despite antibiotic therapy and a dual-chamber pacemaker was implanted.
+
+During hospitalization, the patient complained of fatigue, weight-loss, and night sweating; blood analyses demonstrated a sedimentation rate >100 mm/hr and anemia with a hemoglobin of 5.0 g/mL, thrombocytosis of 615×109 cells/L and C-reactive protein (CRP) of 95. There was no leukocytosis. Gastrointestinal hemorrhage was not suspected due to lack of symptoms from the gastrointestinal tract. The patient was 4 months later diagnosed with an ANCA positive vasculitis due to malaise, low grade fewer, arthritis, sinusitis (biopsy with acute and chronic inflammation, but no necrosis, granulomas or vasculitis signs), interstitial lung disease (ground-glass phenomenon in both lungs on high resolution computed tomography (HRCT) scan (biopsy was not performed) and myeloperoxidaseantineutrophil cytoplasmic antibody (MPO-ANCA) positivity. There were no signs of mononeuritis multiplex, asthma, involvement of skin, kidneys, brain, or gastrointestinal canal. The Birmingham Vasculitis Activity Score (BVAS) score was 15.
+
+The patient underwent treatment with steroids (for 6 months) and methotrexate, and the vasculitis remission was achieved including normalization of MPO-ANCA levels. After 2 years methotrexate monotherapy was discontinued.
+
+After 1 year, the patient presented with respiratory tract symptoms including dyspnea and increasing MPO-ANCA levels. Consequently, steroid and methotrexate therapy was resumed. However, the patient did not improve in respiratory symptoms and the patient was referred for a multidisciplinary examination, including a cardiac, pulmonary, and rheumatic evaluation. The cardiac evaluation included a normal echocardiographic examination with a preserved left ventricular (LV) function, no signs of pulmonary hypertension and a mild-to-moderate aortic regurgitation determined by transthoracic echocardiogram (TTE).
+
+A treadmill exercise test was performed demonstrating severely reduced functional capacity with a peak exercise of 113W (52% of expected) and an adequate chronotropic response. A pulmonary functional test was performed demonstrating severe obstructive pulmonary disease with forced expiratory volume in one second (FEV1) of 1.1 L (29% of predicted), forced vital capacity (FVC) 3.0 L (63% of predicted), a diffusion capacity of 66% and a Tiffeneau-Pinelli index of 37%. A ventilation/perfusion lung scan was performed demonstrating bilateral pulmonary embolisms. In addition, an HRCT was performed demonstrating ground glass phenomenon in both lungs. Testing for thrombophilia and antiphospholipid antibodies revealed no abnormality. BVAS score was 13. Anticoagulant therapy (rivaroxaban) was added to the treatment with methylprednisolone (3 pulses), prednisolone, methotrexate and bronchodilators (LABA/LAMA combination).
+
+During the following 12 weeks, the patient’s dyspnea worsened, and a new echocardiographic examination demonstrated a dilated left ventricle with reduced LV function with an ejection fraction (EF)=30% to 35%; and on this basis, the dual-chamber pacemaker (PM) was upgraded to a cardiac resynchronization therapy (CRT)-PM. As a result of symptomatic improvement of dyspnea after dual-chamber implantation, aortic valve replacement was not relevant.
+
+The patient was closely monitored at the Pulmonology Center for interstitial lung disease, at the Rheumatology Center for connective tissue diseases and at the Department of Cardiology. A development of pneumonia was treated successfully with antibiotics.
+
+After 12 weeks, a new cardiac examination was performed. Transthoracic echocardiography showed a dilated left ventricle and a transesophageal echocardiography showed a tricuspid aortic valve in which the right coronary cusp was immobile/fixed and edematous causing a severe insufficiency with a vena contracta between 8 mm and 9 mm.
+
+We assessed that the substantial cause of dyspnea was due to severe aortic regurgitation. On this basis, the patient was assigned for thoracotomy and implantation of an aortic valve bioprosthesis. Histological analysis of the resectates of aortic cusps showed that 2 of these cusps contained fibrosis and myxoid degeneration. The last of these cusps contained inflammatory alterations, fibrosis, and thickening. An abundance of lymphocytes and plasma cells were evident as well as thickened vessels and granulomatous structures.
+
+After uncomplicated surgery, an intermittent fast atrial flutter was diagnosed. After amiodarone loading, beta blocker initiation, and reprogramming of the pacemaker to DDI mode, ventricular frequency was normalized, and improvement of dyspnea was seen.
\ No newline at end of file
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3360_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3360_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..0505cabeec9ca55a94e9691b45a72a7246347d60
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3360_en.txt
@@ -0,0 +1,17 @@
+A 43-year-old female presented in outpatient clinic with a history of a left adnexal cyst associated with foul-smelling PV discharge for the past 3–4 months. The patient was also under medication, tab. Thyroxine sodium-50 μg per day for hypothyroidism since 2 years. Physical examination revealed no abnormalities on per-abdominal assessment. The lesion in the liver was accidental finding during the ultrasonography of the abdomen and pelvis. Ultrasonography (USG) and CT scans identified a 9 × 8.7 × 8.4 cm well defined hypodense lesion in the right lobe of the liver, with a differential diagnosis of focal nodular hyperplasia in CT scan. The patient got admitted and surgery (hemihepatectomy) was done.
+
+Histopathological findings
+In pathology department, a hemihepatectomy specimen was received. Gross examination of the specimen revealed a well-defined nodular growth measuring 9 × 7 × 5 cm within the liver, with a cut surface displaying a grey-white to brownish appearance. No areas of necrosis were observed.
+Microscopic examination of multiple sections from the tumor mass revealed a well-circumscribed lesion characterized by spindle-shaped tumor cells arranged in fascicles and concentric pattern around numerous thin-walled capillaries. The tumor cells were exhibiting elongated nuclei and moderate cytoplasm. No atypia, mitosis, or necrosis were observed. All submitted margins were free of tumor cells. Surrounding liver parenchyma did not reveal any significant morphological changes.
+
+Immunohistochemistry
+Immunohistochemical staining done were Smooth Muscle Actin (SMA), h-Caldesmon, Desmin, CD34, STAT6, DOG1, S100 and ALK. Our differentials include neural tumors like schwannoma, so S100 was negative, solitary fibrous tumors, CD 34 and STAT6 were negative and vascular tumor, CD 34 was negative. Positivity for SMA and h-caldesmon, confirmed the myopericytic nature of the tumor. CD34 highlighted blood vessel endothelial cells. DOG-1, ALK and Desmin were negative, which ruled out the close differentials like GIST, Inflammatory myofibroblastic tumor and leiomyoma and further supporting the diagnosis of myopericytoma.
+
+Diagnosis
+Based on the clinical, radiological, and histopathological findings, the diagnosis of myopericytoma of the liver was established.
+
+Therapeutic intervention
+Based on the radiological findings, hemihepatectomy was already done. No further intervention was needed after histopathological report.
+
+Follow-up and outcomes
+As the lesion was benign and completely resected, the patient was completely recovered. There were no clinical signs and symptoms related to disease and ultrasonography of the abdomen and pelvis was normal on follow up at 6th months.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3362_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3362_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b632e354d03fc2e2e29ea7c3be388a63451c68a1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3362_en.txt
@@ -0,0 +1,10 @@
+An 82-year-old patient was referred to our clinical immunology department – internal medicine for advice regarding a possible systemic disease. Her main medical history included a Horton disease diagnosed in 2006, for which she received long-term corticosteroid therapy, which was permanently discontinued in 2021, and a pancreatitis of undetermined etiology in 2011.
+The current story began in 2021, with the incidental discovery of multiple hepatic nodules that led to a first liver biopsy in a peripheral hospital. The pathological examination was in favour of ischaemic necrosis lesions of undetermined origin. A few days after the biopsy, the patient presented hepatic cytolysis at 20 times the normal, without cholestasis, with a spontaneous and rapidly favourable evolution, but also with intense pruritus, persisting after several weeks. The diagnosis of prurigo nodularis was made by dermatologists. Dupilumab treatment was then initiated in this indication.
+The patient was re-admitted in July 2022 due to the discovery of hyponatraemia on a follow-up assessment. The abdominal scan showed the persistence of hepatic nodules, motivating a second liver biopsy whose results confirmed an aspect of ischaemic necrosis, as well as a few contributing factors. The thoraco-abdomino-pelvic scan showed a lower right lobar pulmonary image evoking a pulmonary infarction in the first place, as well as a calcifying chronic pancreatitis. The Pet-scanner (18F-FDG) found a moderate hypermetabolism of the pulmonary lesion, leading to the realization of a biopsy in September 2022, showing chronic fibro-inflammatory changes with epithelioid and gigantocellular granulomas very focally necrosing. Bronchoscopy was without particularity and all infectious samples and especially mycobacterial cultures were negative. A tuberculosis was however evoked in view of the whole picture, and a test antituberculous treatment was started at the end of the year 2022, quickly complicated by a cutaneous reaction with pancreatitis and medicinal hepatitis motivating the cessation of treatment.
+She was referred to us in this context for a diagnostic and therapeutic opinion. She was receiving treatment with perindopril, bisoprolol, levothyrox, magnesium, oral iron, and dupilumab (300 mg subcutaneously every two weeks) at the time of the consultation. Her main complaints were persistent asthenia and the reappearance of severe pruritus for several months with dupilumab. She remained very active, however, with estimated walking distance of 10 kilometres per day. She had gained weight since the last hospital admission. She did not have fever or night sweats. The clinical examination was without notable anomalies.
+Biologically, the NFS was unremarkable, CRP negative. Renal function and liver profile were normal, no electrophoresis peak, no hypo- or hypergammaglobulinemia. IgG4 was elevated at 2.21 g/L (N < 1.03 g/L). Autoimmune profile including antinuclear antibodies and ANCA was negative. There was no biological argument for granulomatosis (low ACE, 1.25-OH vitamin D in the norm). Quantiferon was negative. There was no significant proteinuria.
+Following the consultation, the diagnosis of tuberculosis was ruled out by the panel. A thoraco-abdomino-pelvic control scan was performed, revealing the presence of irregular and retractable lower right lobar alveolar condensation of 35 mm. In the abdominal level, there was a general stability of all known hypodens liver nodules. A liver MRI was performed as a complement, without additional diagnostic contribution, including after a specialised re-reading of all previous imaging.
+
+In the case of an IgG4-associated disease, a re-read of the biopsy pieces was also requested, with additional IgG4 marking. The re-read of the pulmonary biopsy confirmed a chronic granulomatous, epithelioid and gigantic cellular inflammation, which was focally necrotic. The re-read of the hepatic biopsies was in favour of foci of non-tumour necrosis with inflammatory fibrosclerous shell, rich in IgG4 plasma cells, with an IgG4/IgG ratio > 40. However, the overall aspect was not in favour of an IgG4-associated disease, due to the absence of a storiform fibrosis or obliterative phlebitis, and the non-classical presence of a granulomatous epithelioid inflammation in the course of this disease.
+The patient was re-admitted to hospital to discuss a new pulmonary biopsy, especially for the purpose of microbiological documentation, in order to exclude a tuberculosis with certainty in the absence of an alternative diagnosis. During the hospital stay, a complete infectious assessment was proposed. Finally, echinococcosis serology was positive in Western blot with a single band at 7 kDa, not allowing a species diagnosis (ELISA Em2+ and Em18 negative). The performance of molecular biology examinations was not possible at that time due to a failure to preserve the biopsy samples. In the case of an alveolar echinococcosis, treatment with albendazole was introduced in March 2023 in consultation with the infectiologists, and treatment with dupilumab was stopped.
+During follow-up, the patient developed a hepatic intolerance to albendazole treatment, then to mebendazole introduced in August 2023 (resolutive cytolysis at the end of treatment), as well as a hyper-eosinophilia. A control scan carried out in January 2024 showing an increase in size of the hepatic lesions, a new hepatic biopsy was proposed. The histology showed essentially a chronic non-specific inflammation, but the PCR E. multilocularis was positive, allowing the diagnosis of alveolar echinococcosis to be confirmed definitively.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3390_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3390_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..01f7bd7290809427a49a02d2c4f2749f161783ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3390_en.txt
@@ -0,0 +1 @@
+Female, 50 years old, admitted for dyspnoea associated with a week-long history of antiphospholipid syndrome, lymphoma B-type of parotid gland (free of disease), SARSCoV-2 mild, resolved without need for admission, and placement of a pin and crown three weeks prior to consultation. The patient did not report allergies or intolerances to any medication. She was using acenocoumarol 2 mg daily and clonazepam 2 mg at night. On physical examination, she was lucid, saturation 93% ambient air with correction to 98% with oxygen cannula of 2 liters per minute, tachycardia (heart rate = 120 beats/minute), no tachypnoea (respiratory rate = 18 respiratory cycles/minute). Good ventilatory mechanics with hypoventilation in the left lung. She was admitted to the general admission ward for diagnosis and treatment. Blood cultures were taken and were positive for Staphylococcus aureus sensitive to methicillin (SAMS). A chest X-ray was requested and showed bilateral pleural effusion with a predominant left side. A thoracentesis was performed and a pleural effusion was found with 6 mm vegetation on the mitral valve. Antibiotic treatment with cefazolin 2 g every 8 hours was initiated. She required pulmonary decortication and laminectomy plus drainage of a bilateral pleural effusion. After 48 hours of initiating treatment with cefazolin, a gradual decrease in platelets, leukocytes and red blood cells was observed without apparent clinical repercussion. On day 14 of treatment, she presented with a tricytopenia (leukocytes = 2400/µl, haemocrit = 26%, platelets = 106 000/µl), so a peripheral blood smear was performed that did not show immature elements. The temporal evolution of the blood series was observed, and on day 19, a marked tricytopenia was found. Given the existence of publications that describe cytopenia secondary to cephalosporins6, cefazolin was discontinued and it was decided to continue treatment with vancomycin 1 g every 12 hours. However, it had to be discontinued 48 hours later due to acute renal injury (glomerular filtration rate - GFR = 39.8 ml/min/1.73m2 for a previous value of 217 ml/min/1.73m2). Antibiotic treatment with daptomycin 10 mg/kg/day was initiated. After seven days of initiating the same, the CPK control value was 70 488 U/L (previous value = 105 U/L). At that time, renal function had improved with creatinemia of 0.98 mg/dL and GFR of 60.1 ml/min/1.73m2. Although the patient did not present myopathy symptoms or new renal impairment, it was decided to rotate daptomycin to linezolid 600 mg every 12 hours orally. Two days after initiating said antibiotic, a change in the hepatic panel was observed with elevation of hepatic transaminases (GOT = 698 U/L and GPT = 296 U/L) from previous normal values (GOT = 14 U/L and GPT = 6 U/L). Cefazolin was discontinued due to hepatoxicity associated with it. After two days without active antibiotic treatment, an improvement in the hepatic panel was observed (GOT = 171 U/L, GPT = 180 U/L) and, due to clinical stability, the patient was discharged with a cotrimoxazole 160/800 mg indication every 8 hours orally as an outpatient treatment and control by external consultations with the objective of completing 8 effective weeks of antibiotic treatment. After 12 days of discharge and still on active antibiotic treatment, the patient attended the hospital after falling from her own height with a traumatic encephalocranium, without loss of consciousness. A subdural haematoma was observed in a brain tomography and thrombocytopenia was detected in the laboratory (3000/µl) associated with leucopenia (leucocytes = 900/µl), so it was decided to re-admit the patient. Considering her background, having overcome the cytopenias associated with cefazolin and the chronology of findings, it was interpreted that the bicytopenia could be due to cotrimoxazole treatment, so it was discontinued. In Table 1, the laboratory parameters associated with the different treatments are detailed for each admission. Finally, once the subdural haematoma was resolved and the laboratory findings improved, the patient was discharged from the second admission with antibiotic treatment with clindamycin 600 mg every 12 hours orally, being able to resolve the endocarditis without new RAM. In all cases, drug interactions that could explain what was observed were discarded, and RAM was reported to the national pharmacovigilance system.
diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_346_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_346_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..28380550dc8afedab8644133d2750afd3c63426d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_346_en.txt
@@ -0,0 +1,3 @@
+A 67-year-old male patient was admitted to the hospital with new onset fever, chest pain and dyspnea for 7 days and previous diagnose of right lung squamous cell carcinoma. His previous medical history was notable for right lung squamous cell carcinoma stage IV (T3N3M1) complicated with mediastinal lymph nodes and liver metastasis 1 year before. Cardiac and pulmonary function was normal at that time. Four cycles of chemotherapy with paclitaxel-cisplatin regimen was initiated but afterwards stopped due to 2019 coronavirus outbreak. Ten months thereafter, he was admitted to the hospital because of right massive pleural effusion. Twice bacterial culture of pleural effusion displayed Prevotella nigrescens, indicating right lung squamous cell carcinoma complicated with empyema. With subsequent treatment of meropenem as the anti-bacterial agent, his symptoms were relieved and his temperature was normal. As a result, chemotherapy was discontinued and replaced with PD-L1 immune checkpoint inhibitor, durvalumab monotherapy for four cycles (500 mg intravenous drip). And he presented with the symptom of fever, chest pain and dyspnea 7 days after last cycle of durvalumab. Moreover, the previous medical, family, and psychosocial history as well as genetic information showed nothing special.
+Physical and laboratory examination was done for the patients upon this admission. The highest temperature was 39.4°C. His blood pressure was 121/69 mmHg. Chest computed tomography (CT) examination indicated right bronchial obstruction, obstructive pneumonia and right pleural effusion . Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 46 mm), increased atrium size (left atrium dimension LA 36 mm) and markedly decrease cardiac ejection fraction (left ventricular ejection fraction 41%), tracing 2 mm pericardial effusion . The electrocardiogram showed sinus tachycardia, low voltage of limb leads, T wave inversion in anterior waves and V1–V3 QS type . Markers of myocardial injury were elevated: Natriuretic peptide BNP 18 942 ng/L; Troponin T 0.066 ng/L; Troponin I 200.83 ng/L; Creatine kinase (CK) and Creatine kinase isoenzyme (CKMB) normal. Moreover, inflammatory indicators were significantly elevated. Erythrocyte sedimentation rate (ESR) was markedly increased with the level of 101 mm/h, and C-reactive protein (CRP) 268.2 mg/L. Interleukin-6 was 44.93 pg/mL.
+Judging by the decreased cardiac function and elevated myocardial injury markers at this admission, the patient was diagnosed of acute immune-associated myocarditis and right lung squamous cell carcinoma complicated with empyema. Treatments included methylprednisolone to suppress inflammation (40 mg, once per day, iv), meropenem to control infection (1.0 g, q8h, iv.drip) and symptomatic and supportive treatments. Seven days after admission, the patient's symptoms were relieved. Myocardial injury and inflammation markers were significantly decreased: Natriuretic peptide BNP was down to 2,298 ng/L; Troponin T, Troponin I, CK and CKMB normal; ESR 41 mm/h; CRP 29.8 mg/L; and Interleukin-6 normal. The electrocardiogram showed normal sinus rate and V2–V5 T wave inversion . Echocardiography revealed ventricle size within normal range (left ventricle end diastolic dimension 48 mm), increased atrium size (left atrium dimension LA 30 mm) and markedly recovered cardiac ejection fraction (left ventricular ejection fraction 66%). The patient was discharged with prescription of continuing oral methylprednisolone (20 mg, once per day, po) and anti-bacterial therapy of faroenem to control infection (150 mg, q8h, po). No further heart failure exacerbations have occurred to date.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_348_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_348_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..40a496bc9e9b741ab14897761865c40e4eaedef8
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_348_en.txt
@@ -0,0 +1,3 @@
+A previously healthy 60-year-old female seeking medical attention through teleconsultation presents with profound dyspnea, oppressive chest pain, fatigue, episodic hallucinations, and difficulty sleeping. The patient describes that her symptoms began 7 days ago with non-productive cough and fever, later progressing to dyspnea that exacerbated with minimal effort, for what she originally sought medical attention at an ER. At the ER triage the patient presented with profound dyspnea, an oxygen saturation of 86% at room air, and a respiratory rate of 32 breaths/min. However, despite the severity of the respiratory compromise, the patient could not be admitted due to hospital oversaturation. Unfortunately, the patient was sent home with medical recommendations, including nebulization with normal saline, acetylcysteine and ambroxol hydrochloride. She was also advised that a chest CT scan was needed.
+At the medical teleconsultation, the patient presented marked respiratory distress accompanied with a respiratory rate of 31 respirations per minute, and an oxygen saturation of 85% at room air. A relative of the patient described what is compatible with skin and mucous membrane dryness, skin pallor and bilateral 1+ pitting edema. The patient handed-off a copy of the CT scan where bilateral pulmonary edema and consolidations with ground-glassing were observed encompassing nearly 90% of the lung parenchyma . A basic panel of laboratory tests, and a PCR test for COVID-19 were ordered, the latter of which confirmed the diagnosis . She was prescribed with IV normal saline for rehydration, pharmacologic management with IV methylprednisolone (250 mg every 24 h for 3 days), followed by prednisone (40 mg for 7 days), nitazoxanide (500 mg every 8 h) for 7 days and a single dose of 40 mg of subcutaneous enoxaparin, all of which were administered by an outpatient registered nurse at home. Standard oxygen therapy through nasal cannula was also recommended. Medical treatment is best depicted in Fig. . Colchicine was added at the third day of treatment (2 mg loading dose, followed by 0.5 mg every 8 h up to the end of treatment).
+Daily follow-ups were established to monitor for signs of clinical improvement. Two weeks later from the initial consultation the patient presented marked improvement in her symptoms, as well as in her CT scan , which prompted in discontinuation of the medications and the oxygen therapy. At one-month follow-up the patient presented a nearly complete resolution of the initial symptoms, with a partially restored capacity to perform her daily activities. At the 45th day a negative PCR test for the viral RNA was reported. However, spirometry and diffusion capacity for carbon monoxide (DLCO) at 3rd, 4th and 6th months showed results compatible with a restrictive pattern evidenced by reduced FVC, FEV1 and DLCO measurements with respect to predicted values , while the 6-min walk test showed a decreased walking distance. Radiographic changes persisted at the 6-month follow-up chest CT scan .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_353_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_353_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..69457098401e737a310bc9849de5bf26dd780eb2
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_353_en.txt
@@ -0,0 +1,2 @@
+The patient, a 58-year-old male, was admitted to the hospital on November 10, 2021, due complaining of fever for 7 days. There was no family history. On November 2019, he was diagnosed with B-cell acute lymphoblastic leukemia and received multiple chemotherapy sessions, during which his bone marrow was retested as minimal residual disease-negative complete remission (MRD-negative CR). On November 26, 2020, the patient underwent allogeneic HSCT and received treatment such as leukocytosis, GVHD prophylaxis, and infection prophylaxis. On December 29, 2020, he developed thrombocytopenia and was treated with platelet transfusion after repeatedly rechecking bone marrow CR and MDR, and the results were negative and complete implantation of FISH donor. Fever occurred repeatedly in February, March, and May 2021, and after anti-infection, anti-fungal, and anti-viral treatment, the patient improved and was discharged.
+7 days before admission, the patient developed a fever with the highest temperature of 39.3°C. He was hospitalized again in a tertiary hospital in Guangzhou, and the chest CT showed multiple inflammations in both lungs . He was given anti-infections such as imipenem/cilastatin, caspofungin, and liposomal amphotericin B, but he still had recurrent fevers. After completing the tracheoscopy, the bronchial fluid was found positive for MTB complex nucleic acid, and MTB was detected again in the NGS. Based on the above clinical data, the patient was considered to be post-HSCT TB, and he was admitted to our hospital after consultation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_362_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_362_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d67592d1012d71fa98fdf3b735354abd5eae3c37
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_362_en.txt
@@ -0,0 +1 @@
+A 31-year-old man suffered an out-of-hospital cardiac arrest during the night while asleep. His girlfriend started CPR immediately. Upon arrival of the emergency medical team, the patient was found in VF and defibrillation could restore spontaneous circulation. He had no significant past medical history and was taking no medications. Family’s medical history revealed that the patient’s sister had implanted a pacemaker due to sick-sinus syndrome, at the age of 22 years. Plasma electrolyte levels, including potassium and calcium, were within normal ranges. Toxicological screening was negative. The ECG at presentation showed sinus rhythm and an ER pattern with substantial J-point elevation in most of the ECG-leads with notching of the terminal part of the QRS complex in the lateral leads and slurring in the inferior leads . Coronary angiography revealed an anomalous origin of the left anterior descending (LAD) coronary artery arising from a separate ostium of the right sinus of Valsalva without any other concomitant congenital anomaly. In the absence of neurological recovery or purposeful movements, a targeted temperature management protocol with a goal temperature of 36 °C was started in the intensive care unit . Three hours later, the patient began to experience very frequent episodes of spontaneous VF. The episodes of VF were induced by short-coupled monomorphic premature ventricular complexes (PVC) falling into the vulnerable descending part of the T-wave . The PVCs showed a right bundle block morphology in V1 and a right-inferior axis in the limb leads, suggesting an origin in the left anterior fascicle. The patient was shocked for more than 10 VF episodes, but the PVC kept reoccurring, sometimes just a few beats after cardioversion . The patient’s condition was finally stabilized by isoproterenol infusion, which successfully suppressed the PVC’s at higher heart rates in sinus rhythm. During the course of the isoproterenol infusion, a reduction of the ER pattern on the 12-lead ECG was observed . Compared to the ECG at presentation the notch in the lateral leads disappeared and the slur in the inferior leads was markedly attenuated. Remarkably, new T wave inversions were present, possibly attributed to cardiac memory. Two days later, the patient was extubated and showed a good neurologic recovery. Cardiac magnetic resonance (CMR) imaging demonstrated normal cardiac structure and function and no late gadolinium enhancement. Regarding the anomalous origin of the LAD from the opposite sinus CMR revealed an interarterial course, in which the LAD passes between the aorta and pulmonary trunk. The left circumflex (LCX) artery was located in its usual expected position at the left sinus of Valsalva . A dual chamber ICD was implanted allowing for continued atrial pacing. A myocardial perfusion imaging with bicycle exercise stress testing was performed four weeks after the hospitalization and showed no signs of ischemia. The patient has not experienced any further arrhythmias during the first two months of follow-up.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_377_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_377_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..d2fd48777d26abf119094bbe35317171f553a0bc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_377_en.txt
@@ -0,0 +1,10 @@
+A 58 year-old gentleman presented to the hospital with worsening bloating and a gradual increase in his abdominal girth. He had also noted a loss of weight of more than 10 kg over the last 2 years. The patient otherwise denied any abdominal pain or change in his bowel habit. He was known to have a history of well-controlled diabetes mellitus, hypertension, hyperlipidaemia and atrial fibrillation. There was no previous history of pancreatitis or abdominal surgery. The patient had recently undergone a gastroscopy and colonoscopy the previous year for iron deficiency anaemia. This had shown gastritis as well as the presence of pandiverticular disease and a sub-centimeter colonic polyp. Histology showed the polyp to be a tubular adenoma with low-grade dysplasia (, , , , , ).
+Clinical examination showed an adequately nourished gentleman but with a large abdominal mass occupying most of his abdomen. It was possible to feel over the superior edge but the inferior edge extended into the pelvis. The mass was non-tender on palpation. Digital rectal examination was unremarkable.
+In view of the above findings, the patient underwent a computed tomography (CT) of the abdomen and pelvis. This showed a large 25 × 17 × 22 cm cystic lesion extending from the mid-abdomen to the pelvis. The lesion was thin walled and contained homogenous low density fluid (14 Hounsfield unit). There was no septations, irregularity or abnormal thickening of the cyst wall. The cyst was noted to have a mass effect but not invading the surrounding bowel loops and the urinary bladder. It was found to be separate from the liver and the kidneys. The pancreas was normal in appearance. The CT scan was otherwise unable to identify the origin of the giant cyst.
+As this was a thin walled cyst with no irregular or solid component, a fine needle aspiration (FNA) was not suitable as there was no specific area to target. Aspiration of the fluid was also unlikely to yield any meaningful finding for diagnosis. Further imaging such as a MRI would also not help in identifying the origin or the diagnosis of the cyst. The possibility of a mesenteric or omental cyst was therefore discussed and surgical excision was offered to the patient. Tumour markers were not performed as it would not have affected the management.
+An elective exploratory laparotomy was performed via a midline incision. A giant cyst was immediately identified but was found to have multiple adhesions to the peritoneum, omentum, mesentery, urinary bladder as well as the small and large intestines. However, the cyst was not found to be originating from any of the above organs or the vas deferens. The cyst was entirely within the abdominal cavity and did not originate from within the mesentery. A controlled decompression of the cyst was made through a purse-string encircled incision in the anterior wall. This was performed to aid with retraction and visualization of the posterior surface. Thick purulent fluid was aspirated until dry. The cyst was subsequently excised in whole.
+The patient underwent an uneventful recovery with a brief period of expected post-operative ileus. He was discharged on post-operative day 6. Follow-up visits showed complete resolution of his initial symptoms and a vast improvement in his appetite.
+Culture of the fluid was positive for Streptococcus agalactiae. Fungal culture and tuberculosis polymerase chain reaction (TB PCR) tests were negative. Cytology of the fluid showed mainly neutrophils.
+Histological examination of the cyst showed thick fibrous walls covered with coarse fibrillary strands admixed with fibrin. There were also large numbers of mature IgG plasma cells with aggregates of neutrophils and scattered lymphocytes. No viable epithelial lining was identified. The walls stained positive for AE1/3 suggesting myofibroblasts. They were negative for CD117 and DOG-1 and therefore not suggestive of a gastrointestinal stromal tumour.
+This was therefore treated as a benign cyst of an undetermined origin.
+The patient was last seen in clinic two months after his surgery with a significant improvement in his appetite and oral intake. He was thereafter discharged from follow-up as the likelihood of recurrence was low considering that the cyst had been excised entirely with no remnant wall left behind.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_398_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_398_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..585b9a32395af6009f670c4d27cd49f680907f7e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_398_en.txt
@@ -0,0 +1,3 @@
+In 2019, a 69-year-old Italian woman presented to our ENT Clinic with a 1-month history of sore throat. She was a smoker with the consumption of 15 cigarettes per day for several years. As for the rest, her past medical history was unremarkable.
+So, a nasopharyngoscopic examination was performed with the incidental finding of multiple, grey-brown, irregular and slightly elevated lesions, ranging from 2 to 4 mm in the maximal diameter, with clearly identified margins, near the right Eustachian tube opening .
+The overlying mucosa was intact, without signs of necrosis or bleeding when touched. Melanoma, melanosis or malignant tumour were suspected on macroscopic evaluation. Examination of neck, nasal cavity and larynx didn’t reveal abnormalities. Under local anaesthesia, one of the larger lesions was biopsied for histological assessment. The surgical specimen was a single, grey-brown, mucosal piece measuring 0.2x0.2x0.1 cm. Microscopic examination revealed a well demarcated lesion, covered by normal respiratory epithelium and composed by several seromucinous glands with diffuse oncocytic metaplasia. Moreover, scattered brown pigments was found in the cytoplasm of oncocytic cells. They were positive for Fontana-Masson staining and negative for Pears’s ones, confirming the melanin nature. There weren’t either cytological atypia nor mitotic figures in the epithelial cells of the glands. Immunohistochemically, dendritic cells were immunoreactive to S-100 protein and negative for HMB-45. Thus, based on these findings, the lesion was assessed as melanotic oncocytic metaplasia of the nasopharynx. Considering the benign nature of MOM, other similar lesions around the right Eustachian tube opening weren’t excised but only followed with periodic nasoscopic examinations. As previously stated, after diagnosis, the patient was controlled with nasopharynx endoscopy each three months. Thus, at nine-month follow-up, lesions in nasopharynx, near the right Eustachian tube opening, were unchanged, without progression to malignancy.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_399_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_399_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..5020d5ec2f186278068909b2b88899fc446e1465
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_399_en.txt
@@ -0,0 +1,5 @@
+A 64-year-old female was admitted to our center due to an incidental mobile abdominal mass.
+Prior to admission, the patient noticed an increase in her abdominal size, which she construed as weight gain.
+On physical examination, a large non-tender mobile mass was palpated in the right abdomen.
+Laboratory examinations showed a cancer antigen 125 (CA125) level of 540.6 U/mL (normal range < 35 U/mL).
+Contrast-enhanced abdominal computed tomography (CT) revealed a huge mass measuring 25.4 cm × 23.0 cm with a mixed density and heterogeneous enhancement . CT three-dimensional (3D) reconstruction showed that the feeding arteries were from the splenic artery and celiac axis . From the imaging findings, we suspected a gastrointestinal stromal tumor (GIST).
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_410_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_410_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..4eb790531028d7f9fe0a284bd8707e6fcdc58b74
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_410_en.txt
@@ -0,0 +1 @@
+The patient was a 53-year-old man who had a history of testicular seminoma that was removed twice, at the ages of 41 and 48 years. The patient had been experiencing disorientation and difficulty in thinking for 1 month before the visit. His Karnofsky Performance Status (KPS) at the time of the first visit was 80. Contrast-enhanced magnetic resonance imaging (MRI) showed a markedly contrast-enhanced mass in the dorsal midbrain and obstructive hydrocephalus . Systemic examination, including whole-body, contrast-enhanced computed tomography, showed no obvious abnormalities. Blood samples showed a high serum soluble interleukin-2 receptor level of 624 U/ml. In addition, α-fetoprotein (3.1 ng/mL) and human chorionic gonadotropin (0.2 mIU/mL) were within normal limits. Neoplastic diseases such as PCNSL, tectal glioma, or intracranial metastasis of seminoma were considered in the differential diagnosis, and endoscopic tumor biopsy was performed with endoscopic third ventriculostomy (ETV). The patient was placed in a supine position under general anesthesia. The burr hole was located 11 cm from the nasion and 2 cm to the right of the midline. A Neuroport mini (Hakko Co., Nagano, Japan) was inserted into the anterior horn, and observation using a flexible endoscope (VEF-V, Olympus, Tokyo, Japan) showed that the aqueduct was stenotic due to the tumor, and the posterior part of the aqueduct was swollen [-]. A biopsy of the swollen area was performed. The lesion was pale pink, soft, and had minimal bleeding after the biopsy. After thorough intraventricular lavage to prevent dissemination, a third ventriculostomy was performed using an expanding balloon catheter (Expander Balloon Catheter SI Fuji Systems, Tokyo, Japan) . Intraoperative cerebrospinal fluid cytology showed a small number of atypical cells with bifurcated nuclear irregularities. Immunohistochemical study of the specimen showed that the tumor cells were CD3 negative, CD20 positive, and CD79a positive, indicating that the tumor was B-cell lymphoma. The final histopathological diagnosis of the tumor was diffuse large B-cell lymphoma . The patient’s postoperative course was uneventful and no new neurological deficit occurred. He underwent three courses of high-dose methotrexate (3.5 mg/m2) and whole-brain irradiation (30 Gy in 15 fractions). His KPS was 100 when he was discharged home.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_425_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_425_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bbfb3a5001a936768f6965481372da6a407beaef
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_425_en.txt
@@ -0,0 +1,7 @@
+A 70-year-old man was referred to our department for an asymptomatic thoracoabdominal aortic aneurysm. He had recently undergone percutaneous coronary procedure due to an ischemic cardiac event (myocardial infarction) and for this reason he was in treatment with a dual antiplatelet therapy (DAPT).
+The patient, a former smoker with arterial hypertension under single medical therapy, had been previously treated for an infrarenal abdominal aortic aneurysm with open surgical repair approximately 15 years before. A computed tomography angiography (CTA) scan performed for other causes, revealed a type III TAAA with a maximum diameter of 55X65 mm . The patient was asymptomatic for abdominal pain, but complained of buttock and thigh claudication, even in the absence of defects in the pelvic perfusion. Symptoms were further evaluated with spinal magnetic resonance angiography (MRA) that showed a severe lumbar spinal stenosis (LSS) . The patient was deemed to be at high risk for open surgery due to concomitant chronic obstructive pulmonary disease and low ejection fraction 40%) and a staged endovascular aortic repair was then planned, consisting of TEVAR followed by a second step to be performed 4 weeks later with a fenestrated custom-made endovascular repair of the visceral and infrarenal aorta.
+Considering that subclavian and hypogastric arteries were patent and the intended length of the tract of thoracic aorta to be covered was less than 20 cm, the procedure was estimated at intermediate risk of SCI for the previous infrarenal aortic repair. Additionally, considering the need for continuing with the DAPT for the recent cardiac procedure, in agreement with the anesthesiologist, it was decided not to place a preoperative CSF drainage.
+The procedure was performed with the deployment of a thoracic endoprosthesis (Cook Medical Inc., Bloomington, ZTEG-2PT-40-30-165-PF), as planned. The intervention was performed under general anesthesia, with a duration of 110 min. At the end of procedure, the patient was transferred to Intensive care Unit for postoperative monitoring, without any sign of clinical complications (Hb > 10 g/dl, mean arterial pressure (MAP) > 90, oxygen saturation > 97%). After 24 h from the procedure, incomplete paraplegia with absence of deep tendon reflex was detected. Therefore, it was decided to immediately insert a spinal catheter for CSF drainage.
+CSF drainage was carried on for 7 days and the patient showed a partial recovery of the sensibility deficit (tactile dolorific hypoesthesia). The patient was transferred to the Spinal Unit, where a satisfactory recovery of the movements of the right leg was noted, whereas plegia of the left leg was still present. The patient was finally discharge in postoperative day 15th to a dedicated neurological rehabilitation center.
+The second staged intervention was than delayed and, 1 week before the date of planned intervention, the patient came to the emergency department for hemoptysis and chest pain. An urgent CTA showed sudden increase of the thoracoabdominal aneurysm (78X63 mm) with contained sac rupture. The patient underwent urgent endovascular exclusion of the TAAA with the 4-branched custom made endoprosthesis: another thoracic stent-graft (Cook Medical Inc., Bloomington, ZTA-PT-36-32-161) was deployed to extend previous TEVAR. All the side branches were stented with Fluency (Bard Incorporated, Karlsruhe, Germany) and reinforced with a self-expandable stent (SMART, Cordis Endovascular, Warren, NJ). Distal abdominal stent grafting with both iliac artery extensions was performed landing distally inside the previous surgical graft.
+Final digital subtraction angiography (DSA) showed complete exclusion of the TAAA and good patency of the visceral vessels. Postoperative course was uneventful. No changes in neurological status occurred. The patient was discharged in the 6th postoperative day. The CTA performed 12 months after the procedure demonstrated the continued exclusion of TAAA and the patency of visceral and renal vessels .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_434_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_434_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..fcc4c8af65f89112554d60333f8da21290df52b4
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_434_en.txt
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+The patient was a 40-year-old Moroccan man who had been vaccinated with bacillus Calmette–Guérin (BCG). He did not have any signs of previous TB infection or a history of sexually transmitted infections. The patient visited our hospital for a urology consultation and presented with dysuria, purulent discharge and a meatic penoscrotal fistula that had developed over a one-year period. The physical examination at admission found nodular lesions, urethral induration on the urethral path extending laterally to the cavernous bodies with multiple fistulas, and penoscrotal pus excretion . The external genitalia examination, testis, epididymis and ductus deferens, were without remarkable signs. His prostate volume was normal with a soft consistency. His prostate volume was normal with a soft consistency.
+The initial biological assessment revealed an inflammatory syndrome corresponding to a sedimentation speed of 80 associated with a urinary tract infection with Escherichia coli susceptible to fluoroquinolones. First, the patient received antibiotherapy based on ciprofloxacin and benefited from urinary drainage by suprapubic catheter. A retrograde and voiding urethrocystography (UCG) was then performed and revealed an extended narrowing of the whole anterior urethra associated with multiple fistulous portions toward the scrotum and perineum. The bladder control showed a bilateral secondary vesico-ureteric reflux . At this stage, we reached a diagnosis of nonspecific sclero-inflammatory urethral stricture with complicating fistulas. After six weeks of urinary drainage and antibiotherapy, we decided to perform a urethroplasty enlargement to clear the narrowing urethral sinus tracts .
+The evolution was marked by delayed wound healing associated with the persistence of fistulas extending into the corpus cavernosum with purulent discharge. It was at this point of the treatment that we suspected TB and we carried out a biological assessment in this regard. His test result for Koch bacillus (BK) in the urine was negative. His tuberculin assessment result was positive. Multiple biopsies were then performed on the periurethral tissue and fistula tracts.
+The histological examination confirmed urethral TB and showed the presence of giant cell epithelial lesions with caseous necrosis characteristic of TB. The treatment for TB was immediately established and marked by a localized, rapid and significant improvement. A second-stage urethroplasty was scheduled for two months after the start of his anti-TB treatment.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_439_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_439_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..15fca3a312cff3b9d5d31c93aff8ef0260ba265a
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_439_en.txt
@@ -0,0 +1,14 @@
+A 49-year-old Japanese man visited our department in November 2017 with chief complaints of indolent right scrotum enlargement and a right inguinal mass. History showed that the patient visited our department of gastroenterology with chief complaints of blackish feces and ill complexion in February 1997. Gastrointestinal fiberscopy was used to treat duodenal ulcer bleeding. Computed tomography (CT) showed a right retroperitoneal tumor, which was removed in the same month.
+Histopathological examination showed a teratoma and yolk sac tumor . He was diagnosed with primary retroperitoneal EGCT and underwent three courses of chemotherapy (bleomycin/etoposide/cisplatin; BEP) starting in May 1997. He was closely followed using procedures including periodic imaging, tumor markers determination, and self-palpation.
+He was followed up on an outpatient basis 5 years after treatment and was subsequently lost to follow-up. In August 1999, he underwent surgery of the right hydrocele. At that time, perioperative findings were unremarkable, indicating no clear tumor in either testicle.
+At the first visit, his height was found to be 163 cm, and weight was 58.5 kg.
+Blood pressure was 128/78 mmHg, heart rate was regular at 62 beats per minute, and body temperature was 36.4 °C.
+He had no history of smoking or drinking, and there was nothing remarkable in the family history.
+On physical examination, the right testicle was found to be elastic, hard, and enlarged to the size of 40 × 40 mm. A 45 × 40 mm sized induration was palpable in the right inguinal area and was adequately mobile. Neurological examination showed no abnormal findings. Blood biochemistry examination, urinalysis, and tumor markers (alpha-fetoprotein [AFP], human chorionic gonadotropin [HCG], and lactate dehydrogenase [LDH]) showed no abnormal findings.
+Ultrasound findings showed a mosaic shadow inside the right testicle, with no abnormal findings in the left testicle.
+During other diagnostic imaging procedures, enlargements of the right external iliac lymph node (24 × 14 mm) and right inguinal lymph node (43 × 29 mm) and a 31 × 22 mm mass with uneven contents were found in the right testicle . There was no evidence of any distant metastasis.
+For the right testicular tumor, the patient underwent high orchiectomy and resection of the right inguinal lymph nodes in November 2017. The testicular tumor was 40 × 40 × 30 mm in size and weighed 34 g. The lymph node was 40 × 40 × 30 mm in size and weighed 21 g. The cut surfaces of both specimens were yellowish and solid, and the testicular tumor was localized in the testicle .
+Histopathological findings showed irregular cobblestone proliferations of germ cell-like atypical cells with clear nucleoli and massive necrotic changes that partially resulted from self-destruction. The tumor did not extend into the tunica albuginea, and no vascular infiltration was found. Spermatic cord stumps were negative. Tumor diagnosis was a classical seminoma with no other elements. Lymph node metastases were also diagnosed as a result of the seminoma .
+Based on the above findings, this seminoma was diagnosed as pT1, pN2, M0, S0, and TNM stage IIB .
+The patient received postoperative chemotherapy with one course of BEP therapy and three courses of etoposide and cisplatin (EP) therapy at the Japan Community Health care Organization Kani Tono Hospital starting in January 2018.
+Post-chemotherapy CT confirmed a complete clinical response (cCR) at the right external iliac lymph node, and this response continued 12 months later .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_440_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_440_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b2a7c83e8cdf96608dab87a6914eb78ddd132b02
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_440_en.txt
@@ -0,0 +1,2 @@
+A 27-year-old Japanese man with mild mental developmental retardation presented with a 1-year history of bilateral visual impairment as well as a 3-month gradually progressive general fatigue. He had no history of epileptic seizures. Neurological examination revealed blindness of the left eye, half-blindness of the right eye on the ear side, and cognitive dysfunction according to the Mini Mental State Examination 21/30. Fundus examination revealed no papilledema. Magnetic resonance imaging (MRI) revealed a 77 × 63 × 85-mm tumor that arose from the pituitary and extended bilaterally through the anterior skull base, the clivus, and the cavernous sinus, with compression of the optic chiasm and the bilateral frontal and temporal lobes . The patient was administered antiepileptics, such as 1000 mg/day levetiracetam, for prevention of seizure attack. His hormone profile showed hyperprolactinemia 25,270.0 ng/ml (3.6–12.8 ng/ml) and dysfunction of the other pituitary hormones (testosterone, < 0.04 ng/ml [1.3–8.7 ng/ml]; follicle-stimulating hormone, 0.54 mIU/ml [2.0–8.3 mIU/ml]; luteinizing hormone, < 0.10 mIU/ml [0.79–5.7 mIU/ml]; thyroid-stimulating hormone, 4.94 μIU/ml [0.5–5.0 μIU/ml]; free thyroxine 4, 0.6 ng/dl [0.9–1.7 ng/dl]; growth hormone, 0.22 ng/ml [0.0–2.5 ng/ml]; and adrenocorticotropic hormone, 1.7 pg/ml [7.2–63.3 pg/ml]) . The patient received a diagnosis of a giant PRLoma with hypopituitarism. We started DA therapy with CAB 0.25 mg once per week, supplemented by daily oral hydrocortisone.
+Eight days after starting DA therapy, the patient had a tonic-clonic seizure with loss of consciousness that developed into status epilepticus. Incubation and general anesthetic therapy were required. The patient was admitted to the intensive care unit. An electroencephalographic examination was continuously performed; however, no findings of epileptic changes were found after general anesthesia. There was no abnormality in the laboratory analysis that may have led to status epilepticus. The patient’s blood level of PRL markedly decreased from 25,270.0 to 948.2 ng/ml. MRI revealed significant reduction of the tumor in a short period without pituitary apoplexy, including hemorrhagic or ischemic change . According to the significant reduction of the tumor, the bilateral mesial temporal lobes returned to medial position. Further, a hyperintense area in left frontal lobe appeared on T2 -weighted images . Because of the possibility that the epileptic seizures were induced by the rapid shrinkage of the tumor, we suspended DA therapy until the seizures were under control with the antiepileptic drug levetiracetam 2000 mg/day. General anesthetic therapy was required for the control of seizures for 2 weeks. After 4 weeks, we resumed DA therapy with extremely low doses of CAB. Both the level of PRL and the tumor size were gradually reduced without further seizures. The patient was able to return to daily life with medication of antiepileptics and oral hydrocortisone and levothyroxine.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_492_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_492_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b850d181120db7b3f1488c02c7933c0c4def80e0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_492_en.txt
@@ -0,0 +1,10 @@
+We describe a case of a 36-year-old multiparous (G3P2) woman who presented with an acute episode of pelvic pain. She was referred to a general gynaecological clinic after ultrasound findings revealed a 4.1 cm complex left ovarian cyst suggestive of an endometrioma.
+She also reported a 2-year history of a bulge that protruded from her vagina and was associated with discomfort and dyspareunia and occasionally required digital reduction especially with tampon use. She had been diagnosed with a vaginal prolapse by a gynaecology clinic at another institution.
+Her past medical history consisted of migraines with aura, exercise induced asthma, and a family history of breast cancer (half-sister). She had never had a PAP smear.
+On bimanual examination, a well-delineated solid mass was found on the anterior vaginal wall in the midline, measuring 5 cm by 5 cm. There was no evidence of pelvic organ prolapse with good support of the uterus, posterior wall, and anterior wall above the mass. The cervix was visualised anteriorly and there was no evidence of cervical excitation. A routine PAP smear was performed with difficulty secondary to the vaginal mass.
+With respect to investigations, Ca 125 was 29 U/mL giving a low relative malignancy index. A repeat ultrasound scan demonstrated a 2.9 cm left ovarian cyst, suggestive of an endometrioma and a solid mass inferior to the uterus and anterior to the vagina, displacing the bladder .
+On Magnetic Resonance Imaging, a 45 mm × 50 mm solid mass in the vesicovaginal septum with a well-defined margin was demonstrated . The mass was displacing the bladder anteriorly and displacing the urethra towards the left of the midline. T2 imaging showed a predominantly hypointense, heterogenous signal with areas of hyperintensity. There was mild enhancement after gadolinium injection. Close to the external urethral orifice, the interface between the mass and the urethra was ill defined. Evidence of a left ovarian endometrioma and endometriosis deposits were seen elsewhere in the pelvis.
+These MRI findings suggested that the mass was either endometriosis with surrounding reactive fibrous and smooth muscle proliferation, neoplasm, or an infection relating to a urethral diverticulum. After a multidisciplinary meeting with a urogynaecologist, the patient underwent an examination under anaesthesia, diagnostic laparoscopy, cystoscopy, excision of endometriosis, and excision of the vaginal mass.
+The vaginal mass was removed with laparoscopic assessment via a midline incision on the anterior vaginal wall with lateral dissection around the cystic structure . A cystoscopy and urethroscopy suggested no involvement and the cyst was enucleated. Multiple haemostatic sutures were needed with surgical snow to achieve haemostasis and the defect was closed. A repeat cystoscopy and urethroscopy showed no injury.
+Histopathological macroscopic assessment of the mass showed pale tan tissue surrounded by a thin capsule and on sectioning a homogeneous whorled tan tissue . Microscopically the low power photomicrographs showed a well-circumscribed border. It comprised collagenised areas of epithelioid to spindled cells with small to thin walled arborizing vessels. Aggregation of cells around vessels was noted and there were no atypical mitoses, necrosis, or atypia .
+The immunohistochemistry showed positive desmin, SMA, CD34, and vimentin. The cells displayed high intensity nuclear positivity for progesterone and oestrogen receptors. These findings were consistent with a diagnosis of angiomyofibroblastoma.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_4_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_4_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f7f3bff9115dc50a059958795320710629de2ebd
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_4_en.txt
@@ -0,0 +1,4 @@
+A 54-year-old woman was referred to us by the Department of Plastic and Reconstructive Surgery in our medical center for further evaluation of prolonged right nipple erosion. She had previously received a diagnosis of right breast cancer and undergone total mastectomy and axillary dissection 15 years ago in another hospital. Histopathology identified an invasive ductal carcinoma with a tumor diameter of 0.9 cm and a nuclear grade of 2; one of 23 lymph nodes showed metastasis. Tissue profiling revealed the following: estrogen receptor (ER), positive; progesterone receptor (PgR), negative; and human epidermal growth factor receptor 2 (HER2), undetermined. As adjuvant therapy, she received six cycles of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF), followed by tamoxifen for 3.5 years. Then, she defaulted her endocrine therapy. Seven years after the surgery, the doctors from our medical center performed ABR with a deep inferior epigastric perforator (DIEP) flap at another facility. The following year, her right nipple was reconstructed by V-shaped resection of the left nipple and an autologous grafting/nipple-sharing technique. The right areola was reconstructed with a penetrating skin graft from the proximal thigh and left areola. Concurrent mastopexy was performed for the left breast .
+After 7.5 years, right nipple erosion appeared, and she visited the Department of Plastic and Reconstructive Surgery in our medical center. At first, it appeared that she had an eczematous nipple lesion caused by an infection, and she was treated with antibiotics; however, the erosion progressed and enlarged over the course of a few months. She was eventually referred to our department. The skin on the right side of her chest around the NAC and the subcutaneous adipose tissue consisted of transferred tissue from her abdomen, as the DIEP flap and grafted nipple were constructed on the skin graft. In the right nipple, normal tissue was almost completely affected by erosion, and there was no abnormality, itching, or pain in the right areola . Scrape cytology revealed malignancy of the epithelial cells, and that the right nipple carcinoma originated from the tissue taken from the left nipple. On magnetic resonance imaging (MRI), the malignant lesion seemed limited to the area around the grafted right nipple , with no malignancy observed in the left breast on MRI and computed tomography (CT) . In addition, no distant metastases were observed on CT. Paget’s disease was clinically suspected, and we performed surgical treatment. Though the standard surgical operation for mammary Paget’s disease is mastectomy, we performed partial breast excision including the right nipple with sufficient lateral and deep margins because there was no mammary tissue in the right reconstructed breast, except for the nipple and areola. The incision was closed with investing sutures.
+The specimen submitted for surgical pathology was composed of epithelial and adipose tissue grafted from the abdomen, areolar tissue grafted from the base of the thigh and left areola, and a nipple graft from the contralateral side. Macroscopically, the lesion spread around the nipple and adipose tissue . Pathological examination identified invasive ductal carcinoma with a few comedo ductal components within the nipple, extensive infiltration of grafted epithelial and adipose tissue , and a tumor diameter of 25 mm. The nuclear grade score was 2 (nuclear atypia score was 2 and mitotic count score was 2), there was no lymphatic or vascular invasion, and the lateral and deep margins were negative. Immunohistochemical staining showed strong positive for ER, weak positive for PgR, positive for HER2 with a score of 3+, and 35% cells showing positive Ki-67 staining.
+As the biological profile classified the tumor as a luminal HER2 type, weekly paclitaxel, trastuzumab, and endocrine therapy were administered as adjuvant therapies. No distant metastases or local recurrence were seen 1 year after the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_512_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_512_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..bd3ca586a4d8835b486e7615374356e2699e396e
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_512_en.txt
@@ -0,0 +1,8 @@
+An 18-year-old Saudi male was referred to our hospital with a 3-month history of upper abdominal pain and yellowish discoloration of the sclera. The pain was colicky and non-radiating, with a severity of 3/10, and was not related to food intake or position. Six months prior to the presentation, the patient was diagnosed with diabetes mellitus type 1 and started on insulin aspart 14/16/8 units and glargine 38 units HS. There was no family history of hepatobiliary, hemoglobinopathy, or gastrointestinal malignancy. Two weeks prior to the presentation, the patient was admitted to another hospital during which magnetic resonance cholangiopancreatography (MRCP) was performed and showed a filling defect in the distal common bile duct (CBD). Endoscopic retrograde cholangiopancreatography (ERCP) could not be done there due to unavailability.
+His physical examination was unremarkable, apart from scleral jaundice. Liver function test revealed a total bilirubin of 6 mg/dL, alanine aminotransferase 70 U/L, alkaline phosphatase 258 U/L, and gamma-glutamyl transferase 474 U/L. Complete blood count, renal function test, calcium level, amylase, and lipase levels were normal. The parathyroid hormone was elevated (171 pg/mL); however, TSH, free T4, LH, FSH, prolactin, ACTH, cortisol, and testosterone levels were normal.
+Abdominal ultrasound revealed a dilated CBD of 8 mm and a single gallbladder stone . During the ERCP, two duodenal polypoid lesions were noted, one of them overlying the ampulla of Vater, with erythematous and ulcerated surface . The common bile duct was cannulated, and the cholangiogram revealed dilated extra and intrahepatic bile ducts and a lower CBD filling defect . Multiple biopsies were obtained from both the duodenal lesions, and a plastic stent was inserted in the CBD. CT scan of the abdomen with IV contrast showed multiple enhanced well-defined lesions in the peri-ampullary area as well as the pancreaticoduodenal groove. No distant metastasis was detected .
+The histopathological evaluation revealed infiltration of the intestinal mucosa by a few small solid nodules. These nodules were composed of cells with round uniform nuclei and stippled chromatin. Immunohistochemical studies of the nodules showed positive reactivity for CK7, CDX2, CD56, chromogranin A, and synaptophysin and stained negative for CD20 . Less than 2% of the cells were labeled with the proliferation marker Ki-67, and the mitotic rate was 1/2 mm2. Accordingly, a histopathological diagnosis of NET grade 1 was made.
+Tc-Octreotide scan showed multiple large intraluminal and extraluminal duodenal masses with no radiotracer uptake due to necrotic component. Two left para-aortic lymph nodes, the larger one measuring 2.6 cm × 2.8 cm, showed intense radiotracer uptake . There was no abnormal focus of activity in the liver, bones, and rest of the body.
+Further workup showed an elevated 24-h urinary normetanephrine of 4,394 μg/24 h; however, the 24-h urinary metanephrine was normal as was the chromogranin (52 ng/mL; reference value <93), urine 5-hydroxyindoleacetic acid, gastrin, somatomedin, and glucagon. Tumor markers including carcinoembryonic antigen, alpha-feto protein, and CA19-9 were normal. Colonoscopy, MRI pituitary, and parathyroid ultrasound were unremarkable. Sequence analysis of MEN1 gene was negative for any pathogenic variants.
+After a multidisciplinary team discussion, the patient underwent a conventional Whipple procedure followed by para-aortic lymph node dissection. Lymph nodes draining the head of the pancreas and duodenum were dissected, and the surgeon was keen on removing as many lymph nodes as possible. Gastrointestinal reconstruction was done as follows: pancreaticojejunostomy was performed as a two-layer end-to-side full-thickness pancreatic neck inside the jejunum; hepaticojejunostomy was done with end-to-side common hepatic duct to antimesenteric border of the jejunum 15 cm distal to pancreaticojejunostomy, and gastrojejunostomy was done using handsewn anastomosis. Jejunojejunostomy was created around 60 cm from the biliary-enteric anastomosis. All the surgical margins were negative for tumor, and among the 39 lymph nodes excised, 12 lymph nodes showed metastatic NET. The tumor was confirmed to be NET grade 2. Two presumed para-aortic lymph nodes turned out to be paragangliomas.
+After the surgery, the patient had improved apart from diarrhea responding to pancreatic enzymes. The patient was started on intramuscular octreotide 30 mg monthly based on the oncology recommendation and considering the presence of lymph node metastasis. Gallium-68 DOTATATE showed no residual uptake in the postoperative bed, and apart from an avid left para-aortic lymph node, no other DOTATATE-avid lymph node was noted. Over the 18-month follow-up, gallium-68 DOTATAE and CT scan have been showing the stability of the avid left para-aortic lymph node with no local recurrence.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_537_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_537_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..c78b8e796e1e2b776684f82cb0b9b260fb3a59a5
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_537_en.txt
@@ -0,0 +1,4 @@
+A retired, 60-year-old female who was apparently healthy, presented in August 2020 to the COVID-19 treatment center of the Korle-Bu Teaching Hospital in Accra from a referral facility. She had a week’s history of low-grade fever, chills, rhinorrhoea, and generalized limb weakness. The patient had tested positive for COVID-19 infection 3 days following the onset of symptoms. There was no history of cough, pleuritic chest pain, exertional dyspnea or dyspnea at rest, recent calf pain/swelling, prolonged bedrest, long-distance travel and cancer diagnosis in the last 6 months. The generalized weakness was of sudden-onset and progressive, initially involving the lower limbs and extending to the upper limbs. There was no associated bowel or bladder incontinence and no sensory deficit. Her past medical history was negative for hypertension, diabetes or asthma.
+The patient on presentation was not acutely ill-looking but febrile: 38.2 C, not clinically pale, anicteric, acyanosed, and well-hydrated. There was no palpable lymphadenopathy. A neurological exam revealed a conscious and alert woman with no cranial nerve deficits. She had hypotonia, areflexia and zero power in all limbs (Medical Research Council, MRC - 0/5). The plantar response was absent bilaterally. No sensory level was elicited. The pulse rate was 96 beats per minute with a regular rhythm, normal precordial findings and the blood pressure reading was 164/94 mm Hg. The respiratory rate was 20 cycles per minute with oxygen saturation of 98% on room air and normal chest findings. The abdominal exam was essentially normal whiles fasting blood glucose reading was 9.1 mmol/L.
+Lumbar puncture for cerebrospinal fluid (CSF) analysis, neurophysiological studies, chest computed tomography pulmonary angiogram confirmed Guillain-Barre syndrome and pulmonary embolism .
+The nerve conduction study shows electrodiagnostic evidence suggestive of absent motor responses in all the motor nerves evaluated in the upper and lower limbs. The median sensory nerve shows prolonged onset latency, reduced (Sensory nerve action potential) SNAP amplitude and slowed conduction velocity on the Right. All F-Wave latencies were absent. There was evidence of muscle electrical instability in the muscles evaluated in the upper limbs.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_53_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_53_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..52fbcc7e02cf6708ffa251c5a7f570739969eef6
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_53_en.txt
@@ -0,0 +1,7 @@
+A 63-year-old male was admitted to our hospital with an uncontrolled itching sensation and whole body jaundice.
+Six months prior he had experienced intractable itching, which led to suspicion of obstructive cholangitis. Despite endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic retrograde biliary drainage, which ruled out malignancy, the itching became aggravated and obstructive-pattern jaundice developed.
+The patient’s medical history was non-specific with the exception of hypertension and diabetes mellitus, which were well controlled by medication. He was ex-smoker of ten years and a social drinker.
+No previous illnesses were reported and there was no family history of oncologic and rheumatic diseases.
+The physical examination revealed icteric sclerae with multiple itching scratches on the skin.
+The patient’s laboratory results were as follows: Hemoglobin 10 g/dL (normal, 13-17 g/dL), hematocrit 30.6% (normal 39%-52%), platelet count 348000/L (normal, 130000-450000/L), aspartate aminotransferase 71 U/L (normal, 0-40 U/L), alanine aminotransferase level 44 U/L (normal, 0-41 U/L), gamma-glutamyl transferase level 233 U/L (normal, 5-61 U/L), alkaline phosphatase level 315 U/L (normal, 35-130 U/L), total bilirubin level 8.6 mg/dL (normal, 0-1.2 mg/dL), BUN level 26.7 mg/dL (normal, 6-20 mg/dL), creatinine level 1.37 mg/dL (normal, 0.5-1.2 mg/dL), erythrocyte sedimentation rate 120 mm/h (normal, 0-20 mm/h), C reactive protein (CRP) level 1.81 mg/dL (normal, 0-0.5 mg/dL), antinuclear antibody titer 1:2560 (nucleolar pattern), IgG level 2416 mg/dL (normal, 700-1600 mg/dL), and serum IgG4 level 465 mg/dL (normal, 0-135 mg/dL).
+Abdominal computed tomography (CT) showed intrahepatic duct (IHD) dilatation with intraductal soft tissue attenuation and periductal enhancement . The common bile duct (CBD) was dilated with mild luminal narrowing but without findings of AIP . There was no definite obstructive lesion or suspected malignancy. CT also showed fibrotic enhancement around the infrarenal aorta.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_576_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_576_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..15f78344c8b825454ba44b19e9a7dbef51d8d93b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_576_en.txt
@@ -0,0 +1,4 @@
+A 21-year-old man, with a previous diagnosis of HHT and embolization of multiple P-AVM in the past, was admitted at another hospital, while on holidays, with fever, headache and malaise. A non-enhanced computed tomography (CT) of the head showed no significant findings. He was diagnosed with typhoid fever based on clinical features and serology. Consequently, he was discharged with oral antibiotic therapy consisting of ciprofloxacin 500 mg bid and cotrimoxazole 800/160 mg bid.
+Two weeks later, he came to our emergency department because of the persistent fever and headache. At our center, the neurologic, cardiac and pulmonary examination were normal. Routine hematology showed a white cell count of 17.6 × 103/ml leucocytes (4.0–11.5) and 14.33 × 103/ml neutrophils (1.5–7.5). The C-reactive protein was 2.00 mg/L (0.1–10) and the arterial blood gases were normal. A chest radiograph appeared to be normal other than visualization of previous embolization material .
+A contrast-enhanced CT scanner of the head revealed a mass in the right thalamic-capsular region, compatible with an abscess. An MRI, performed later, confirmed the findings showing the typical ring-like contrast enhancement.
+Further investigations were performed. A cardiac transesophageal echography was normal. A CT of his lungs confirmed the presence of embolization material inside the lumen of pulmonary vessels feeding the malformations. After reviewing the images with our radiology team, they concluded that the lesions were successfully treated. Pulmonary angiography was not performed in light of these results and because our patient was being followed for that pathology in another center.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_58_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_58_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f98346075b8046c84a785ebdebc150052f77d833
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_58_en.txt
@@ -0,0 +1,2 @@
+A 32-year-old immunocompetent woman without any history of medical or surgical diseases, referred to our clinic, with unilateral edematous plaque on the left side of the face involving cheek, eyelids, nose and lips, with some ulcers which had purulent exudates on them .
+The lesion had begun from 18 months ago. The lesion persisted till 5-6 months ago with no cure. Since then, the surrounded skin gradually became red, erythematous, and other ulcers appeared on the skin. On physical examination, the left side of the face was edematous and red and some ulcers with purulent exudates were seen. The lesion involved the nose and the lips but nasal and buccal mucosa was intact. CT-scanning of paranasal sinuses showed soft tissue thickness of the left cheek without involvement of the ipsilateral sinuses. Evaluations on exudate specimens revealed branched and aseptate hyphae, indicating mucormycosis. Punch biopsy and then surgical biopsy were done and both showed granulomatos dermatitis accompanying broad branched and aseptate hyphae that invaded the vascular endothelium. These findings confirmed the diagnosis of mucormycosis and therapy with Amphotricin-B deoxycholate was begun. After the patient became stable, extensive repetitive debridement of the involved area were performed. Therapy with amphotricine-B deoxycholate continued for a total dose of 2 g with good outcome and recovery of the lesion. The patient was then referred for plastic surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_603_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_603_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ecd5aa2195991f67e6abda3607310c48f413d003
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_603_en.txt
@@ -0,0 +1 @@
+Patient 01B (G1 P1), the older brother of patient 01A, was 18 years old at the time of examination. He was of normal height and weight when compared to his peers. He had mild dysmorphic features including a depressed nasal bridge and midface hypoplasia. He had no history of respiratory infections or other major medical treatments and no history of seizures or epilepsy. He has not been hospitalized, and is otherwise healthy apart from an occasional cold. A previous computed tomography (CT) scan showed no obvious abnormalities. He learnt to walk at 20 months and currently walked and ran slightly unsteadily. He liked to walk on his toes, but could not jump with both feet off the floor. He had no language, but could passively understand simple phrases as spoken by his mother. He was able to eat by himself, and stayed in his room alone at all times other than meal times. He liked to look at cars on the street and was very excited by wheels. When happy, he put his hands to his mouth and laughed loudly. He flapped his hands a lot and did not engage in interaction with others, but laughed often. Although this patient was 18 years at the time of examination, his cognitive, language and motor skills were in the range of 6 to 15 months as measured by Bayley Scales of Infant Development-3 . His ADOS score of 17 was well above the cutoff for autistic disorder .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_633_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_633_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..12978e686f67aa93de56357a5bc4002abd7e5682
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_633_en.txt
@@ -0,0 +1,9 @@
+A 60-year-old man with end-stage renal disease (ESRD) on hemodialysis via arteriovenous (AV) fistula presented to the emergency department (ED) from home on March 18, 2020, with a chief complaint of fever, cough, shortness of breath, and diarrhea. He has a history of IgA nephropathy and a failed kidney transplant due to rejection in 2013. He lives alone at home in western Iowa and had no recent travel history or visits to any healthcare facilities except for a local dialysis center for routine dialysis.
+The patient receives hemodialysis three times a week (Monday, Wednesday, and Friday) at a local dialysis center. The symptoms started on Monday, March 16, 2020, while he was at his routine dialysis when he began to feel feverish and experience chills. His temperature taken at the dialysis center was 37.8 °C. After dialysis, he developed a headache, non-productive cough, sore throat, runny nose, poor appetite with nausea, vomiting, and abdominal pain, which progressively worsened over the next 2 days. On March 17, he started to have generalized myalgias, mild shortness of breath, and diarrhea with liquid green stool without visible blood. He missed his hemodialysis on Wednesday, March 18 and presented to the ED.
+On arrival at the ED, the patient was provided a mask and placed in a private room in accordance with the ED screening protocol. He was ill-appearing with a fever of 38.6 °C. His respiratory rate was 23 per minute, and other vital signs were unremarkable. Physical examination was significant for diffuse rhonchi and bibasilar rales on auscultation. Chest X-ray showed right midlung consolidation, and patchy left lower lung opacities, concerning for multifocal pneumonia. Rapid influenza antigen test was positive for influenza A; viral subtypes were not specified. A nasopharyngeal swab specimen was sent for real-time reverse-transcriptase polymerase chain reaction (RT-PCR) test (NEcov19 assay) at the Nebraska Medical Center Clinical Lab to rule out COVID-19 infection. He was placed on contact and airborne isolation precautions with eye protection for concerns of probable COVID-19 as per the Centers for Disease Control and Prevention (CDC) recommendations.
+Lab workup was significant for elevated procalcitonin and lymphopenia . The electrocardiogram showed normal sinus rhythm. Computed tomography (CT) of the chest demonstrated multifocal areas of consolidation and tree-in-bud opacities within multiple lobes of the lungs compatible with multifocal pneumonia, as well as small bilateral pleural effusions and extensive mediastinal and bilateral hilar adenopathy. CT abdomen and pelvis showed mildly dilated gas and fluid-filled loops of small bowel and bowel wall enhancement, reflecting possible partial distal obstruction or ileus and enteritis. Blood cultures were taken, and the patient was started on oseltamivir (30 mg, oral, once per day on Mon Wed Fri, given after hemodialysis) for influenza. He is anuric; therefore, we did not test urine streptococcal and legionella antigen. The patient was then admitted to a negative pressure room on an isolation ward while awaiting COVID-19 results.
+On hospital day 2, his RT-PCR test was positive for SARS-CoV-2 E and/or N gene RNA, confirming the diagnosis of COVID-19. The local health department was notified to investigate the source of infection. The patient reported feeling extremely fatigued but was afebrile. His cough and shortness of breath improved. His primary complaint was severe liquid green diarrhea, although the Gastrointestinal (GI) pathogen panel and Clostridioides difficile (C. diff) toxin assay were negative. The repeated procalcitonin level was elevated on day 2, suggestive of potentially fivefold increased risk of severe disease of COVID-19 . The patient was continued on vancomycin and cefepime for possible superimposed bacterial pneumonia. Notably, he had multiple episodes of hypotension with systolic pressure in the high 80s (mmHg) to 90s with mean arterial pressure (MAP) in the low 60s. We administered 500 ml of lactated Ringer’s solution for volume resuscitation. However, aggressive fluid resuscitation was avoided to prevent volume overload. Oral fluids were encouraged to maintain normal volume status. For his COVID-19, as there were no proven specific therapeutic options, the treatment was mainly supportive. He was deemed not a candidate for the clinical trial with remdesivir due to his ESRD. Corticosteroids were not given at that time for concerns that they may delay viral clearance and prolong the disease course .
+Hemodialysis resumed at the bedside as per the CDC guidelines on hospital day 3 . He remained afebrile, and his blood pressure improved with midodrine and albumin after the dialysis.
+Since hospital day 4, the patient started to feel better with increased appetite and improvement of diarrhea, cough, and shortness of breath. Blood cultures demonstrated no bacterial growth at 5 days. With a multidisciplinary approach and optimal medical management, he continues to show clinical improvement despite his comorbidities.
+To optimize the use of personal protective equipment (PPE), the patient’s dialysis schedule was changed to Tuesday, Thursday, and Saturday to decrease the dialysis days during his hospitalization. His volume status was closely monitored, as inadequate oral fluid intake and diarrhea could lead to hypovolemia and delay dialysis.
+The patient was discharged home on hospital day 9 based on a test-based strategy as per CDC guidelines because of his history of solid organ transplant . No outpatient dialysis precautions were recommended to the patient as he had two negative COVID-19 tests (≥24 h apart) .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_674_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_674_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..74067028fc5e3a902108faaedf833d5651c3b150
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_674_en.txt
@@ -0,0 +1,5 @@
+A 24 year-old right handed male consulted the neurology outpatient clinic for recurrent headaches evolving since one year. He described bilateral frontal and/or temporal attacks of throbbing headache, moderate to severe in intensity, worsened by head movements and accompanied by nausea, photophobia and phonophobia. The headaches were alleviated by rest and paracetamol 1 g tid he took no more than 10 days per month. Attacks lasted between 12 and 60 hours if untreated. There was no identified trigger factor. He never had symptoms suggestive of a migraine aura or an epileptic seizure. He reported a mean frequency of 2 to 3 attacks per month during the first 5 months of appearance of the headaches whereafter attacks progressively increased in frequency up to 5 to 7 severe attacks per month, which significantly impacted on his social and professional life. On taking history, the patient reported having consumed undercooked porcine meat. He had no history of head trauma, weight loss or chronic medical condition. He had no previous personal or family history of headaches or migraine.
+General physical examination was normal. Blood pressure was 115/70, heart rate 68 beats per minute, respiratory frequency 15 cycles per minute and axillary temperature of 36.8°C. The patient weight was 71 Kg.
+Neurological examination was totally normal. Cranial nerve examination was normal; there were no motor, sensory or cerebello-vestibular abnormalities. There was no neck stiffness or Kernig’s sign. Temporo-mandibular joint examination and sinus point palpation were normal. There was no neck or pericranial tenderness on palpation.The EEG was unremarkable. Neuroimaging was scheduled to rule out a secondary headache. Brain CT scan showed two contiguous occipital cystic lesions with ring enhancement and surrounding edema suggestive of cerebral neurocysticercosis . On laboratory work-up, blood serology for cysticercal antibodies was positive. Full blood count, erythrocyte sedimentation rate, c-reactive protein level, human immunodeficiency virus serology, liver and hepatic function were all normal.
+Albendazole (1000 mg/day) and prednisolone (60 mg/day) were prescribed for seven days. He was asked to take ibuprofen 600 mg bid during headache attacks. A migraine calendar was provided to the patient to monitor the headaches.
+The patient was examined again two months after the end of his treatment. There was a reduction in headache frequency (from 5–7 to 2 attacks/month) and severity. A control brain CT scan was proposed, but could not be afforded by the patient. Six months after treatment of neurocysticercosis, the patient is still presenting 1 to 2 attacks/month, with no interference with his daily activities and easily relieved by ibuprofen intake.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_692_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_692_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..685360919e8d2b2cf076fbd0989a0b3468df0c0c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_692_en.txt
@@ -0,0 +1,4 @@
+A 30-year-old healthy Caucasian male presented to the emergency room after feeling a pop while playing basketball. He had a history of recurrent intermittent posterior calf pain. He endorsed having recently trained for and completed a marathon two weeks before the presentation. His initial management was for a presumptive Achilles rupture; he was placed in a boot and advised to be weight-bearing as tolerated. He then presented to an orthopedic foot and ankle clinic for follow-up. His examination was notable for a palpable defect in the Achilles tendon, about 3 cm proximal to the insertion. There was asymmetry in the resting position of his feet when prone with his knees flexed, and Thompson’s test was abnormal. He was also noted to have a prominent bony mass in his posterior calf. The bony prominence was in close proximity to the Achilles rupture site. He was aware of the prominence and told during adolescence that it was a benign bony growth. The bone mass had previously caused irritation in his calf with restrictive shoe wear, the donning of boots, and activities requiring significant pushoff and forced dorsiflexion. The aforementioned irritants lead to a history of well-established symptoms of discomfort near the site of the current injury. The patient noted a “pulling” sensation at his Achilles tendon during symptomatic periods. Despite having known symptoms, he had not experienced discomfort or functional limitations significant enough to consider specialist care. The patient did not have a history of bony lesions at other sites and denied familial or hereditary genetic conditions associated with multiple bony lesions. We believe this solitary lesion was sporadic in nature.
+Radiographic evaluation at presentation was significant for posterior bony prominence in the distal tibia with soft tissue irregularity at the Achilles tendon proximal to the insertion . The patient sustained an acute traumatic Achilles tendon rupture in the setting of a longstanding osteochondroma in the posterior tibia. On exam, the rupture site was very close to the site of the osteochondroma. We discussed treatment options, both operative and nonoperative, and ultimately, he elected to proceed with surgery. The surgical plan included Achilles tendon repair and excision of the posterior tibial osteochondroma to prevent future mechanical irritation at the repair site.
+A posterior open incision was made and carried down through skin and subcutaneous tissue to the paratenon . The tendon rupture was identified . The edges were cleaned, and any nonviable portions were debrided. Next, we found the bony mass was immediately palpable and in contact with the tendon. The lesion had eroded through the anterior paratenon, and the posterior tip was visible through the rupture site . Therefore, we elected to proceed with the excision of the osteochondroma. We opened the deep compartment, mobilized the FHL tendon laterally, and dissected between the neurovascular bundle and the muscle belly. We exposed the bony mass, isolated it from all surrounding tissue, and then used an osteotome to remove it. Once the mass was no longer prominent, we used a rasp to smooth any sharp edges . We confirmed appropriate resection both clinically and fluoroscopically, irrigated the site, and placed bone wax on open areas to prevent regrowth and augment hemostasis from bleeding bone. The ruptured tendon was repaired using Suture Tape (Arthrex, Inc., Naples, FL) with a running Krakow proximal and distal. The tendon edges were approximated, and sutures were tied together to complete the Achilles tendon repair. This was then augmented with a running-peritendinous repair. The wound was closed in layers and splinted in resting plantarflexion. He was made non-weightbearing for 2 weeks, followed by the initiation of our usual functional rehabilitation protocol . The resected lesion was evaluated by pathology. The gross specimen was found to be partially surfaced with roughened cartilage. Histologic exam findings were consistent with exostosis with fatty marrow and focal partially acellular trabeculae .
+At his first post-operative evaluation, 2 weeks post-surgery, his wound was well healed, radiographs were obtained, and he started physical therapy (PT) . He continued to do well with minimal pain and had made progress regarding range of motion with PT. He noted some subjective stiffness in the great toe range of motion, which was resolved by the final follow-up. At 3 months post-operatively, he was participating in PT and continued to do well. He has returned to work without issue and is resuming athletic activities. At the final follow-up, he reported no pain with activities and that he had returned to running 4 miles a day as well as playing basketball recreationally. He feels clinically improved and is particularly relieved to no longer feel the mass in his posterior calf.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_695_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_695_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..af37ab3580afe21b634ae7e987278924f4d19895
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_695_en.txt
@@ -0,0 +1,7 @@
+Our patient is a 31-year-old Sudanese female from Sudan who came to Canada in July of 2017 as a refugee. She is recognized as a Government-Assisted Refugee (GAR) which is defined as “a person who is outside Canada and has been determined to be a Convention refugee and who receives financial and other support” .
+Upon arrival in Canada with her 5 children - aged 5 to 16 years - she underwent medical evaluation and was put in contact with a “Welcome Clinic” which specializes in medical evaluation of refugees. After undergoing routine medical evaluation, she was diagnosed with HIV and severe dental caries in August 2017. When she was tested 1 year prior to arriving in Canada, she was negative for HIV.
+After being diagnosed with HIV she was put into contact with an HIV specialist with whom she is currently following up with. The patient is on government assistance and is receiving financial aid for herself and her children. The cost of living is automatically deducted from her bank account. The government assistance will expire in a year and then she must provide for herself or resettle [, ]. The patient does not understand how the financial aid system works and reports that she constantly worries about what will happen to her and her children after the year of assistance have expired.
+She reports that she has not told anyone about her diagnosis; she has only told those that are involved in her medical care. She is embarrassed and afraid of what people will think about her after learning about her diagnosis. Her only support system is her children and she refuses to tell them about her diagnosis.
+In her refugee camp in Sudan, she was given education regarding HIV including how HIV is transmitted, the risk factors associated with it, and practices regarding HIV risk reduction. When discussing her diagnosis, however, she did not know that treatment was lifelong and she was under the impression that after one course of treatment, she would be cured.
+When discussing if she has any other concerns with her diagnosis or her transition to Canada, she explains that her teeth are still sore, and her dental carries have not been resolved yet (almost 5 months after visiting the dentist). According to the patient’s record, the dentist was unable to provide any care due to administrative issues. She also goes on to state that transportation is a very big issue for her here as she does not understand how the transport system works here -she relies on a social worker from the Welcome Clinic to assist her in her transportation. Similarly, language has been a concern for her as her dialect of Arabic is different than those in her medical care team and therefore, she expressed that she has difficulty in speaking with medical staff.
+Currently, the patient is stable on her antiretroviral’s (ARVs) and is following up with her infectious diseases specialist.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_70_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_70_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a96e2cf50ba630f180392a5b1be1e564bc6a5d66
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_70_en.txt
@@ -0,0 +1,14 @@
+A 29-year-old male complaining of bilateral forearm tingling and bilateral upper extremity weakness visited the outpatient clinic of our department.
+His primary symptoms were bilateral forearm tingling and pain. These symptoms began 6 mo prior to the visit. Within a few days, bilateral upper extremity weakness also began. There was no improvement in symptoms for several weeks. Thus, he visited the neurology department of another hospital. Under suspicion of radiculopathy, cervical spine magnetic resonance imaging (MRI) with enhancement and electrodiagnostic study were performed. However, abnormalities were not found. During the follow-up period at that hospital, brain MRI, computed tomography, and arteriography of the left upper extremity were performed, but a diagnosis could not be made.
+Later, when the patient visited the hospital, he complained of bilateral forearm tingling, weakness, and bilateral arm muscle spasms.
+The patient was not taking any medications and had no previous diagnoses. The patient did not have any history of hospitalization or surgery.
+He had no familial history of congenital, allergic, or systemic disease. The patient smoked approximately half a pack of cigarettes a day for 5 years and did not drink alcohol.
+On physical examination, no external wound was observed. The circumference of both arms was not different and distinct atrophy of biceps or deltoid muscles was not present. The range of motion for both shoulders and elbow joints was not limited. The pain was not aggravated by movement.
+Paresthesia was present in both forearms, but the symptom site did not match with peripheral nerve distribution or cervical root dermatome. Manual muscle testing was grade 5 throughout the right and left upper extremities except in bilateral elbow and shoulder flexion. Manual muscle test of bilateral elbow and shoulder flexion showed grade 4. The patient could flex both his elbows with a 2 kg dumbbell but not with a 5 kg. The deep tendon reflex of both bicep muscles was symmetrically decreased.
+Before the symptoms began, he started working out at a fitness center. He did weight training, which is commonly practiced. However, he extensively stretched his pectoralis minor muscles. Figure shows the stretching exercise of the pectoralis minor that the patient described. Both shoulder joints were mildly extended, 90° externally rotated, and 45° abducted. Both scapulae were retracted, and the elbow joints were bent approximately 90°. The patient placed his elbows on the wall right next to the door and pushed his trunk forward.
+There were no abnormalities in laboratory tests including complete blood count, electro profile, liver function test, kidney function test, routine urine analysis, blood coagulation test, and thyroid function test. Acetylcholine receptor antibody, erythrocyte sedimentation rate, C-reactive protein, vitamin B12, and folate were within normal limits. In addition, blood calcium, ionized calcium, creatine kinase, and phosphate were within normal limits.
+Tables and show the electrodiagnostic study of the patient. Bilateral axillary, musculocutaneous, median, and ulnar compound motor action potential (CMAP) were within normal limits. Bilateral median, ulnar, and bilateral lateral antebrachial cutaneous SNAP were within normal limits. Bilateral median F-waves were within normal limits. Electromyography of the bilateral upper extremities showed abnormal spontaneous activities in the bilateral biceps and brachialis muscles with reduced recruitment and interference pattern. These electrophysiologic findings were indicative of bilateral musculocutaneous neuropathy.
+Tables and show the patient’s electrodiagnostic study performed at a previous hospital approximately 4 mo before the follow-up study. Compared with Table , Table shows that amplitude of each musculocutaneous CMAP was decreased.
+As mentioned above, electrophysiologic findings were indicative of bilateral musculocutaneous neuropathy. To confirm the diagnosis, MRI of both arms was performed.
+Figures and showed the MRI of both arms and brachial plexus of the patient. Significant abnormality was not observed in either brachial plexus and distal peripheral nerves.
+Figure showed the patient’s cervical spine MRI performed at a previous hospital approximately 6 mo before the visit to our clinic. Specific abnormalities were not observed on cervical spine MRI.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_711_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_711_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..f5decc8d57cd9e1fa6391d89179e36aea525474f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_711_en.txt
@@ -0,0 +1,7 @@
+An 85-year-old white male patient was initially taken care of by an emergency medical team for a trauma following a car accident. The car exited the road and underwent five somersaults. There were no other victims involved. On primary evaluation, the patient presented a head trauma with loss of consciousness, a left ear lobe trauma, and a left thoracic trauma with emphysema. Consciousness restored spontaneously with a Glasgow Coma Score of 15/15 after a few minutes.
+The patient was sent to the nearest hospital where a whole-body computed tomography (CT) scan was performed. A brain CT scan revealed air inside both lateral ventriculi and in the basal cisterns . There were no associated skull fractures or intracranial bleeding. There was also perimedullar air in the spine at levels C3–C4 and C7–T1 . No spinal fractures were seen. There were posterior fractures of all left ribs, anterior fractures of the fourth and fifth left ribs, and a left non-compressive hemopneumothorax. The left scapula was fractured. Soft tissue emphysema ranged from the left thorax to the neck with retropharyngeal extension. There was a pneumomediastinum. A CT scan showed no sign of tracheal or bronchial fistula.
+After the CT scan, the patient’s hemodynamic and respiratory state worsened. The patient was intubated; norepinephrine infusion and blood transfusion were initiated. A left thoracic drainage was performed and drew 500 mL of blood. The patient was then transferred to our surgical intensive care unit (ICU) for thoracic surgery due to the displacement of the left costal fractures.
+On arrival in our ICU, our patient presented with hemorrhagic shock due to parietal thoracic bleeding and hemothorax. Our patient was on high doses of norepinephrine. Transfusion was continued with red blood cells (RBC), fresh frozen plasma (FFP), and fibrinogen. Costal osteosynthesis of left ribs 3–9 was performed by thoracotomy and a new thoracic drainage was put in place, which allowed the control of the shock.
+After reviewing the brain CT scan and examination by the neurosurgical team, there were no signs of skull fracture to account for the pneumocephalus thus no neurosurgical indication was retained.
+A control CT scan was performed on day 6 and showed total regression of the pneumocephalus and the pneumorachis. The evolution was marked by multiple ventilator-acquired pulmonary infections requiring the pursuit of invasive ventilation and sedation. Multiple attempts of sedation withdrawal were performed but full neurological recovery could never be obtained due to agitation or a rapid need for sedation for ventilatory purposes. A follow-up CT scan performed on day 30 revealed no intracranial bleeding or stroke, but a left pleural hernia between ribs 5 and 6.
+Our patient’s state finally worsened with septic shock due to ventilator-associated pneumonia leading to multiple organ failure with acute respiratory distress syndrome requiring prone positioning, acute kidney failure on continuous hemodialysis, and major hemodynamic failure despite high doses of norepinephrine. Our patient died on day 37.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_712_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_712_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2c8fbd23629cf0738db483cb2c6140d9b0ba474f
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_712_en.txt
@@ -0,0 +1,4 @@
+A 60-year-old Chinese male has developed slow response, abnormal behavior and sleep disorder for 1 month. At first, after admitted to the hospital in his hometown and given only sodium supplement and support treatment, his symptoms disappeared but quickly reoccurred. After that, his symptoms became more and more serious and he gradually developed seizures and irritability. He demonstrated confusion, memory loss, insomnia and abnormal behavior when transferred to our hospital in April 2020.
+He had no particular previous medical history except for typhia 40 years ago and recovered with no sequel. Neurological exam revealed poor mental state, slow response and damaged memory, attention, calculation and orientation. Cranial nerves, cerebellar function, motor system, sensory system, deep tendon reflexes and pathological reflexes remained normal.
+Serum sodium was 119 mmol/L (reference range: 135 ~ 153 mmol/mL) and chlorine was 81 mmol/L (reference range: 90 ~ 110 mmol/L) at first admission. Serum procalcitonin was 0.048 ng/mL (reference range: < 0.046 ng/mL), C reaction protein was 8.05 mg/L (reference range: < 5 mg/L). Cerebrospinal fluid (CSF) electrophoresis IgG index was 0.71 (reference range: 0.3 ~ 0.7). Intracranial pressure was 150mmH2O. CSF routine biochemistry for protein content and glucose were normal and infectious test for virus, including herpes simplex virus, tuberculosis, fungal and Cryptococcus were negative. CSF cytology and cytometry were negative for malignant cells. Serum AE antibody spectrum demonstrated positive anti-LGI1 IgG and anti-GABABR1 IgG using cell-based assays, while other AE-related auto-antibody, such as anti-NMDAR, anti-AMPAR1, anti-AMPAR2, anti-CASPR2 were negative . Mini mental state examination score was 15. Electroencephalogram (EEG) indicated moderate diffusion abnormality . Brain enhanced MRI scan was normal. Tests for screening malignancy, including tumor markers and an ultrasound of the liver, gallbladder, spleen, pancreas, kidney, testicle were normal. Chest enhanced CT scan revealed mild inflammation in left lower lobe.
+For treatment of AE with coexistent anti-LGI1 and anti-GABABR1, he received 1 g and 0.5 g intravenous methylprednisolone separately, 3 days for each dosage, and then remained on an oral steroid taper for half year. After intravenous and oral sodium supplement, blood sodium and chlorine gradually increased to normal . His symptoms improved greatly and EEG recovered to normal.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_728_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_728_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..02bdde767f251ca22176cf92fecb1e188d874d9b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_728_en.txt
@@ -0,0 +1,9 @@
+The patient was a 53 years old woman with a history of hypertension and diabetes mellitus type II who was referred to a heart center for inserting an implantable cardioverter defibrillator (ICD) after a few attacks of sudden ventricular tachycardia and loss of consciousness that had not responded to medical therapy. The ICD was successfully inserted.
+After six months, the patient returned to the heart center complaining of an awkward and unpleasant sensation from the moments the ICD sensed the tachyarrhythmia and shocked her. Following is the patient's drug history: Mexiletine, diabezide, aspirin, amlodipine, metohexital, metformin, atorvastatin, valsartan, and empagliflozin. Stellate ganglion block was done twice in the center, aiming to modulate the pulse rate and ICD shock number. Aspirin was discontinued four days before each block.
+The first session of SGB was done six months after the insertion of the ICD. The block was performed unilaterally under fluoroscopy guidance with 40 mg triamcinolone and 6cc ropivacaine 0.25%, first on the right side and the next day on the left side in two successive days with the same method and the same drugs. Generation of horner's syndrome and unilateral block side change in the temperature of the upper limb was determined as block success (, -).
+After these successful blocks, the patient was symptom-free for about two months. Symptom-free means there was no activity or shocking ICD due to tachyarrythmias. After this time, another event of ICD's shock happened. The patient was admitted, and another session of unilateral SGB was done with the same method and drugs. At this time, such as the previous time, the symptom-free period was also about two months.
+Finally, it was decided to perform radiofrequency SGB to increase the duration of the effect. Before initiating the procedure, we consulted with a cardiologist. He visited the patient a few days earlier and came to the operating room at the beginning of the procedure initiation. Monitoring vital signs, including heart rate, blood pressure, and electrocardiogram (six leads) was performed in the operation room, and the cardiologist deactivated the ICD with a magnet before initiating the block. Furthermore, the cardiologist stayed in the operating room all over the time of block until the end and then reactivated the ICD again.
+Patient preparation with neck extension and slight head rotation to the opposite side was done in the supine position. The skin was sterilized with betadine and alcohol. By linear ultrasound transducer, 5 - 12 MHz (Sonosite, EDGE2, USA), the anterior tubercle of the transverse process of C6 and, after moving caudally, the C7 transverse was confirmed. Then under the guidance of sonography with a short axial view, the internal jugular vein, the longus colli muscle, and the carotid artery were identified . For better screening of the vessels through the needle course, color Doppler mode was used. After skin infiltration, with a real-time ultrasound guide, an RF sharp needle 22-gauge with a 5 cm length and 5 mm active tip (Cosman, USA) from the lateral side of the probe was introduced in-plane (from the left direction for doing unilateral RF neurolysis). As we first performed PRF, which had no significant pain and irritation, we did not inject any local anesthetic before doing PRF. The needle tip was placed on the longus Colli muscle and under the prevertebral fascia. Aspiration for cerebrospinal fluid, air, or blood was negative, and 1 mL of saline was injected. A neuro-term RF electrode with a 50 mm length was inserted and connected to the generator. The RF needle was positioned perpendicular to the ganglion for performing PRF, and for thermal RF, the needle was placed alongside the SG. In the next step, sensory stimulation was performed with 50 Hz, 0.1 - 0.5 V, with no neural numbness to the upper limbs or other areas. We checked the proximity to recurrent laryngeal nerves, phrenic or the segmental nerve, which are crucial.
+For motor stimulation, at 2 Hz, 0.4 - 1.0 V exercise test, no corresponding segmental muscle tremors, and the jumping sensation was observed. Motor stimulation was performed by asking the patient to say "ee" to check for preservation of the motor function and exclude needle malposition. After the negative sensory and motor test, high voltage (60 V) PRF at 42°C for 360 s, 20 ms pulse width, and 2 Hz frequency started. Then before starting RF at 80ºC, we injected 1cc lidocaine 2% to prevent irritation and pain that may result from neurolysis at high temperatures. At 80ºC for 60 seconds, thermal left unilateral RF neurolysis was performed and repeated four times after needle-tip rotation and directed to the most medial site and most ventral aspect of the C6 and C7 transverse process under US guidance, with repeated sensory and motor stimulation before RF lesioning. Thirty minutes after the procedure's termination, a follow-up ultrasound screening was done to exclude any hematoma formation.
+From pre- to post-block, there was an increase in the forehead and hands temperature, as recorded by a skin thermometer, which was used as a surrogate for a successful block.
+After doing RF neurolysis in multiple time intervals, we visited the patient 1, 3, 6, 12, and 14 months later, and observed no signs of ventricular tachycardia. The patient did not complain about the unpleasant sensation of ICD activity and shock. At this time, she did not have the problem up to 14 months after the procedure and showed no sign of recurrence of the cardiac tachyarrhythmia.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_73_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_73_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..1e9817f797c9f28bd0e6d0f3022948f6afe9f1f1
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_73_en.txt
@@ -0,0 +1,7 @@
+A 48-year-old man was admitted to Jinhua People's Hospital on June 29, 2021 due to change in stool habit for 5 d.
+His symptoms started 5 d previously and were accompanied by a change in stool habit (yellow, thin, pasty stools 3-5 times a day, without mucus and blood). No significant change in body weight was noted.
+The patient had a history of surgery for hypofractionated adenocarcinoma of the stomach 6 mo ago. According to the World Health Organization (WHO) Classification of Digestive System Tumor, hypofractionated adenocarcinoma is defined as the cancer cells are short columnar or indefinite, arranged in small nests or strands, and basically without glandular tube structure.
+The patient had no relevant personal and family history.
+On examination, his abdomen was soft, old surgical scars were visible in the upper abdomen, and no pressure pain, rebound pain, or masses were found.
+Laboratory examinationsshowed that routine blood, urine, stool, liver and kidney function, carcinoembryonic antigen, alpha-fetoprotein and carbohydrate antigen 199 were all within the normal range.
+The patient was advised to undergo abdominal enhanced computed tomography (CT) and colonoscopy, and the results of colonoscopy on July 1, 2021 suggested a submucosal bulge approximately 1.0 cm × 1.0 cm in the rectum 8 cm from the anal verge, with red surface erosion . Narrow band imaging (NBI) and magnification colonoscopy showed uneven caliber and distribution of blood vessels. Type2B was considered according to JNET staging .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_743_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_743_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..727da4791e94dc9ffb2c05fd8fbc0b54fe4e80ba
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_743_en.txt
@@ -0,0 +1,4 @@
+A 38-year-old male (Caucasian) patient from Turkey presented with a persistent severe headache with a duration of approximately three months. Both the severity and duration of the symptoms increased gradually during this time. Vomiting, nausea, and temporary gait disturbance were present during the three weeks leading up to his hospital visit. According to his clinical history, his headache did not respond to any prescribed medication, and his complaints did not correspond to a specific posture. Hematological parameters were within normal limits, and the serological test for human immunodeficiency virus was negative. Visual field and visual quality were tested with standard clinical finger confrontation. The results of tests were free of abnormal findings. A fundoscopic examination revealed that his optic disc margins, ratio of artery to vein sizes and venous pulsation were within normal limits. Mid-line cerebellar function was tested by having our patient walk on a straight line, and hemispheric cerebellar function was tested by having our patient perform rapid alternating movements and by rapidly having him touch his nose or the physician's moving index finger. The examinations of cerebellar, ganglionic, and cortico-spinal pathways were all normal. The results of all of these neurological examinations were within normal limits and suggested that our patient did not have any symptoms of neurological disturbance. To identify the underlying pathology, magnetic resonance imaging (MRI) was performed. This examination revealed that the third ventricle was completely filled with a mass-like lesion that was hypointense on T1-weighted scans and hyperintense on T2-weighted scans. The lesion was partially obstructing the foramen of Monro; however, it did not cause severe hydrocephalus . Our patient underwent surgery for a craniotomy.
+An intra-hemispheral transcallosal approach was performed, allowing access to his right ventricle and the foramen of Monro. Due to tumoral expansion, the foramen of Monro was dilated. Although analysis of a frozen section was consistent with PCNSL, the tumor was completely resected without complication.
+Histopathological examination revealed increased lymphoma sheets of round cells with small to moderate amounts of cytoplasm . Our patient underwent a staging evaluation that included a whole-body positron emission tomography/computed tomography (PET/CT) scan, bone marrow biopsy and analysis of blood chemistry. All of these procedures failed to reveal any abnormalities. The PET/CT scan showed a slight accumulation of 2-[18F] fluoro-2-deoxyglucose in the original location of the tumor.
+A post-operative cranial computed tomography (CT) scan concluded soon after surgery revealed a hematoma in the third ventricle . The neurological examination was free of symptoms. Follow-up CT scans were conducted and revealed a blood clot that obstructed the foramen of Monro, resulting in hydrocephalus. However, the follow-up cranial CT scan did not show the hydrocephalus, which indicated that the hematoma was no longer present. Our patient refused all treatment options except corticosteroids. A follow-up cranial MRI conducted six months after surgery showed that the lymphoma had not reoccurred . Our patient was available for follow-up after one year.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_74_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_74_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..2d6328aa449f9f2bf6e0ec7abe5881f7eb119203
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_74_en.txt
@@ -0,0 +1,11 @@
+A duodenal mass that had been discovered 2 mo previously
+A 47-year-old man was admitted to our hospital on November 20, 2015 because of a duodenal mass that had been discovered 2 mo previously. Electronic gastroscopy at another hospital revealed a duodenal papillary mass that had been considered to be a high-grade intraepithelial neoplasia and was left untreated. The patient reported having no significant, recent weight loss. We carried out relevant examinations, confirmed the diagnosis, and took further treatment measures.
+The patient was healthy before.
+The patient and families were healthy before.
+The patient’s vital signs were: Temperature, 36.2 ℃; pulse rate, 75 bpm; respiratory rate, 20 breaths/min; and blood pressure, 110/70 mmHg. The physical examination revealed a normal countenance; absence of superficial lymph node enlargement and heart abnormalities; a flat abdomen; liver and spleen not palpated below the costal margin; hypogastric region tenderness; no shifting dullness absent; bowel sounds of 4 times/min, with no increase or decrease; and gurgles and abdominal vascular murmurs not audible.
+Laboratory test results included: White blood cell count, 4.5 × 109/L; erythrocyte count, 4.42 × 1012/L; hemoglobin, 144 g/L; platelet count, 130 × 109/L; normal liver and kidney function; prothrombin time, 14 s; fibrinogen, 3.09 g/L; tumor marker CA-125, 7.19 U/mL (normal < 35 U/mL); CA-199, 7.07 U/mL (normal < 37 U/mL); alpha-fetoprotein, 3.17 ng/mL (normal 0.89-8.78 ng/mL); and CEA, 1.67 ng/mL (normal < 5 ng/mL). The rest of the parameters were within the normal range.
+Abdominal computed tomography showed a space-occupying lesion at the head of the pancreas and the duodenal bulb . Due to the aforementioned imaging findings, a preliminary diagnosis of a duodenal papillary space-occupying lesion was made.
+Two days before the operation, the patient was fed a liquid diet. After fasting for 8 h before surgery, an intravenous injection of 2 g cefazoxime sodium was given 30 min before surgery to prevent infection. A patient-controlled analgesia pump was provided postoperatively. The patient was treated by hemostasis, nutrition, and water and electrolyte supplementation. Routine blood and biochemical indexes were monitored.
+After general anesthesia, the patient was placed in a supine position, and then disinfected and trocar inserted. A laparoscopic exploration was then performed. As the gallbladder wall tension was not increased, the hepatoduodenal lymph nodes were not significantly enlarged, and there were no other significant findings in the peritoneal and pelvic cavities, we decided to perform a pancreas-preserving duodenectomy with a median abdominal incision. The gastrocolic ligament was opened to expose the duodenum, which was dissociated along the upper edge of the duodenum until the ligament of Treitz. The branch vessels entering the upper end of the duodenal bulb and the pancreas were ligated using USP 0 sutures. On turning the descending part of duodenum to the right and freeing the common bile duct and pancreatic duct on the inner side of the descending part of the duodenum , a 3 cm × 3 cm solid mass with a hard, firm texture was palpable. The mass was not found to involve the pancreas and hepatoduodenal ligament. The common bile duct was freed along the duodenal papilla upward, until no significant mass invasion could be found. The common bile duct was severed at the pancreas side and the pancreatic duct was freed from the head of the pancreas toward the inner side until no significant mass invasion was found. After the distal part of the stomach, duodenum, and the tissues surrounding the pancreas were freed, the stomach was transected 6 cm from the pylorus using an endoscopic linear cutter and the jejunum was also transected 5 cm under the ligament of Treitz using a 6-0 linear cutter. After removing the specimen, the distal part of the jejunum was lifted from behind the colon to the level of the porta hepatis. An incision with a length equivalent to the opening of the bile duct was made on the contralateral edge of the mesojejunum, 5 cm from the jejunal stump. Bilioenteric anastomosis was performed through full-thickness continuous sutures using 6-0 prolene sutures. The residual pancreatic body and tail were freed and lifted for placement of an infusion tube scalp needle with an opening on the side. The main pancreatic duct and jejunal mucosa were continuously sutured using 5-0 proline sutures, and the head of the pancreas and the seromuscular layer of the jejunum were sutured in an interrupted manner, using USP 0 sutures. A Frankenman 25 stapler was used for Billroth I in situ anastomosis between the pyloric part and the jejunum, and the serous layer at the anastomosis site was sutured using USP 0 sutures . The operation was successful and the tumor was completely removed. The operative time was 295 min, and the intraoperative blood loss was 100 mL. There were no obvious postoperative complications, and the patient was discharged 14 d after the operation.
+The macroscopic examination of the surgical specimen showed a cancerous tumor with a white-gray color and a hard texture in the duodenal papilla . A pathological diagnosis of adenocarcinoma of the duodenal papilla with infiltration in the full thickness of the intestinal wall was made. The stumps of the pancreatic duct and bile duct and the lymph nodes were negative and thus an R0 resection was achieved. No atypical cells were found in the pancreatic tissues surrounding the pancreatic duct and bile duct (pT2N0M0).
+A patient-controlled analgesia pump was provided postoperatively. The patient was treated by hemostasis, nutrition, and water and electrolyte supplementation. Routine blood and biochemical indexes were monitored. The patient refused to receive chemotherapy, and no obvious abnormalities were found in relevant examinations.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_760_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_760_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a8ab597fa7c3758d2a0776f955c7c7c2d87c7fcc
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_760_en.txt
@@ -0,0 +1,7 @@
+A 24-year-old woman (height, 169.2 cm; body weight, 79.2 kg) with WD was scheduled for emergency cesarean delivery at 30 weeks of gestation.
+The patient was diagnosed with WD at 3 years of age. Her liver function had deteriorated severely enough to require liver transplantation at 20 years of age. However, anti-copper therapy improved her liver function and was continued during pregnancy. She was hospitalized at 25 weeks of gestation for thrombocytopenia and fetal growth restriction (FGR) caused by placental insufficiency. Aspartate aminotransferase (AST) and alanine aminotransferase (ALT) serum levels were normalized during pregnancy, while antithrombin III (AT-III) levels were significantly lower . On hematological evaluation, performing anticoagulation therapy with AT-III concentrate was suggested to prevent thrombophilia-induced placental dysfunction.
+The patient’s body weight had rapidly increased by 1 kg/day with marked ascites and severe edema. She experienced dyspnea and could not ambulate due to dramatic weight gain. She was also diagnosed with obstetric DIC presenting with oliguria, thrombocytopenia, respiratory distress, liver dysfunction, and severe coagulopathy . At 30 weeks of gestation, emergency cesarean delivery was performed under general anesthesia to improve her liver function. We performed supplementation with 10 units of platelet transfusion, 3 packs of cryoprecipitate, and 3 g fibrinogen concentrate.
+In the operating room, a 16G venous catheter was inserted. We used rotational thromboelastometry (ROTEM® sigma, Tem Innovations GmbH, Munich, Germany), which showed normal coagulation function . Under standard monitoring and bispectral index, we performed rapid sequence induction using 130 mg propofol, 0.05 mg remifentanil, and 70 mg rocuronium. Because her face and tongue were edematous and the Mallampati classification was III, intubation difficulties were expected. Therefore, we used a video laryngoscope (McGRATH MAC#3) for tracheal intubation. We maintained with oxygen in nitrous oxide (2:3) and 0.7% sevoflurane until delivery.
+After delivery, the baby (1173 g) showed respiratory distress. Tracheal intubation and administration of intratracheal lung surfactant were performed. One- and 5-min Apgar scores were 2 and 5, respectively. The neonatologists performed mechanical ventilation management for 2 days after delivery. The infant was discharged without further complications.
+After delivery, continuous intravenous administration of propofol and remifentanil was started. Intraoperatively, 0.5 mg intravenous fentanyl was administered, and continuous fentanyl injection was started at 0.04 mg/h for postoperative analgesia. Intraoperative hemorrhage was 1813 mL (including amniotic fluid), and ascites was 1000 mL. The operation time was 61 min, and anesthesia time was 179 min. Urine volume was 80 mL, and infusion volume was 1954 mL (654 mL of crystalloids and 1300 mL of colloids). The patient also received 3 units of red blood cells and 6 units of fresh frozen plasma (FFP). The operation was completed without massive bleeding. However, a postoperative chest X-ray indicated pulmonary edema. We decided to continue mechanical ventilation in the intensive care unit (ICU). Albumin and diuretic administration improved the patient’s oxygenation and allowed for extubation the next day. She was transferred to the obstetrics ward 3 days postoperatively.
+On the 15th postpartum day, her body weight showed a decrease of 20 kg, and she was discharged from the hospital. Subsequently, coagulation status was improved to pre-pregnancy levels 40 days after delivery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_793_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_793_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..b6e173c663319e880683bd2421efdc5e2a6f9865
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_793_en.txt
@@ -0,0 +1 @@
+A 63-year-old, G3Y3, postmenopausal, morbid obese woman presented to the outpatient clinics with the complain of vaginal bleeding. Physical examination was compatible with atrophy in vulva, vagina and cervix. Pap smear test was reported as negative. Transvaginal sonography revealed endometrial thickness of 12 mm. Following endometrial biopsy was reported as atypical, complex endometrial hyperplasia. Thus, laparoscopic hysterectomy and bilateral salpingo-oophorectomy and omental biopsy were performed. 10 mm telescope and advanced bipolar energy modalities were used during surgery. First, 10 mm trocar was directly inserted through subumbilical incision of 1 cm. laparoscope was inserted following insufflation of 3–4 l co2. Three 5-mm-trocars were inserted abdominally through 2 ipsilateral inguinal and single contralateral inguinal incisions. Rumi (R) II uterine manuplator was used for uterine manipulation. The frozen sections of hysterectomy specimen was compatible with a myometrial invasion more than 1/2. Therefore, bilateral pelvic lymphadenectomy was processed. We recognized that the right obturator nerve was transected accidentally by 5-mm Ligasure(R) during right obturator lymph node dissection . It was seen that the nerve was transected in a full-thickness manner, besides thermal injury was occured at nerve ends. Following debridement (1 mm in size) of thermally injured areas,the nerve ends were reapproached . An end-to-end reanastomosis without tension was performed by epineural sutures (4-0 polypropylene) via laparoscopy (, ). The duration of repair was 21 min, while overall operation session was 180 min. Volume of blood loss was 150 mL. No marked loss of adductor function was observed during early postoperative period. The patient was discharged on day 3, postoperatively. On month 2 of the operation, the patient reported numbness at medial aspect of thigh and minimal difficulty in climbing upstairs. Complete clinical recovery was detected on month 6. No neurological deficit was detected in the muscle group innervated by obturator nerve in her EMG at the end of the 6th month, postoperatively.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_797_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_797_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..245bd963634e7ccbd20cde98099f61a07d169f8d
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_797_en.txt
@@ -0,0 +1,4 @@
+A 37-year-old man presented to our emergency department (ED) with recent history of fever . He was born in Sierra Leone and of African ethnicity, and had lived in the Netherlands since 2005. History revealed that the patient had fallen on his left knee 3 days ago after he collided with a car while riding a bicycle. He had a superficial skin defect just below his left knee from scraping the pavement. There was no penetration of the knee joint. Since then he had a swollen left knee and a sore right hip. In the days prior to presentation to the ED, the pain increased and he developed progressive dyspnea. His prior medical history included posttraumatic stress disorder, alcohol abuse, and epilepsy, of importance he reported no prior joint swelling or pain. Furthermore, he had no recent travel history and he did not smoke or use drugs.
+During examination there was a free airway with a respiratory rate of 39/minute with oxygen saturation of 81% on room air. Chest X-ray showed bilateral pleural effusion with bilateral peripheral consolidations . His blood pressure was 109/85 mmHg with a pulse of 145 bpm. Transthoracic ultrasound showed normal left and right ventricular function without any valve abnormalities. Despite a mildly decreased Glasgow Coma Scale of 13, no other neurologic symptoms were observed, in particular no sign of meningism or other neurological abnormalities such as symmetric paralysis of limbs, head, and facial musculature. Glucose levels were normal. Initially, the temperature was 37.1 °C but a few hours after admission temperature rose to 39.3 °C. The most remarkable finding during physical examination was an extremely painful, swollen left knee with an abrasion on the left lower leg.
+Laboratory findings on admission revealed a C-reactive protein of 460 mg/L, leukocyte count of 11.8 × 109/L with severe acute renal insufficiency (creatinine 245 µmol/L), arterial blood gas with metabolic acidosis based on a lactate of 6.6 mmol/L and a bicarbonate level of 19.0 mmol/L. X-ray of the left knee showed osteolytic bone lesions of the tibia and gas in the suprapatellar pouch . No blood samples were taken on admission to measure ethanol levels. Based on these findings, we concluded that he developed severe shock with organ dysfunction, but without meeting the definition of septic shock at that moment according to the Sepsis-3 guidelines . This was probably caused by bacterial arthritis or as a differential diagnosis as a result of pneumonia based on the dyspnea and chest X-ray. Pulmonary embolism and tuberculosis were ruled out by computed tomography (CT) angiography of the chest.
+The patient was treated according to the Surviving Sepsis guideline . Blood cultures were taken, and cefuroxime was administered within an hour after presentation at the emergency department, as well as administration of a tetanus vaccine. Based on physical examination and X-ray of the left knee, a bacterial arthritis was deemed most likely. Therefore, an arthroscopy was performed to confirm the diagnosis and perform a debridement. During the procedure, high quantities of pus were removed. Antibiotic treatment with flucloxacillin was started, according to the local empirical treatment of septic arthritis. In addition, thiamine was given due to the history of alcohol abuse. Postoperatively he developed severe septic shock with rapidly progressive multiorgan failure including acute respiratory distress syndrome (ARDS) with severe hypoxemia . We treated the hypoxemia with mechanical ventilation and the shock by resuscitation with fluids and high doses of norepinephrine. Despite all efforts, the patient died. Blood cultures (Biomerieux Bact/ALERT®), on admission and day 1, and synovial fluid cultures (local routine culture methods) grew C. botulinum after 1 day of incubation without any other pathogens. Sequencing (16S) of aspirated synovial fluid of the left knee showed C. botulinum. Autopsy was performed, no other cardio, pulmonary or internal organ abnormalities were found. A small superficial abrasion just below the tense swollen left knee showed yellow pus. Cross section of the tibia behind the abrasion showed a lytic lesion.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_804_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_804_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6fbf9e76cae4113aeffcbbc6e425dc1e3f8e16ee
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_804_en.txt
@@ -0,0 +1,5 @@
+A 71-year-old woman with chronic kidney failure was transferred to our hospital to treat upper abdominal pain that persisted for 4 days. The patient was conscious, but visibly distressed. Her body temperature, blood pressure, heart rate, and respiratory rate were 36.3 °C, 167/68 mmHg, 82 bpm, and 28 bpm, respectively. Physical examination revealed diminished bowel sounds, lower abdominal distension, and rebound tenderness around the umbilicus. Her laboratory investigations were unremarkable (creatinine phosphokinase 53 U/l, lactate dehydrogenase 212 IU/l) except for significant kidney failure with a creatinine level of 7.73 mg/dl, blood urea nitrogen level of 48.6 mg/dl, and mild elevation of C-reactive protein (0.5 mg/dl). Arterial blood gas analysis revealed a low pH of 7.30, partial pressure of carbon dioxide 32.9 mmHg, and severe metabolic acidosis with a bicarbonate ion level of 16.0 mmol/l, a base excess of − 9.1 mmol/l, and lactate level at 0.7 mmol/l under room air atmosphere.
+A computed tomography (CT) scout image showed distension in the right abdomen . Abdominal CT scan revealed ascites around the liver and the spleen, small bowel extension, sausage-shaped sign from the transverse colon to the rectum, and a mass (40 mm in diameter) in the rectum . Based on these findings, we diagnosed the patient with a strangulated bowel obstruction induced by intussusception associated with the intra-rectal mass and subsequently performed emergency surgery.
+Laparotomy was performed with the patient in the lithotomy position under general anesthesia. We found bloody ascites and intussusception. The mass served as a lead point and was moved to the anal side by peritoneal reflection. We were unable to relieve this invagination by the Hutchinson maneuver alone. Therefore, we performed the trans-anal procedure to push the mass gently through the anus to the oral side. Subsequently, we released the invagination using the Hutchinson maneuver . Although the bowel was not necrotic, we found a potentially malignant tumor in the cecum with mobile cecum, which was considered to be the lead point of this intussusception . We found that the regional lymph nodes were not swollen and that the tumor moved well against the intestinal wall, indicating that it had not invaded the muscularis propria. There was no right colic artery and vein arising from the superior mesenteric artery or vein. We cut the roots of the ileocecal artery and vein and resected the ascending colon and the ileocecal portion with D2 lymph node dissection as the formal oncologic treatment. The intestine was then reconstructed by functional end-to-end anastomosis. All the procedures were successfully performed without any adverse events.
+The resected mass was reddish, round, elastic, and soft, with a granular surface measuring 45 mm in length and 40 mm in width in the cecum . Histopathological examination of the specimen revealed a moderately to well-differentiated tubular adenocarcinoma in the tubulovillous adenoma . The cancerous lesion was found superficially in the mucosal layer with no regional lymph node metastasis.
+The cecorectal intussusception seemed to have occurred secondary to the cecum cancer with mobile cecum based on the intraoperative and histopathological findings. The patient had an uneventful postoperative course, except postoperative pneumonia, and was discharged from the hospital on the 25th postoperative day after an antibiotic infusion therapy. No recurrence of cecum cancer was identified 3 years after the surgery.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_855_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_855_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..a9eae4b230a3f4bd489e0e06054e5383e29b630c
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_855_en.txt
@@ -0,0 +1,8 @@
+A 14-year-old male patient came to our clinic presenting a traumatic crown fracture of the permanent, maxillary right central incisor .
+The patient had preserved the broken fragment in saline solution and it was checked for goodness of adaptation to the tooth .
+To lessen the ordeal for the already traumatized young patient, we decided to treat him using Er:YAG and Nd:YAG lasers we had at hand at our practice (Fidelis III Plus; Fotona, Ljubljana, Slovenia). Due to the patient’s age, an informed consent form for the procedure was signed by his parents.
+The trauma had left the pulp exposed ; our first decision was to perform Nd: YAG laser (SP mode, 4 W, 40 Hz, 300 μm contact fiber) pulp capping .
+We then proceeded to use the same Er:YAG device with a different wavelength (SSP mode, 200 mJ, 10 Hz, quasi-contact tip-less handpiece) to prepare the bonding surfaces of both the fragment and the tooth .
+The same surfaces were further prepared with orthophosphoric acid ( and ); bonding agent was applied, and flow composite resin was used to replace the fragment ( and ).
+For esthetic purposes, we prepared the borderline area surface with the Er:YAG laser before applying orthophosphoric acid and flow composite resin once more .
+No form of anesthesia was required nor requested by the patient. Follow-up visits performed after one, three, six, twelve, and sixteen months demonstrated the vitality of the tooth .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_856_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_856_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..e69c80f64cd1821c1150b5874b35e22bf61aacc9
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_856_en.txt
@@ -0,0 +1,2 @@
+In 2017, a 10-month-old female infant was admitted to the Department of Gastroenterology, Children’s Hospital of Soochow University, because of a history of elevated liver transaminases for more than 3 months. She was born at 30 weeks of gestation, her birth weight was 2.35 kg, and she had a history of intrauterine growth retardation. She had shown global developmental delay since birth. She defecated once every 3–4 days and was crying and restless during defecation. Her parents were physically healthy and were unrelated. She had a brother who died of “convulsion” at the age of 10 months, and there was no family history of inherited diseases.
+Physical examination was normal except for slightly high ankle tension. Her liver biochemical profile revealed elevated levels of alanine transaminase (147 U/L; normal range, 5–40 U/L) and aspartate transaminase (112 U/L; normal range, 8–40 U/L). Blood tests revealed mildly elevated levels of lactate (4 mmol/L; normal range, 0.5–2.5 mmol/L) and normal levels of IgG, IgA, IgM, and IgE immunoglobulins. Lymphocyte subset analysis was normal, as was blood coagulation function, thyroid function, blood tandem mass spectrometry, and levels of trace elements, ammonia, alpha foetal protein, and urine reducing substances. Pathogen testing was positive for cytomegalovirus IgM, and PCR for cytomegalovirus DNA in peripheral blood revealed the presence of 2.54 × 103 copies/ml; other pathogens such as Epstein-Barr virus and hepatitis A, B, C, and E were all negative. Ambulatory electroencephalography (EEG) monitoring suggested epilepsy in the form of subclinical seizures. Magnetic resonance imaging of the brain demonstrated increased extracerebral space . After the patient admission into hospital, she was treated with rehabilitation training and oral compound glycyrrhizin tablets (2.5 mg/kg per day) for 10 days. Liver transaminase levels were slightly reduced compared to the first presentation.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_891_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_891_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..6fecaf5ecf371cbccac54b2f6da4ba66934e3bb0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_891_en.txt
@@ -0,0 +1,4 @@
+A 91-year-old Thai woman with bilateral pseudophakia presented with acute left eye pain and redness. The best-corrected visual acuity was 6/9. On slit-lamp examination of the left eye, diffuse conjunctiva injection and the dendritic ulcer with terminal bulbs, highlighted by fluorescein staining, were observed on the superotemporal side of the cornea . There were no cells in the anterior chamber. She was diagnosed with herpes simplex keratitis (HSK) on the left eye. Noticeably, there was also a localized encapsulated bleb on the superonasal conjunctiva with a negative Seidel test . No peripheral iridectomy was seen and the IOP was 12 mmHg. Fundus examination revealed a cup-to-disc ratio of 0.5 with an intact neural rim.
+The patient had no underlying systemic/ocular diseases, or any significant trauma to this eye, and denied use of any topical anti-glaucoma medications. According to the medical record, she had only had two surgeries; the first operation was a nasal pterygium excision with bare sclera technique and adjunctive MMC performed 26 years ago. Unfortunately, the operative note of the previous pterygium excision, including the concentration and duration of MMC, was unavailable. The second operation was an uneventful ECCE with intraocular lens implantation 8 months after the pterygium excision. She was seen for 3 years at our hospital without any complications and then was lost to follow-up. The first notice of the bleb was approximately a year ago, which was 25 years after the surgeries.
+Gonioscopic examination revealed 5° of a localized area of peripheral anterior synechiae (PAS) at the superonasal quadrant anterior chamber angle without any fistula or fish-mouthing appearance of wound gape. Anterior segment ocular coherence tomography (ASOCT) illustrated a thick-wall cystic space . Noticeably, at the 158° cut, a straight, sharp-edged fistula, parallel to the iris plane and connected between the bleb and anterior chamber at the scleral spur, was also revealed . These characteristics corresponded with the site of the ECCE scleral wound. The location of the fistula from ASOCT coincided with the PAS in the gonioscopic view. According to the area of pterygium scar, it is highly suggestive that the site of this fistula was within the area of previous MMC application. An inadvertent bleb formation, the late complication of MMC, was diagnosed.
+She was treated successfully with a 1 week course of hospital-made topical 2% ganciclovir, five times daily for herpes simplex keratitis. The bleb was observed without further management as it was inactive and had no ocular hypotony. The patient had been informed about the warning symptoms/signs of bleb-related infection.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_89_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_89_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..ef67e9c05127e3147c185f9e81ddddb2eec5d6ae
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_89_en.txt
@@ -0,0 +1,6 @@
+A 36-year-old woman with a medical history of asthma and urticaria under treatment with levocetirizine and a combined oral contraceptive was admitted to the hospital for the study of acute diarrhea (1-2 liquid stools per day with no blood or mucus), associated with abdominal discomfort, abdominal swelling, early satiety, and asthenia with onset 2 weeks before. The patient also reported wheezing episodes on the previous week. During this period, she looked for medical assistance three times being discharged with symptomatic treatment and cotrimoxazole with no improvement. Physical examination revealed normal blood pressure (122/64 mm Hg) and heart rate (77 bpm), no fever (auricular temperature 36.5°C), 98% peripheral oxygen saturation, no mucocutaneous alterations, and cardiac and pulmonary auscultation without alterations, with moderate volume ascites as the only remarkable finding.
+Laboratory results showed peripheral eosinophilia (7,000 eosinophils/μL, 45% of the leucocytes, ref. range <500/μL) and increased seric immunoglobulin E (1,083 IU/mL, ref. range <129 IU/mL). An abdominal ultrasound revealed diffuse small bowel wall thickening and moderate volume ascites. The cell count of the ascitic fluid revealed 89% of eosinophils (8,337/μL, Table ). Serum ascites albumin gradient was inferior to 1.1, suggesting a peritoneal cause for the ascites. A thoraco-abdominopelvic computerized tomography presented no lung findings , yet it was identified a slight thickening of the distal esophagus , and diffuse jejunal and ileal wall thickening , without lymph node enlargement. An upper and lower endoscopy with segmental biopsies was performed, revealing a normal endoscopic appearance of the mucosa . At this point, the considered differential diagnosis was EoG, eosinophilic granulomatosis with polyangiitis (Churg-Strauss syndrome), hypereosinophilic syndrome, and, less likely, parasitosis, infectious gastroenteritis, food or drug hypersensitivity, celiac disease, connective tissue diseases, inflammatory bowel disease, and hematologic neoplasia [, ].
+An exhaustive screening for systemic eosinophilia causes was carried out. The peripheral blood smear did not reveal cellular atypia. Serum levels of vitamin B12 were normal − 441 pg/mL (ref. range 211–911 pg/mL), such as folate 7.2 ng/mL (ref. range 3.5–17.5 ng/mL); serum iron was slightly below normal − 31 μg/dL (ref. range 50–170 μg/dL). Serum ferritine, total iron-binding capacity (TIBC), and transferrin saturation presented normal values. Microbiologic and parasitological stool examinations were negative for pathogenic strains. Serum antibodies anti-toxocara canis, anti-echinococcus, and anti-fasciola were also negative. The immunological study revealed negative antinuclear antibodies and antineutrophil cytoplasm antibodies. There was a slight elevation of the inflammatory marker C-reactive protein (12.9 mg/L; ref. range <3) with normal erythrocyte sedimentation rate. Anti-VIH I/II antibodies were negative. Total serum immunoglobulin E was increased (1,083 UI/mL; ref. <129). Immunoglobulin subtypes other than IgE and serum protein electrophoresis were within the normal range. The inhalatory allergen panel (Rast IgE) was positive, yet the food allergen panel was negative. Skin prick tests were negative for food allergens and positive for dust mites, dog and grass allergens. Electrocardiogram presented a sinusal rhythm without alterations. Troponin I and CK-MB seric levels were normal. Spirometry presented a mild restrictive ventilatory pattern. Liver tests were normal except for slightly elevated ALT levels at admission, which normalized 3 days later. Renal dysfunction markers and urinary sediment were within the normal range. In sum, an extensive investigation of the alternative causes of peripheral eosinophilia and infiltration of other organs by eosinophils was negative.
+Empirical treatment for EoG with oral prednisolone 40 mg per day and the six-food elimination diet (eggs, milk, soy, nuts, seafood, wheat) was initiated with the support of a dedicated nutritionist. A rapid clinical improvement was observed with normalization of bowel habits and a reduction of abdominal volume. Additionally, a rapid reduction in peripheral eosinophilia with normalization at 3 weeks was observed.
+Posteriorly, results of the endoscopic biopsies confirmed eosinophilic infiltration of the duodenum and ileum (>50 eosinophils per high-power field [HPF]), less expressive on esophageal and colonic biopsies (10 eosinophils/HPF; Fig. ), which sustains the diagnosis of EoG. Gastric biopsies were negative for Helicobacter pylori.
+Three months after the initial episode and upon the terminus of the oral steroid course, the patient was in clinical and laboratorial remission and so a progressive reintroduction of eliminated foods was conducted with close monitoring. It was observed a resurgence of diarrhea and abdominal pain with seafood ingestion ceased with subsequent restriction of these foods in the patient's diet. Two years after the diagnosis, the patient repeated upper endoscopy and colonoscopy with ileal and colonic biopsies, which revealed no eosinophilic infiltration. Three years after the initial episode, the patient is asymptomatic on a diet with a restriction of seafood without relapses or the need for any treatments.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_910_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_910_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..22bb69d87661b540d8662e573d6481e12590f8f3
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_910_en.txt
@@ -0,0 +1 @@
+An 86-year-old man with no medical history presented with a persistent erythema, oozing and scaling of the left nipple. The lesion was initially characterized as mammary Paget's disease, based on clinical signs. Additionally, there was no history of predisposing factors to breast lesions such as drug use (i.g. prostate cancer treatment), gynecomastia or hormonal imbalances, such as obesity and/or testicular disorders. Physical examination revealed a mass localized in the subareolar area. Fine needle aspiration biopsy was performed on the mass and malignancy was revealed on histopathological examination. The diagnosis was made after the histological examination of a breast gland segment (14 × 11 × 6 cm in size) covered by a spindle-shaped skin (13 × 9 cm in size) bearing the nipple. The mass was well circumscribed 5 × 7 × 6 cm in size of soft and friable consistency with mucoid texture. The result from the histological examination revealed mucinous carcinoma of the breast gland (grade II) . The diagnosis was based on the presence of large amounts of extracellular mucin, in the background and detached epithelial tumor ceels in trabecular and micro papillary formations. Fibrous stroma was sparse. Immunohistochemical evaluation revealed that the neoplastic cells were positive for estrogen (ER) and progesterone receptors (PR). Therapeutically, after the modified radical mastectomy chemotherapy and tamoxifen was administered.
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_911_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_911_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..582d19c43001458e56ef063cdedc8f293579d4f0
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_911_en.txt
@@ -0,0 +1,4 @@
+A 36-year-old male patient was hospitalized due to complaints of a gradually aggravated pain on the lateral side of the left scapula for 6 months. Imaging examination showed that the neoplastic lesions on the left side of C7-T2 invaded the vertebral body of T1, T2, and caput costae of the second rib . Tumor metastasis in the left ilium was suspected . A computed tomography (CT)-guided core needle biopsy was performed to obtain the tissue samples of the paravertebral lesion in T2 and the lesion in the left ilium. The pathological results confirmed the diagnosis of FDCS. Diffuse small spindle cells were found in the hematoxylin and eosin (H&E) staining of both paravertebral and iliac lesions. Immunohistochemical staining of the paravertebral sample was positive for cytokeratin (CK){pan} and vimentin; partially positive for cluster of differentiation 68 (CD68){KP1} and epithelial membrane antigen (EMA); slightly positive for S100 and CD34; and negative for SRY-box transcription factor 10 (Sox10), Langerin, thyroid transcription factor 1 (TTF-1), and prostatic specific acid phosphatase (PSAP) . Immunohistochemical staining of the iliac sample was positive for CK{pan}, vimentin, CD68{KP1}, and epidermal growth factor receptor (EGFR); partially positive for Clusterin; slightly positive for S100, CD35, and CD20; and negative for CD21, Sox10, Langerin, and CXC chemokine ligand 13 (CXCL13) .
+Tumor resection and nerve root decompression were performed as treatment for thoracic disease. A midline incision was made, and the lamina and facet joints of T1–T3 were exposed. Four pedicle screws were implanted in T1 and T3 . The left lamina and facet joint of T1 and T2 were resected . The left second costovertebral joint and the second rib head were also resected. Transpedicular curettage was performed to ensure sufficient neural decompression of the tumor, providing a safe target volume for radiation.
+The body gamma knife was used as a radical treatment for iliac tumor and as an adjuvant treatment for thoracic disease. Body gamma knife planning and delivery were similar to those reported in previous studies (, , ). The patient was placed in a supine position and immobilized using a vacuum negative pressure bag and a body frame bed, allowing to breathe naturally. Markings were made on the four areas of the body that will receive the radiation to ensure reproducible body position. The CT images were transferred to the OPEN body gamma knife treatment planning system. A local bone destruction lesion was found at the posterior lower edge of the left ilium (near the sacroiliac joint) with clear boundaries and soft tissue density. The treatment target area was determined in the bone window on the CT image using the body gamma knife treatment planning system (window width, 1,000 HU; window level, 300 HU). The gross target volume (GTV) was delineated according to the lesion identified in the bone window. The clinical target volume (CTV) was generated by extending the GTV by 5 mm in all directions. The planning target volume (PTV) was generated by extending the CTV by 5 mm in all directions. The 50% radiation dose covered 100% of the PTV, the 60% dose covered 100% of the CTV, and the 70% dose covered 100% of the GTV. For the iliac lesion, the prescription dose for the PTV, CTV, and GTV margins were 40, 48, and 56 Gy in 10 fractions, respectively. The highest physical dose delivered at the center of the target area was 80 Gy. The biological effective dose (BED) of the RT was calculated using a linear quadratic (LQ) model, assuming an α/β ratio of 10. The BEDs at the margins of PTV, CTV, and GTV were 56, 71.04, and 87.36 Gy, respectively, and the highest BED delivered at the center of the target area was 144 Gy. For the thoracic lesion, the prescription doses for PTV, CTV, and GTV margins were 36, 43.2, and 50.4 Gy in 12 fractions, respectively. The highest physical dose delivered at the center of the target area was 72 Gy. The BEDs delivered to the margins of the PTV, CTV, and GTV were 46.8, 58.752, and 71.568 Gy, respectively, and the highest BED delivered at the center of the target area was 115.2 Gy. Radiotherapy target planning of thoracic and iliac lesions was presented in . The treatment process proceeded smoothly, the patient had no complaints, and no abnormal findings were found on blood tests after RT.
+The patient did not receive systemic treatment or other local control treatments after the body gamma knife treatment. CT examination of the iliac bone showed that the lesion size was slightly larger than that before the 2-month postoperative follow-up . Thus, iliac bone lesion resection was performed 10 weeks after RT. The pathological examination of the left iliac bone tumor suggested a small amount of bone tissue, fibrous tissue hyperplasia and hemorrhage, myofibroblast reaction, lymphocyte and plasma cell infiltration, a small amount of necrosis, and tissue cell deposition, while no tumor tissue was observed . Thus, the body gamma knife treatment resulted in PCR. The patient was followed up for 1 year, and the VAS score for back pain reduced from 8 at preoperatively to 1 at the last follow-up. Thoracic and pelvic magnetic resonance imaging (MRI) examinations showed no significant enlargement or recurrence of the tumors after 15 months of follow-up . The timeline of major clinical events during treatment and follow-up is shown in .
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diff --git a/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_91_en.txt b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_91_en.txt
new file mode 100644
index 0000000000000000000000000000000000000000..781253e936e75f7086b3616609e5aeb2a91df79b
--- /dev/null
+++ b/data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_91_en.txt
@@ -0,0 +1,9 @@
+We report here the case of an 82-year-old Japanese woman who had received yearly intravenous denosumab for 4 years and presented with a fracture fulfilling the criteria for an atypical fracture, except for being located at the tibial diaphysis. There was no history of bisphosphonate or oral glucocorticoid use. She was found to have stage 4 breast cancer with multiple bone metastases 4 years prior. Since then, she has been treated with an aromatase inhibitor and denosumab.
+The patient had no obvious history of trauma. One day, while walking, pain appeared in her left shin. A few days after the pain occurred, she visited an outpatient orthopedic clinic. X-ray images from the initial visit are shown below .
+Because her fracture was without any accompanying dislocation, she was followed up at home with full weight bearing on her left leg. Her pain persisted for a month after the initial visit, and she had difficulty walking because of the shin pain. She returned to the orthopedic outpatient clinic, and X-ray images demonstrated a non-displaced transverse fracture of the proximal third of the left tibial diaphysis .
+She had multiple bone metastases to several spinal and pelvic bones 4 years prior, due to breast cancer. .
+The tibial fracture was also considered a differential for a pathological fracture due to a metastatic bone tumor. Therefore, the patient underwent additional imaging examination, including CT and MRI scans. The CT and MRI images did not show any positive findings to suggest a metastatic bone tumor, but they could not rule out the possibility either. At the time of the fracture, the serum biochemical parameters of bone metabolism and cancer markers were 25-hydroxyvitamin D 32 ng/mL, total calcium 10.3 mg/dL, tartrate-resistant acid phosphatase 5b (TRACP-5b) 192 mU/dL, carcinoembryonic antigen (CEA) 66.3 ng/mL, and cancer antigen 15-3 (CA15-3) 109.7 U/mL.
+Her tibial fracture pattern fulfilled all the major criteria (except for the location) and several minor criteria of an atypical fracture. We suspected from these findings that her tibial fracture was atypical.
+She had difficulty walking due to pain and underwent surgical treatment. Treatment consisted of an intramedullary nail that immediately resolved the pain . The cancellous bone within the medullary cavity of the fracture was harvested during intramedullary reaming. The skin near the medial fracture site was also incised, and external periosteum and bone tissue around the fracture site were collected. Pathological examinations were performed on both bone tissue samples. Both samples had no neoplastic changes that could be considered breast cancer-associated bone metastases. Therefore, a pathological fracture due to bone metastases from breast cancer was ruled out, and we diagnosed her tibial fracture as an ATF. Four months after surgery, the fracture site exhibited bone fusion .
+Upon literature review, we discovered that only three previously reported cases of atypical tibia fracture with denosumab had been published. We searched the PubMed database for papers related to atypical tibia fractures and discovered 97 references. After checking all of the titles and abstracts, we found three reports of atypical tibia fractures related to denosumab use [–]. The results are shown in Table .
+In one case, the patient had a giant cell tumor of the femur and was administered 120 mg denosumab once a month, the same dose as in this case. All three reports described bilateral tibial lesions. The patient in this study had no pain in the right tibia and no cortical thickness (beaking sign), as was observed in the X-ray images of her left tibia, in the right tibia. Informed consent for the acquisition of data to present in this case report was obtained during the hospitalization, and signed by the patient herself.
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+A 46-year-old male presented with a chief complaint of progressively worsening right hip pain over the past decade. The patient denied antecedent trauma or any hip injuries since childhood. The patient did note that he was previously very active and went running and cycling on a regular basis. However, he became limited due to pain in his groin, buttock, and thigh, which were all exacerbated by weight-bearing activities. On a day-to-day basis, the patient reported difficulty with stairs, limping while ambulating, and significant trouble getting in and out of a car. The patient’s medical history was significant for a lumbar disc herniation 8 years prior, for which he underwent a microdiscectomy at L5-S1. Past medical, family and social history were otherwise unremarkable. Conservative management, including nonsteroidal anti-inflammatory medications, activity modification, and physical therapy, only provided minimal relief.
+Initial orthopedic examination revealed the patient walking with a coxalgic gait and abductor lurch to the right. To test for anterior impingement, while lying supine, the patient’s hip was internally rotated and adducted during passive flexion to 90°, which reproduced the patient’s symptom of groin pain. The hip was able to internally rotate to neutral and externally rotate to 30°. On range of motion testing, abduction was 30°and the patient had 0°of adduction. Patrick’s test (flexion, abduction, and external rotation) was also positive and associated with severe groin pain and restricted sacroiliac joints. There were groin and buttock pain with passive hip motion in all directions. Lower limb neurologic and vascular examination was unremarkable. Plain film radiographs revealed severe right hip osteoarthritis with bone-on-bone apposition, subchondral cysts and sclerosis . A rounded focus of ossification adjacent to the acetabulum was found, which may have reflected os acetabuli or ossified labrum. Cam-type configurations were seen bilaterally. The left hip also demonstrated moderate-to-severe joint space narrowing. Degenerative changes of bilateral sacroiliac joints were also identified. A lengthy discussion was had regarding hip resurfacing versus hip replacement; however, based on the patient’s age and activity level, conservative hip resurfacing with metal-on-metal (MoM) parts was deemed an appropriate option. The patient agreed, given his desire to run at least 5 miles twice per week, competed in triathlons, and work. Risks and benefits were discussed in detail with the patient. We discussed surgical approaches to the hip joint and the rationale for a posterior approach.
+The patient was brought to the operating room and was placed on the hip table in the lateral decubitus position. The patient’s surgical area was prepped and draped in the standard, sterile fashion. Two threaded pins for a minioptical navigation tool (Intellijoint HIP®, Intellijoint Surgical Inc., Waterloo, ON, Canada; off-label use) were placed into the iliac crest, approximately 2 cm posterior to the ASIS. The navigation system camera was then attached, and registration was performed. Next, a standard posterolateral incision was made through the skin and dissection was carried down through subcutaneous tissue to the underlying fascia achieving hemostasis where necessary. The posterior short external rotators were identified, and the piriformis, conjoined tendons, and quadratus femoris were detached and tagged. Following elevation of the gluteus minimus, a 360° circumferential capsulotomy was performed. The femoral disc for navigational leg length measurements was impacted onto the greater trochanter, and registration of the hip center of rotation was performed. Once the hip was dislocated, the femoral head and neck were exposed. Osteophytes from the anterior superior aspect of the femoral neck were now removed, restoring the anterior head-neck offset. The femoral head was then measured as to its diameter. The head-neck templates were placed along the posterior aspect of the femoral neck to measure the sizing. Lines were marked along the midpoint of the femoral neck in both the coronal and sagittal planes. At this point, attention was turned toward the acetabulum. The labrum, as well as the tissues from the acetabular fossa, was removed. Reaming was begun, with the plan for a 1 mm press-fit. Reaming was first directed medially and then in the desired alignment of the acetabular implant. A trial implant was impacted into place and marked as to its depth of insertion using electrocautery. The actual implant (58mm M2a-Magnum cup; Biomet Inc., Warsaw, IN, USA) was then placed on its insertion handle and impacted into place. The alignment was checked using external alignment guides, bony landmarks, and corroboration with pre-operative templating. The navigation unit was then used to confirm final acetabular component position, measuring 14° of anteversion and 39° of inclination as selected by the surgeon intraoperatively. Following femoral preparation, the trial femoral implant was passed around the prepared bone to ensure adequate bone preparation and contact. With the trial femoral implant in place, the hip was reduced and the navigation device used to confirm the restoration of leg lengths, measuring 4 mm of lengthening . The hip was again dislocated and the trial head removed. It was then decided that the bone was sufficiently supportive to allow for uncemented fixation and the actual implant was impacted. The head was relocated into the acetabulum, after ensuring that there was no debris or soft tissue interposed. The capsule and short external rotators were reattached through a bony bridge in the greater trochanter. The quadratus femoris and gluteus maximus tendon insertion were also repaired. The navigation hardware was then removed. We returned the patient to the supine position. We verified that all lower extremity compartments were soft and compressible and that we had intact distal pulses. The patient was then transferred to the recovery room in stable condition.
+Standard, pre- and post-operative AP pelvic radiographs were obtained and analyzed using TraumaCad (Brainlab, Chicago, USA). Final values for cup position and leg length were measured in triplicate and averaged. Radiographic analysis revealed a final post-operative cup position of 14.3° anteversion and 38.3° inclination on the post-operative radiograph , as well as a lengthened operative leg of 5 mm between pre- and post-operative images.
+At 1-year post-operative, the patient was doing extremely well, demonstrating range of motion in the operative hip of 0°–120° flexion, 40° external rotation, 10° internal rotation, 40° abduction, and 10° adduction. Harris Hip Score was 91.8, with no instability in the joint and both neuromuscular and vascular examinations normal. The patient was able to walk unlimited distances, run, cycle and swim with no physical limitations.
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+A 29 years old female proband experienced an episode of venous thrombosis at the age of 18. The thrombosis of left deep femoral vein occurred at the background of oral contraceptives. She also had a family history of thrombosis - father and grandmother had had thromboembolic events . The proband was diagnosed with primary AT deficiency type I based on coagulation profile. Her main concern was to determine the hereditary nature of AT deficiency; she was highly interested in prospective and reproductive genetic counseling and planning for pregnancy. No DNA testing had been performed prior to our counseling.
+The proband’s phenotype was unremarkable, no findings specific for syndromic or metabolic diseases were made. The level of antithrombin was measured routinely by colorimetric method (CS-5100i, Sysmex, “Berichrom Antithrombin III” kit). Mutation screening in the coding and adjacent intronic areas of the SERPINC1 gene was performed by PCR-based bi-directional Sanger sequencing: oligoprimer design was performed in the Laboratory of medical genetics with PrimerQuest and NCBI Primer Blast tools; Sanger sequencing was performed on Applied Biosystems™ 3730xl DNA Analyzer, followed by sequence analysis with Chromas DNA Sequencing Software. Bioinformatic resources PolyPhen2, SIFT, Mutation Taster, NetGene2, and NetNGlyc 1.0 Server were used for in silico analysis of genetic variants. Databases “1000 Genomes”, “dbSNP”, and “Exome Variant Server” were used to evaluate the frequency of detected variant. Assessment of clinical significance of the detected variant was evaluated according to Joint Consensus Recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology . SWISS-MODEL integrated service was used for SERPINC1-W221S protein modeling [–]. We also used NGlycPred Server to evaluate the probability of glycosylation occurring at a newly created site.
+In the proband the residual antithrombin level was found to be significantly decreased down to 44–48% (AT deficiency type I) in independent repetitive measurements. Repetitive measurements were performed in order to confirm the low level of antithrombin in our patient and to rule out the artificially low results. A new genetic variant c.662G > C (p.W221S) in 4 exon of the SERPINC1 gene was detected in the proband. Cascade family screening was performed; genetic variant c.662G > C (p.W221S) was found in the symptomatic father of the proband and was absent in the healthy sister. Variant c.662G > C (p.W221S) had not previously described in the literature and was absent in the “1000 Genomes” and other available databases. PolyPhen2, Mutation Taster and SIFT resources characterize c.662 G > C (p.W221S) as probably damaging; no possible splicing effect was detected.
+To improve the predictive value of the variant we proceeded with in silico analysis. Loss and acquisition of the glycosylation sites were both described in AT deficiency. Consequently, we analyzed glycosylation pattern in wt-AT and in W221S-AT using NetNGlyc 1.0 resource. According to NetNGlyc 1.0 Server prediction, p.W221S could create an additional glycosylation site .
+To evaluate the possibility of glycosylation occurring at a 219–221 site in the mutated SERPINC1 protein we built a model of it using a SWISS-MODEL service and analyzed it with NGlycPred Server. Both protein models with and without ligands were analyzed. According to NGlycPred Server prediction, the newly created 219–221 glycosylation site will not be glycosylated .
+Our classification of the c.662 G > C (p.W221S) variant was based on familial screening, population data from open-access databases (Exome Sequencing Project, 1000 Genomes, ExAC) and in silico analysis. We also assume that a PP4 criterion is applicable to our case, because clinical findings in our patient are specific for hereditary AT deficiency which is a monogenic disorder. No functional studies are available for this variant.
+The proband was diagnosed with AT I deficiency, which is highly likely to be of hereditary nature. Based on all the evidence we classify the c.662 G > C (p.W221S) variant as a variant of unknown clinical significance.
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+A 69-year-old Hispanic male with no documented past medical history presented to the emergency department with a 3-week history of shortness of breath, intermittent chest pain, and lower extremity edema. Initial vital signs were notable for an elevated blood pressure of 150/86 mmHg and a heart rate of 73 bpm. Jugular venous distention was markedly elevated to 12 cm of water (cm H2O), alongside sparse bibasilar crackles on pulmonary exam and 1 + pitting pedal oedema. Brain natriuretic peptide was as high as 881 pg/mL [reference range (RR): 0–100 pg/mL] with a high sensitivity troponin I of 16 ng/L [RR: 0–20 ng/L], which peaked to 18 ng/L 2 h later. Chest radiograph revealed trace pulmonary vascular congestion and cardiomegaly. Electrocardiogram demonstrated sinus rhythm with non-specific T-wave abnormalities . Transthoracic echocardiogram (TTE) demonstrated a left ventricular systolic ejection fraction (EF) of 68%. Left ventricular diastolic function was found to include an E/A ratio of 2.91, E/e′ ratio of 11.15, and deceleration time of 151 msec. Additional findings included a dilated left and right atrium with severe tricuspid regurgitation (TR), moderate mitral regurgitation (MR), malcoaptation of the tricuspid valve leaflets, and a myxomatous mitral valve (, , ). There was a moderately enlarged right ventricle with moderately reduced systolic function and evidence of pulmonary hypertension (see , ). The patient was subsequently hospitalized for newly diagnosed acute decompensated right heart failure with preserved left ventricular EF.
+Two days after the initiation of aggressive diuresis with intravenous furosemide, a right heart catheterization demonstrated mildly elevated right heart pressures (mean right atrial 8 mmHg, right ventricle 31/8 mmHg, pulmonary artery 31/12 mmHg, and pulmonary capillary wedge pressure of 10 mmHg). A coronary angiogram revealed normal coronary arteries. The aetiology of this patient’s heart failure remained unclear. Given the significant valvular abnormalities, thyroid studies were sent for further workup. Thyroid-stimulating hormone (TSH) was significantly low at <0.010 uIU/mL (RR: 0.45–4.12 uIU/mL), along with an elevated free T4 of 1.96 ng/dL (RR: 0.60–1.12 ng/dL).
+Subsequent serological data revealed slightly elevated thyroid peroxidase antibody of 11 IU/mL [RR: <9 IU/mL], negative thyroid-stimulating immunoglobulin (TSI index <1.0), and negative thyroglobulin antibody (<1 IU/mL). Thyroid ultrasound showed a 4.9 cm lesion in the left thyroid lobe . The patient’s thyrotoxicosis was believed to likely be attributed to toxic adenoma. It was determined that the patient’s heart failure and valve abnormalities were likely consistent with thyrotoxic heart disease. Methimazole 10 mg once daily was initiated for treatment in addition to furosemide for diuresis and carvedilol and losartan for hypertension. The patient was discharged to a shelter, but unfortunately, he was lost to follow-up and did not obtain a TTE after completion of treatment due to social circumstances.
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