diff --git "a/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_0_v1.json" "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_0_v1.json" new file mode 100644--- /dev/null +++ "b/data/data_annotator_data/new_v1/crowdsourcing_input_en_shard_0_v1.json" @@ -0,0 +1,662 @@ +[ + { + "index": 0, + "label": "low_health_literacy", + "original_doc": "This is about a 20-year-old woman. She had a kidney problem since age eight that made protein leak into her urine. The problem first showed up when a big blood clot blocked veins in her brain, and a clot also went to her lungs. She took blood thinners and steroid pills. Later she took a medicine that calms the immune system to help her use fewer steroids. Tests showed no inherited blood-clotting problem. She had several flare-ups of the kidney problem. Steroid pills controlled them until 2017. After that she had no relapses. Her doctors stopped the blood thinner and the immune-calming medicine. One year later she had sudden, very bad belly pain all over. She threw up after eating. Both legs were swollen. Tests showed the kidney problem was back. A special X-ray picture (CT scan) showed a new clot in the main artery that feeds the small intestine. It was like a plug in a pipe that stops water. Blood could not reach the intestines. In surgery, most of her small intestine was dead. Taking out that much bowel would not allow life. She died 48 hours later.", + "wiki_anchor": "Thrombocytopenia : The drug is contraindicated in patients with platelet counts of less than 100,000 per \u03bcl because no clinical experience exists regarding such patients.\n Chronic kidney disease : Eptifibatide undergoes kidney elimination. In such patients with chronic kidney disease where a glycoprotein IIb/IIIa inhibitor is likely to provide benefit, Abciximab (trade name: Reopro) is an alternative medication.\n Current bleeding tendencies or abnormally prolonged coagulation parameters observed within 30 days before starting therapy with eptifibatide is intended.\n Coagulation parameters such as ACT, aPTT, TT, and PT should be followed closely during therapy and afterwards.\n Allergy to eptifibatide and/or other ingredients.\n Severe, uncontrolled hypertension.\n Pregnancy : No experience exists. Pregnant patients should be treated only when clearly needed.\n Lactation : No human data exists. Breast-feeding should be avoided during treatment in order to prevent damage to the newborn.\n Geriatric patients : No differences in side effects compared with younger patients have been seen. Nevertheless, geriatric patients should be very closely observed for bleeding and other side-effects.\n Pediatric patients : Eptifibatide is not indicated in patients below 18 years of age, because no experience exists.", + "doc_fkgl": 4.138157894736846, + "wiki_fkgl": 13.340714285714288, + "doc_tree_depth": 4.5, + "wiki_tree_depth": 5.2, + "fkgl_delta": -9.202556390977442 + }, + { + "index": 0, + "label": "intermediate_health_literacy", + "original_doc": "A 20\u2011year\u2011old woman had a 12\u2011year history of idiopathic nephrotic syndrome that initially presented with extensive cerebral venous thrombosis and pulmonary embolism. She was treated with anticoagulation and oral corticosteroids, then mycophenolate mofetil as a steroid\u2011sparing agent. A comprehensive thrombophilia work\u2011up was negative. She experienced multiple relapses controlled with steroids until 2017, then remained in remission; anticoagulation and MMF were discontinued. One year later, she developed sudden diffuse abdominal pain with postprandial vomiting and bilateral leg edema. Laboratory tests confirmed a relapse of nephrotic syndrome. Abdominal CT showed acute superior mesenteric artery thrombosis causing acute mesenteric ischemia. At surgery, there was extensive small\u2011bowel necrosis not compatible with survival. She died 48 hours later.", + "wiki_anchor": "Symptoms and signs\nNephroptosis is asymptomatic in most persons. However, nephroptosis can be characterized by violent attacks of colicky flank pain, nausea, chills, hypertension, hematuria and proteinuria. Persons with symptomatic nephroptosis often complain of sharp pains that radiate into the groin. Many persons also suggest a weighing feeling on the abdomen. Pain is typically relieved by lying down. It is believed that flank pain on standing that is relieved by lying down is due to movement of the kidney causing intermittent renal tract obstruction. The attack of colic pain is called 'Dietl's crisis' or 'renal paroxysm'.", + "doc_fkgl": 15.20401179941003, + "wiki_fkgl": 10.039821428571429, + "doc_tree_depth": 4.888888888888889, + "wiki_tree_depth": 6.285714285714286, + "fkgl_delta": 5.1641903708386 + }, + { + "index": 0, + "label": "proficient_health_literacy", + "original_doc": "A 20\u2011year\u2011old woman had been followed since age eight for idiopathic nephrotic syndrome (NS) inaugurated by cerebral venous thrombosis extended to the right jugular vein with a massive pulmonary embolism, without sequelae and without personal or family thrombotic history. Kidney biopsy was deferred because there was no kidney failure, gross hematuria, hypertension, or extra\u2011renal signs suggestive of secondary NS at presentation. She was treated with an oral vitamin K antagonist and oral corticosteroids with good evolution. Subsequently, she had multiple steroid\u2011dependent relapses and was started on mycophenolate mofetil (MMF) as background therapy to spare corticosteroids and ensure normal growth. An exhaustive thrombophilia assessment was negative: homocysteine, fibrinogen, protein C, protein S, antithrombin III, factor V Leiden, JAK\u20112, cryoglobulins, anticardiolipin antibodies, lupus anticoagulant, and anti\u2011\u03b22\u2011glycoprotein I antibodies were all normal. Anticoagulation was stopped after nine years. Several relapses occurred but were controlled with oral corticosteroids. NS remission was documented from 2017; MMF was gradually discontinued in 2019, and she remained asymptomatic without relapse.\n\nOne year later, she presented to the emergency department with acute intense diffuse abdominal pain without irradiation, associated with postprandial vomiting and bilateral lower\u2011limb edema for six hours. Examination showed intense epigastric tenderness with normal vital signs (BP 120/70 mm Hg, HR 83 bpm, SpO2 100% on room air) and no fever or neurological impairment. Urinalysis detected proteinuria. Hemogasanalysis showed metabolic acidosis with respiratory compensation. Labs revealed hypoalbuminemia, hypercholesterolemia, prothrombin time 90%, elevated D\u2011dimer, LDH, and creatine phosphokinase, with inflammatory markers (CRP 37 mg/L) and leukocytosis (26.4 \u00d7 10^3/\u00b5L); renal and liver function were normal. Urgent abdominal ultrasound showed a low\u2011to\u2011moderate intra\u2011abdominal effusion. Contrast\u2011enhanced CT demonstrated acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. She underwent emergency laparotomy: intraoperative exploration confirmed mesenteric ischemia with extensive necrosis of almost the entire small bowel, rendering resection incompatible with life. She died 48 hours later.\n\nThis case illustrates catastrophic arterial thrombosis in the setting of NS despite a negative thrombophilia work\u2011up. NS is a hypercoagulable state with multifactorial mechanisms, including urinary loss of anticoagulant proteins (e.g., antithrombin III, protein S), increased fibrinogen, hemoconcentration, dyslipidemia, and systemic inflammation. While venous thromboembolism is more common in NS, superior mesenteric artery thrombosis is rare but often fatal, underscoring the need for high clinical suspicion and rapid imaging when severe acute abdominal pain occurs in patients with active or relapsing NS.", + "wiki_anchor": "Presentation\nClinically, the syndrome affects at least three organs and may affect many organ systems. The syndrome usually occurs with small vessel thromboses affecting organ systems such as the gastrointestinal tract and manifestations of the acute respiratory distress syndrome (ARDS), a type of systemic inflammatory response syndrome (SIRS). Peripheral thrombosis may be encountered affecting veins and arteries. Intra-abdominal thrombosis may lead to pain. The body contains \u03b22-GPI, a glycoprotein in the blood, which is considered a natural anticoagulant due to its inhibitory effects on certain aspects of platelet synthesis and function. Because the formation of anti-\u03b22-GPI antibodies can occur after exposure to bacteria, the body favors a hypercoagulable state, which has been noted to activate toll-like receptor 4 resulting in what is known as a cytokine storm or a thrombotic storm. A thrombotic storm may also occur due to the following precipitating events: alterations in coagulation and fibrinolysis, which induce high mortality rates, and infections amongst pediatric patients where IgM and IgG anti-\u03b22-GPI antibodies induce an endothelial signal, leading to a procoagulant state. It is also hypothesized that thrombotic storms occur due to prothrombotic genetic risk factors, which trigger a sped-up form of thrombosis after its first occurrence, rather than being caused solely by environmental factors. Cardiovascular, nervous, kidney, and lung system complications are common. More specifically with the heart, Asherson's syndrome can lead to complications such as mitral valve regurgitation (MVR) in which the mitral valve does not shut properly allowing backflow of blood into the heart as well as angina (chest pain) and myocardial infarction (heart attack). Furthermore, complications in the kidneys may occur, including low urine production and high blood pressure, while complications with the lungs can result in rapid breathing (hyperventilation) and low oxygen levels (hypoxemia). The affected individual may exhibit skin purpura and necrosis. Cerebral manifestations may lead to encephalopathy and seizures. Myocardial infarctions may occur. Strokes may occur due to the arterial clotting involvement. Death may result from multiple organ failure.", + "doc_fkgl": 17.108284910965327, + "wiki_fkgl": 15.547597477064219, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.75, + "fkgl_delta": 1.5606874339011085 + }, + { + "index": 1, + "label": "low_health_literacy", + "original_doc": "She is 34 years old and pregnant. She had a seizure and trouble speaking clearly. She was sent right away for a head MRI scan. The scan showed a pattern doctors call the \u201cMedusa head.\u201d This means the veins in her brain are arranged in an unusual way that she was born with. There is a small blood clot at the outer part of this vein pattern. The blood is also moving slowly closer to the main vein.", + "wiki_anchor": "Diagnosis\nWhile the white blood cell count, erythrocyte sedimentation rate, and C-reactive protein tests may be abnormal and there may be abnormally high levels of platelets in the blood or too few red blood cells in the blood, none of these findings is a reliable indicator of the disease. A slit-lamp examination is essential. Recent work has suggested that high-resolution MRI and antibodies to inner ear antigens may be helpful. Cogan syndrome can occur in children, and is particularly difficult\nto recognize in that situation.", + "doc_fkgl": 3.5813553113553134, + "wiki_fkgl": 13.243382352941179, + "doc_tree_depth": 5.142857142857143, + "wiki_tree_depth": 7.25, + "fkgl_delta": -9.662027041585866 + }, + { + "index": 1, + "label": "intermediate_health_literacy", + "original_doc": "A 34-year-old woman who is 8 weeks pregnant had a first-time generalized seizure with temporary slurred speech. Because she is pregnant and this was her first seizure, doctors obtained an urgent brain MRI. The MRI showed the classic \u201cMedusa head\u201d sign, which indicates a developmental venous anomaly (DVA)\u2014a vein pattern you are born with. Imaging also suggested a partial clot along the peripheral portion of the draining system and slower blood flow closer to the main draining vein. These findings support the diagnosis: a developmental venous anomaly with peripheral partial thrombosis and proximal slow flow.", + "wiki_anchor": "Minor physical anomalies (MPAs) are relatively minor (typically painless and, in themselves, harmless) congenital physical abnormalities consisting of features such as low-set ears, single transverse palmar crease, telecanthus, micrognathism, macrocephaly, hypotonia and furrowed tongue. While MPAs may have a genetic basis, they might also be caused by factors in the fetal environment: anoxia, bleeding, or infection. MPAs have been linked to disorders of pregnancy and are thought by some to be a marker for insults to the fetal neural development towards the end of the first trimester. Thus, in the neurodevelopmental literature, they are seen as indirect indications of interferences with brain development.", + "doc_fkgl": 11.942105263157895, + "wiki_fkgl": 15.990364077669906, + "doc_tree_depth": 6.4, + "wiki_tree_depth": 8.25, + "fkgl_delta": -4.04825881451201 + }, + { + "index": 1, + "label": "proficient_health_literacy", + "original_doc": "A 34-year-old woman, 8 weeks pregnant and without other relevant history, presented with generalized convulsions and postictal dysarthria that resolved within two hours. On examination she was alert, oriented, and without focal language, motor, or sensory deficits; a right lateral tongue bite was noted. Laboratory tests and ECG were unremarkable. Given a first epileptic seizure in pregnancy, an urgent cranial MRI was performed. The protocol included 3D T1 pre- and post-contrast (axial, coronal, sagittal), axial FLAIR, axial T2, VEN BOLD and magnetic susceptibility sequences, as well as axial diffusion and ADC mapping. MRI demonstrated multiple venous cortico-medullary vascular structures converging centripetally to a large central draining vein that emptied via the inferior anastomotic vein into the left transverse sinus, forming the classic \u201cMedusa head\u201d sign. On T1 post-contrast, the drainage vein showed increased signal with central hyphocaptation, suggesting partial thrombosis versus slow flow. On T2 and FLAIR, the parenchyma surrounding the drainage vein was hyperintense, without diffusion restriction, compatible with edema. Overall, the findings are diagnostic of a developmental venous anomaly with signs of partial peripheral thrombosis and more proximal slow flow, causing perilesional edema. Management was initiated with clexane 60 mg every 12 hours and levetiracetam 500 mg every 12 hours, with symptomatic improvement and stability after one week. Contextually, DVAs are typically benign venous variants; however, pregnancy-associated hypercoagulability may predispose to thrombosis. Partial thrombosis and impaired outflow in a DVA can lead to venous congestion and edema, manifesting clinically with seizures.", + "wiki_anchor": "Cerebral AVMs may present themselves in a number of different ways:\n Bleeding (45% of cases)\n \"parkinsonism\" 4 symptoms in Parkinson's disease.\n Acute onset of severe headache. May be described as the worst headache of the patient's life. Depending on the location of bleeding, may be associated with new fixed neurologic deficit. In unruptured brain AVMs, the risk of spontaneous bleeding may be as low as 1% per year. After a first rupture, the annual bleeding risk may increase to more than 5%.\n Seizure or brain seizure (46%). Depending on the place of the AVM, it can contribute to loss of vision.\n Headache (34%)\n Progressive neurologic deficit (21%)\n May be caused by mass effect or venous dilatations. Presence and nature of the deficit depend on location of lesion and the draining veins.\n Pediatric patients\n Heart failure\n Macrocephaly\n Prominent scalp veins", + "doc_fkgl": 16.247417695473253, + "wiki_fkgl": 8.438901242642252, + "doc_tree_depth": 6.083333333333333, + "wiki_tree_depth": 5.363636363636363, + "fkgl_delta": 7.808516452831 + }, + { + "index": 2, + "label": "low_health_literacy", + "original_doc": "A 22-year-old woman had painful mouth sores. The sores made eating and drinking hard. The problem started after a fever. Small pimples showed up on her lips. She had been vaping for about one year. The checkup found no spots on the rest of her body. Her lips had crusts with a little blood. The corners of her mouth were raw and bled easily. Inside her mouth there were white sores with yellow edges. The sores were different shapes and sizes and were in several places. A test for the cold-sore virus was negative. The doctor said this was a mouth reaction called oral erythema multiforme. She was treated with salt-water compresses on the lips. She used a mouth rinse with an anti-swelling medicine (dexamethasone) mixed with a coating gel (hyaluronic acid). She put 2% miconazole cream on the sores at the mouth corners. She used petroleum jelly on her dry lips. She was told to stop vaping. Her mouth got better after one week of treatment.", + "wiki_anchor": "Symptoms and signs\nPeople with X-SCID often have infections very early in life, before three months of age. This occurs due to the decreased amount of immunoglobulin G (IgG) levels in the infant during the three-month stage. This is followed by viral infections such as pneumonitis, an inflammation of the lung which produces common symptoms such as cough, fever, chills, and shortness of breath. A telltale sign of X-SCID is candidiasis, a type of fungal infection caused by Candida albicans. Candidiasis involves moist areas of the body such as skin, the mouth, respiratory tract, and vagina; symptoms of oral candidiasis include difficulty in swallowing, pain on swallowing and oral lesions. Recurrent eczema-like rashes are also a common symptom. Other common infections experienced by individuals with X-SCID include diarrhea, sepsis, and otitis media. Some other common symptoms that are experienced by X-SCID patients include failure to thrive, gut problems, skin problems, and muscle hypotonia.", + "doc_fkgl": 4.63312375249501, + "wiki_fkgl": 12.692279411764705, + "doc_tree_depth": 5.277777777777778, + "wiki_tree_depth": 7.875, + "fkgl_delta": -8.059155659269695 + }, + { + "index": 2, + "label": "intermediate_health_literacy", + "original_doc": "A 22-year-old woman presented with a month of painful stomatitis that made eating and drinking difficult. The illness began with a fever and pimple-like lesions on the lips. She had been vaping regularly for about one year. Examination showed no skin lesions elsewhere. The lips had serosanguineous crusts and erosions at the labial commissures that tended to bleed. Intraorally, there were multiple irregular white ulcers with yellowish borders on several sites of the oral mucosa. Anti\u2013HSV-1 IgG was non-reactive. The diagnosis was oral erythema multiforme, likely related to vaping. Management included normal saline compresses to the lips, a dexamethasone mouth rinse mixed with hyaluronic acid, 2% miconazole cream applied to the lip corner, petroleum jelly for dry lips, and stopping vaping. Her oral condition improved within one week.", + "wiki_anchor": "Symptoms \nMany of those who are infected never develop symptoms. Symptoms, when they occur, may include watery blisters in the skin or mucous membranes of the mouth, lips, nose, genitals, or eyes (herpes simplex keratitis). Lesions heal with a scab characteristic of herpetic disease. Sometimes, the viruses cause mild or atypical symptoms during outbreaks. However, they can also cause more troublesome forms of herpes simplex. As neurotropic and neuroinvasive viruses, HSV-1 and -2 persist in the body by hiding from the immune system in the cell bodies of neurons, particularly in sensory ganglia. After the initial or primary infection, some infected people experience sporadic episodes of viral reactivation or outbreaks. In an outbreak, the virus in a nerve cell becomes active and is transported via the neuron's axon to the skin, where virus replication and shedding occur and may cause new sores.", + "doc_fkgl": 10.328562500000004, + "wiki_fkgl": 11.94095070422535, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 6.75, + "fkgl_delta": -1.612388204225347 + }, + { + "index": 2, + "label": "proficient_health_literacy", + "original_doc": "A 22-year-old woman presented to Oral Medicine with a 1-month history of painful oral ulcers causing difficulty eating and drinking. The episode began with fever followed by pimple-like lesions on the lips. She had used pod-type vapes for approximately one year, often trying different e-liquid flavors; she had never smoked conventional cigarettes. She reported no medication exposure prior to onset (no antibiotics, analgesics, anticonvulsants, NSAIDs, or antifungals), no drug or food allergies, and unhealthy eating habits. Extraorally, there were no lesions elsewhere on the body. The lips exhibited serosanguineous crusts with an erosive area at the right labial commissure that tended to bleed. Intraoral examination showed multiple painful white ulcers with yellowish edges, irregular and variable in size, on the labial and buccal mucosa, lateral and ventral tongue, and floor of mouth. Anti-HSV-1 IgG was non-reactive. Based on isolated oral mucosal involvement, absence of cutaneous lesions, and negative HSV serology, a diagnosis of vaping-related oral erythema multiforme, minor type, was established. Management comprised 0.9% NaCl\u2013moistened gauze compresses to the lips three times daily; a dexamethasone mouthrinse (1 mg in 10 mL hyaluronic acid) three times daily with a 30-minute post-rinse fasting period; 2% miconazole cream applied to the wound at the right labial commissure twice daily; and vaseline album (petrolatum) for dry lips. Adjunctive advice included brushing teeth and tongue twice daily (after breakfast and before bed), cessation of vaping, and avoidance of foods containing monosodium glutamate. At 1-week follow-up, the oral condition had improved. Ethical considerations: written informed consent was obtained; the case conformed to the Helsinki Declaration and had institutional approval. Context: Erythema multiforme is a mucocutaneous hypersensitivity reaction classically triggered by infections (e.g., HSV) or drugs; in this case, vaping exposure and frequent e-liquid flavor changes were considered plausible triggers in the absence of medication exposure and with non-reactive anti-HSV-1 serology.", + "wiki_anchor": "Bacterial skin infections affected about 155 million people and cellulitis occurred in about 600 million people in 2013. Bacterial skin infections include:\n Cellulitis, a diffuse inflammation of connective tissue with severe inflammation of dermal and subcutaneous layers of the skin. Further, cellulitis can be classified based into purulent and non-purulent cellulitis, based on the most likely causative agent and the symptoms presentation. Purulent cellulitis is often caused by Staphylococcus aureus, including both methicillin-sensitive (MSSA) and methicillin-resistant S. aureus (MRSA). Non-purulent cellulitis is most often associated with group A beta-hemolytic streptococci, such as Streptococcus pyogenes. In rare cases, the infection can progress into necrotizing fasciitis, a serious and potentially fatal infection.\n Erysipelas, a bacterial infection which primarily affects superficial dermis, and often involves superficial lymphatics. Unlike cellulitis, it does not affect deeper layers of the skin. It is primarily caused by the Group A beta-hemolytic streptococci, with Streptococcus pyogenes being the most common pathogen.\n Folliculitis, a skin condition in which hair follicle, located in the dermal layer of the skin, becomes infected and inflamed. It is predominantly caused by bacterial infections, especially Staphylococcus aureus, leading to superficial bacterial folliculitis. Other causative agents of folliculitis include fungi (most commonly Malassezia species), viruses (such as herpes simplex virus), and mites (Demodex species).\n Impetigo, a highly contagious ABSSSI (acute bacterial skin and skin structure infection) common among pre-school children, primarily associated with the pathogens S. aureus and S. pyogenes. Impetigo has a characteristic appearance with yellow (honey-coloured), crusted lesions occurring around mouth, nose, and chin. It is estimated, that at any given time, it affects 140 million people globally. Impetigo can be further classified into bullous and nonbullous forms. Nonbullous impetigo is the most common form, representing approximately 70% of diagnosed cases. The remaining 30% of cases represent bullous form, which is primarily caused by S. aureus. In rare instances, bullous impetigo can spread and lead to Staphylococcal Scalded Skin Syndrome (SSSS), a potentially life-threatening infection.", + "doc_fkgl": 14.527236842105264, + "wiki_fkgl": 14.618813664596274, + "doc_tree_depth": 7.214285714285714, + "wiki_tree_depth": 6.631578947368421, + "fkgl_delta": -0.09157682249101029 + }, + { + "index": 3, + "label": "low_health_literacy", + "original_doc": "At 32 weeks of pregnancy, a routine scan found one small lump inside the baby\u2019s heart. It caused no symptoms. This was the only problem seen. Doctors watched it with clinic visits until 39 weeks plus 1 day. Then the baby was delivered by C-section (a surgery to deliver the baby). After birth, the child had checkups on day 1, day 7, day 30, month 7, and month 12. At each visit, the child\u2019s growth and behavior were healthy for age. The heart lump stayed the same size; it did not grow or shrink. By 1 year old, there were no signs of a related condition called tuberous sclerosis complex.", + "wiki_anchor": "The Doctor confirms Seven's diagnosis. The fetus is seven weeks old, and perfectly healthy, except for a genetic defect that causes abnormal spine curvature in Klingon females. B'Elanna, who is half Klingon, had surgery as a baby to correct this defect. The Doctor says that nowadays genetic resequencing is the preferred treatment and that he can perform the procedure the following day. He also shows B'Elanna and her husband Tom Paris a holographic projection of what their daughter will look like. Tom thinks she is beautiful but B'Elanna is distressed to learn her daughter will have Klingon facial ridges.", + "doc_fkgl": 4.623939393939395, + "wiki_fkgl": 10.392474747474747, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 6.333333333333333, + "fkgl_delta": -5.768535353535352 + }, + { + "index": 3, + "label": "intermediate_health_literacy", + "original_doc": "This case describes an isolated, asymptomatic fetal cardiac rhabdomyoma first detected at 32 weeks\u2019 gestation. The pregnancy was monitored as an outpatient until 39 weeks plus one day, when delivery occurred by cesarean section. Postnatal follow-up at day 1, day 7, day 30, 7 months, and 12 months showed normal growth and neurodevelopment. The intracardiac mass remained stable in size across all visits. Up to one year of age, the child did not meet any clinical diagnostic criteria for tuberous sclerosis complex (TSC).", + "wiki_anchor": "Prenatal Diagnosis \nPrenatal diagnosis is an option in some forms of acrocephalosyndactyly. A prenatal genetic diagnosis is only possible if the gene mutation responsible for the syndrome is known and the mutation causing the disease has been identified within the family genome. This can be done using amniocentesis or chorionic villus sampling, which test the embryonic stem cells in the amniotic fluid or placental cells, respectively. There has been a case of a prenatal diagnosis of Apert syndrome using fetoscopy. Alternatively, there has been interest in using non-invasive techniques like ultrasound to detect fetal skull abnormalities.", + "doc_fkgl": 11.214120481927715, + "wiki_fkgl": 14.637583333333332, + "doc_tree_depth": 5.4, + "wiki_tree_depth": 7.0, + "fkgl_delta": -3.423462851405617 + }, + { + "index": 3, + "label": "proficient_health_literacy", + "original_doc": "A 29-year-old gravida V para IV (3 spontaneous vaginal deliveries, prior cesarean for failed induction 4 years earlier) presented for ANC at 32 weeks by LNMP. Maternal labs: VDRL, HBsAg, and urinalysis negative; CBC within normal limits; blood group A Rh-positive. Obstetric ultrasound revealed normal fetal anatomy except the heart. Fetal echocardiography showed normal situs; atria of comparable size; normally positioned atrioventricular and semilunar valves with normal motion; ventricles comparable in size and contractility; left ventricle forming the apex; no ventricular septal defect. Two circumscribed, round, echogenic masses were noted on the left ventricular papillary muscles, measuring 18.2 \u00d7 8.3 mm and 13.5 \u00d7 8.3 mm. LVOT and RVOT anatomy and function were normal on 2D and color flow. Impression: cardiac rhabdomyoma. Given the association with tuberous sclerosis complex (TSC), detailed neurosonography and systemic evaluation were performed and were unremarkable. She continued routine ANC without complications to 39 weeks. At 39 weeks + 1 day, a cesarean section (repeat on request at term) delivered a 3200 g female, Apgar 10 and 10 at 1 and 5 minutes. Postoperative courses for mother and neonate were uneventful; discharge occurred on postoperative day 3. The neonate was evaluated on days 1, 7, and 30: physical examinations were normal; no seizure activity or new cutaneous lesions; mass dimensions were similar to the antenatal findings. At 7 months, development was age-appropriate; pediatric echocardiography showed well-circumscribed hyperechoic masses on both left ventricular papillary muscles measuring 21.8 \u00d7 9.2 mm and 14.7 \u00d7 8.5 mm, without left ventricular inflow obstruction. At 12 months, anthropometric and neurobehavioral development remained normal. Echocardiography again demonstrated well-circumscribed hyperechoic masses on both left ventricular papillary muscles with no size increment and no left ventricular inflow obstruction. Up to one year of age, apart from the persistent intracardiac rhabdomyomas, the child met none of the clinical diagnostic criteria for TSC. Notably, while cardiac rhabdomyomas often regress spontaneously in infancy, these lesions were stable through 12 months.", + "wiki_anchor": "Variation \nThere is a large variability in size, shape, thickness, and texture of the persistent eustachian valve, and in the extent to which it encroaches on neighboring structures such as the atrial septum. At one end of the spectrum, the embryonic eustachian valve disappears completely or is represented only by a thin ridge. Most commonly, it is a crescentic fold of endocardium arising from the anterior rim of the IVC orifice. The lateral horn of the crescent tends to meet the lower end of the crista terminalis, while the medial horn joins the thebesian valve, a semicircular valvular fold at the orifice of the coronary sinus. At the other extreme, it persists as a mobile, elongated structure projecting several centimeters into the right atrial cavity. In this case, it may demonstrate an undulating motion in real time echocardiography; and when it is quite large, it may be confused with right atrial tumors, thrombi, or vegetations. Occasionally, the eustachian valve crosses the floor of the right atrium from the orifice of the IVC and inserts into the lower portion of the interatrial septum adjacent to the atrioventricular valves. However, higher insertion of a giant eustachian valve, which mimics the echocardiographic appearance of divided right atrium, is very rare. This type of abnormality may be confused with cor triatriatum dexter. Very rarely, such a configuration of a large eustachian valve may mimic a right atrial cystic tumor.", + "doc_fkgl": 13.580182389937107, + "wiki_fkgl": 14.262659574468092, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 7.9, + "fkgl_delta": -0.6824771845309847 + }, + { + "index": 4, + "label": "low_health_literacy", + "original_doc": "This is about a 13-year-old boy. He has had small growths in his throat since he was two years old. The growths were in his voice box and windpipe. They narrowed his breathing tube, so he had trouble breathing. It was like trying to breathe through a pinched straw. A chest scan showed several small cysts in his lungs. Doctors removed the throat growths. They also placed a breathing tube through a small hole in his neck to help him breathe. He got one dose of a medicine called bevacizumab (400 mg) through a vein. He also had breathing therapy. He got better. The problem has not come back during follow-up.", + "wiki_anchor": "Diagnosis \nAn ENT specialist or otolaryngologist will be able to confirm the diagnosis as well as provide any necessary treatment if required. The ENT will use an instrument called a laryngoscope in order to push the tongue down and in order to lift up the epiglottis which is the small flap in the back of the throat that covers the windpipe. The epiglottis opens during breathing but closes during swallowing in order to prevent choking. The ENT will then use an instrument to remove any visible small growths or they will use a swab to sweep over the growth and send it to a lab where it can be examined for further testing.", + "doc_fkgl": 2.581463963963966, + "wiki_fkgl": 12.762013274336287, + "doc_tree_depth": 4.583333333333333, + "wiki_tree_depth": 9.5, + "fkgl_delta": -10.18054931037232 + }, + { + "index": 4, + "label": "intermediate_health_literacy", + "original_doc": "A 13-year-old boy with recurrent respiratory papillomatosis since age two presented with breathing difficulty, noisy breathing (stridor), and hoarseness. Airway evaluation showed multiple nodules narrowing the larynx and trachea. Chest CT revealed several pulmonary cysts. He underwent surgical removal of the papillomatosis lesions and a tracheostomy. He received a single 400 mg intravenous dose of bevacizumab and respiratory therapy. He recovered well, and there has been no recurrence on follow-up.", + "wiki_anchor": "\u2013 lung diseases, interstitial\n \u2013 alveolitis, extrinsic allergic\n \u2013 bird fancier's lung\n \u2013 farmer's lung\n \u2013 bronchiolitis obliterans\n \u2013 bronchiolitis obliterans organizing pneumonia\n \u2013 goodpasture syndrome\n \u2013 histiocytosis, langerhans-cell\n \u2013 pneumoconiosis\n \u2013 asbestosis\n \u2013 berylliosis\n \u2013 byssinosis\n \u2013 caplan's syndrome\n \u2013 siderosis\n \u2013 silicosis\n \u2013 anthracosilicosis\n \u2013 silicotuberculosis\n \u2013 pulmonary fibrosis\n \u2013 radiation pneumonitis\n \u2013 sarcoidosis, pulmonary\n \u2013 granulomatosis with polyangiitis", + "doc_fkgl": 12.728571428571431, + "wiki_fkgl": 36.885000000000005, + "doc_tree_depth": 5.166666666666667, + "wiki_tree_depth": 12.0, + "fkgl_delta": -24.156428571428574 + }, + { + "index": 4, + "label": "proficient_health_literacy", + "original_doc": "A 13-year-old male from Cusco with recurrent respiratory papillomatosis (RRP) since age two (tracheostomy at age three) and a maternal history of genital papilloma presented after 16 days of predominantly nocturnal respiratory difficulty, inspiratory laryngeal stridor, and moderate dysphonia. He had previously received azithromycin and supplemental oxygen without improvement. On exam, there was mild subcostal retraction, decreased vesicular breath sounds over the left hemithorax, and scant wheezes predominating on the right; he required 4 L/min oxygen via binasal cannula. Laboratory studies showed WBC 8.03 \u00d7 10^3/\u03bcL, platelets 209 \u00d7 10^3/\u03bcL, hemoglobin 13.2 g/dL, and CRP 36.6 mg/L. Imaging included a chest study and head and neck tomography; chest tomography visualized several pulmonary cysts. Forty-eight hours after admission, he developed worsening stridor and respiratory distress, prompting emergent OR transfer for tracheostomy, microlaryngoscopy, and excision of papillomatous lesions. Intraoperative findings demonstrated extensive papillomatous disease with appendicular tumor-like lesions and ventricular bands involving the epiglottis, glottic surface, vocal cords, subglottis, and trachea to ring 5. Histopathology showed koilocytotic atypia consistent with HPV and mild focal dysplasia. Postoperatively, he was managed in the PICU with respiratory monitoring and was weaned off oxygen within 48 hours. He received a single intravenous dose of bevacizumab 400 mg and showed prompt clinical improvement. He completed a seven-day hospitalization with normalization of oxygen saturation and progressive oxygen weaning, then was transferred for ongoing care. He also received respiratory therapy. On telemonitoring at eight months, there was no evidence of recurrence or intercurrent events. Clinical context: RRP is typically HPV-related (often low-risk types) and can cause multifocal papillomas leading to airway stenosis; anti-VEGF therapy such as bevacizumab is used off-label to reduce angiogenesis and disease recurrence, and in this case was associated with a favorable short- to mid-term outcome.", + "wiki_anchor": "Extended FAST \nThe eFAST allows for the examination of both lungs by adding bilateral anterior thoracic sonography to the FAST exam. This allows for the detection of a pneumothorax with the absence of normal \u2018lung-sliding\u2019 and \u2018comet-tail\u2019 artifact (seen on the ultrasound screen). Compared with supine chest radiography, with CT or clinical course as the gold standard, bedside sonography has superior sensitivity (49\u201399% versus 27\u201375%), similar specificity (95\u2013100%), and can be performed in under a minute. Several recent prospective studies have validated its use in the setting of trauma resuscitation, and have also shown that ultrasound can provide an accurate estimation of pneumothorax size. Although radiography or CT scanning is generally feasible, immediate bedside detection of a pneumothorax confirms what are often ambiguous physical findings in unstable patients, and guides immediate chest decompression. In addition, in the patient undergoing positive-pressure ventilation, the detection of an otherwise \u2018occult\u2019 pneumothorax prior to CT scanning may hasten treatment and subsequently prevent development of a tension pneumothorax, a deadly complication if not treated immediately, and deterioration in the radiology suite (in the CT scanner).", + "doc_fkgl": 15.644583333333337, + "wiki_fkgl": 19.77555555555556, + "doc_tree_depth": 6.769230769230769, + "wiki_tree_depth": 7.333333333333333, + "fkgl_delta": -4.130972222222223 + }, + { + "index": 5, + "label": "low_health_literacy", + "original_doc": "This 54-year-old man had long-term kidney disease. He took steroids and other medicines that weaken the body\u2019s defenses for a long time. He came to the lung department with fever, cough with mucus, and trouble breathing. A scan showed many cloudy spots in both lungs, like frosted glass. Blood tests showed a lot of inflammation. This suggested an infection from germs such as bacteria, a virus, or a fungus. A blood test was positive for RSV antibodies. Tests for other germs were not positive. His immune system was weak. His antibody level (IgG) was low. His infection-fighting T cells (CD4 and CD8) were also low. Doctors gave strong medicines for infection and support to help his breathing. His illness got worse quickly. He died from breathing failure.", + "wiki_anchor": "Coccidioidomycosis is amazingly diverse in terms of its scope of clinical presentation, as well as clinical severity. About 60% of Coccidioides infections as determined by serologic conversion are asymptomatic. The most common clinical syndrome in the other 40% of infected patients is an acute respiratory illness characterized by fever, cough, and pleuritic pain. Skin manifestations, such as erythema nodosum, are also common with Coccidioides infection. Coccidioides infection can cause a severe and difficult-to-treat meningitis in AIDS and other immunocompromised patients, and occasionally in immunocompetent hosts. Infection can sometimes cause acute respiratory distress syndrome and fatal multilobar pneumonia. The risk of symptomatic infection increases with age.", + "doc_fkgl": 5.415573678290215, + "wiki_fkgl": 14.871428571428577, + "doc_tree_depth": 4.785714285714286, + "wiki_tree_depth": 6.0, + "fkgl_delta": -9.455854893138362 + }, + { + "index": 5, + "label": "intermediate_health_literacy", + "original_doc": "A 54-year-old man with chronic kidney disease on long-term corticosteroids and immunosuppressants was admitted to respiratory medicine with fever, cough with sputum, and shortness of breath. Chest CT showed multiple bilateral ground-glass opacities. Laboratory studies showed elevated inflammatory markers, indicating possible bacterial, viral, or fungal infection. RSV antibodies were positive, while tests for other pathogens were negative. He was immunocompromised from prolonged corticosteroid and immunosuppressant use, with low total IgG and reduced CD4 and CD8 T-lymphocyte counts. Despite intensive anti-infective therapy and escalating respiratory support, his condition deteriorated rapidly, and he died from respiratory failure.", + "wiki_anchor": "Coccidioidomycosis is amazingly diverse in terms of its scope of clinical presentation, as well as clinical severity. About 60% of Coccidioides infections as determined by serologic conversion are asymptomatic. The most common clinical syndrome in the other 40% of infected patients is an acute respiratory illness characterized by fever, cough, and pleuritic pain. Skin manifestations, such as erythema nodosum, are also common with Coccidioides infection. Coccidioides infection can cause a severe and difficult-to-treat meningitis in AIDS and other immunocompromised patients, and occasionally in immunocompetent hosts. Infection can sometimes cause acute respiratory distress syndrome and fatal multilobar pneumonia. The risk of symptomatic infection increases with age.", + "doc_fkgl": 16.420789473684213, + "wiki_fkgl": 14.871428571428577, + "doc_tree_depth": 6.166666666666667, + "wiki_tree_depth": 6.0, + "fkgl_delta": 1.5493609022556356 + }, + { + "index": 5, + "label": "proficient_health_literacy", + "original_doc": "A 54-year-old male with membranous nephropathy II and nephrotic syndrome on long-term oral glucocorticoids and immunosuppressants (immunocompromised) presented to the Department of Respiratory Medicine with 5 days of fever, cough, expectoration, and progressive dyspnea. He had a 20 pack-year smoking history and no family history of hereditary disease. A chest x-ray one month prior was normal. On admission (August 8, 2016): BMI 24.5 kg/m2, T 39.0\u00b0C, tachypnea 35 breaths/min, severe hypoxemia (SaO2 86%). Auscultation revealed good bilateral air entry with scattered diffuse crackles and rhonchi. Chest CT demonstrated multiple bilateral ground-glass opacities. Initial labs showed a normal WBC count with elevated neutrophils and increased inflammatory markers (CRP, ESR) and elevated (1\u21923)-\u03b2-D-glucan. Serology was positive for RSV antibodies on hospital day 4; other pathogen testing was negative. He had laboratory evidence of immunosuppression with decreased total IgG and reduced CD4 and CD8 T-lymphocyte counts, consistent with chronic exposure to corticosteroids and immunosuppressants.\n\nManagement: Immediate respiratory monitoring and supplemental oxygen were initiated. Empiric anti-infective therapy included antibiotics (moxifloxacin for 4 days, then cefminoxine for 8 days) and antifungal therapy (voriconazole for 10 days). The glucocorticoid and immunosuppressant doses were largely unchanged. After 10 days, clinical status and oxygenation worsened with radiographic progression. He was transferred to the Emergency ICU for noninvasive mechanical ventilation, broad-spectrum antibiotics (i.v. meropenem, oral moxifloxacin, cotrimoxazole), antifungal therapy (micafungin), systemic corticosteroids (methylprednisolone 40 mg bid i.v.), and supportive care. Ganciclovir was added for possible viral coinfection (e.g., CMV). Five days later, chest x-ray showed further aggravation. Despite escalation to invasive ventilator-assisted ventilation, higher-dose methylprednisolone (80 mg bid), additional antibacterials (cefoperazone-sulbactam, tigecycline, cotrimoxazole), and continued micafungin, he developed rapid progression culminating in respiratory failure and death two days later.\n\nInterpretation: The presentation is consistent with severe viral pneumonia due to RSV in an immunocompromised host, with imaging showing multifocal ground-glass opacities and laboratory evidence of systemic inflammation. Elevated (1\u21923)-\u03b2-D-glucan prompted antifungal coverage, while broad-spectrum antibacterial and antiviral regimens addressed possible coinfections. Profound immunosuppression (low IgG, reduced CD4/CD8 T cells) likely contributed to rapid deterioration and refractory hypoxemic respiratory failure despite intensive anti-infective therapy and advanced respiratory support.", + "wiki_anchor": "Manifestations include:\n Skin: Raynaud's phenomenon is universal and almost always is present at the beginning of the disease course. The absence puts the diagnosis in question. The capillary alterations are similar to that of scleroderma. Other cutaneous alterations can be observed similar to the types observed in LES and scleroderma.\n Arthritis: Swollen fingers and occasionally diffuse edema are distinctive signs. Arthritis usually is more frequent and severe than that observed in SLE. Approximately 60% present with an obvious arthritis, with deformities similar to those observed in rheumatoid arthritis. \u00a0\n Myositis: Myalgias \u2013 muscular aches and pains \u2013 are common, but in the majority of patients muscular debilitation, electromyographic alterations, and elevations in muscular enzymes, like in pure polymyositis are not observed.\n Cardiac disease: Pericarditis is the most common cardiac manifestation, observed in 10\u201330% of patients. Myocardial involvement can also be observed, usually secondary to pulmonary hypertension, as well as conduction anomalies.\n Pulmonary involvement: Is observed in 75% of patients. It can present as pleural effusion, pulmonary hypertension, interstitial lung disease, thromboembolic disease, and others.\n Renal disease: The absence of severe renal disease is a marker of MCTD. Membranous nephropathy can be observed in some cases.\n Gastrointestinal disease: The most common change is the alteration of esophageal motility like that observed in scleroderma.\n Central nervous system involvement (CNS): The original description of this disease stressed the absence of changes to the CNS; however, there have been trigeminal neuropathies (cranial nerve V), sensorineural hearing loss, and headaches observed in patients with MCTD.\n Hematologic anomalies: The presence of mild anemia and hypergammaglobulinemia are common, other hematologic anomalies such as those observed in SLE can also be observed.\n Laboratory value changes: Rheumatoid factor is positive in 50\u201370% of patients, and anti\u2013citrullinated protein antibody is detected in 50% of patients. The universal serological findings in patients with MCTD is the presence of anti-nuclear antibody, with anti-nRNP specificity, especially antibodies against protein 68 kD.", + "doc_fkgl": 16.479367816091955, + "wiki_fkgl": 14.438329156223894, + "doc_tree_depth": 6.15, + "wiki_tree_depth": 6.7894736842105265, + "fkgl_delta": 2.041038659868061 + }, + { + "index": 6, + "label": "low_health_literacy", + "original_doc": "A 34-year-old woman had new lower back pain. She saw blood in her urine. She also had a big bruise under the skin on her right buttock. She had never had bleeding problems before. Because these bleeding signs were serious, she was sent to the emergency room. Doctors did blood-clotting tests. One test mixed her blood with normal blood to see how it clotted. Another test looked for a blocker against a clotting protein called factor eight. These tests confirmed the diagnosis.", + "wiki_anchor": "Problems with blood transfusion\nThe first person found to have the Bombay phenotype had a blood type that reacted to other blood types in a way never seen before. The serum contained antibodies that attacked all red blood cells of normal ABO phenotypes. The red blood cells appeared to lack all of the ABO blood group antigens and to have an additional antigen that was previously unknown.", + "doc_fkgl": 4.512113821138211, + "wiki_fkgl": 11.08417910447761, + "doc_tree_depth": 4.444444444444445, + "wiki_tree_depth": 9.333333333333334, + "fkgl_delta": -6.572065283339398 + }, + { + "index": 6, + "label": "intermediate_health_literacy", + "original_doc": "A 34-year-old woman with no prior bleeding history developed lower back pain, passed a kidney stone, and then had three days of haematuria. She later developed painful thigh and right gluteal bruising after an intramuscular injection. Because the bleeding was extensive, she was transferred to the emergency department. Her coagulation work-up showed a markedly prolonged aPTT. A mixing study only partially corrected the aPTT, and factor VIII activity was very low with a measurable factor VIII inhibitor (8.64 BU/mL), confirming acquired haemophilia A, likely postpartum. She was treated with prednisone and cyclophosphamide, and received bypassing therapy (initially FEIBA, then switched to recombinant factor VIIa due to side effects). Her bleeding improved and she was discharged.", + "wiki_anchor": "Massie was born with severe classical hemophilia, also known as \"Factor VIII hemophilia\", a genetic disease that prevents the blood from clotting. Though many associate hemophilia with uncontrolled external bleeding through cuts, the most severe consequence was internal joint bleedings. Such bleedings cause rapid and extremely painful swelling. Recovery and reabsorption of blood took weeks, during which the internal joints surfaces were corroded. As a result, Massie used leg braces and a wheelchair from the ages of 5 to 12. \n \nUntil 1968 the only treatment was regular intravenous transfusions of blood factors that were both extremely expensive and difficult to store and administer. The development of more affordable and easily administered blood factors greatly improved Massie's care but his childhood joint damage was not reversible.", + "doc_fkgl": 11.051032608695653, + "wiki_fkgl": 12.708685714285718, + "doc_tree_depth": 5.0, + "wiki_tree_depth": 7.142857142857143, + "fkgl_delta": -1.6576531055900645 + }, + { + "index": 6, + "label": "proficient_health_literacy", + "original_doc": "A 34-year-old female, 2 months post\u2013cesarean section (37 weeks) with persistent postoperative wound bleeding and no childhood/adolescent bleeding history, presented with a 4-week illness. The clinical course began with lower back pain attributed to bilateral renal lithiasis; after spontaneous passage of a stone she had 3 days of haematuria and was given tranexamic acid q12h. Three weeks later she developed progressive pain and induration of the left distal thigh. Following intramuscular diclofenac for persistent pain, she developed ecchymosis and ongoing bleeding in the gluteal area despite compression. An outside \u201cparticular Doppler ultrasound\u201d reportedly showed deep venous thrombosis (left lower limb), and she was started on enoxaparin 30 mg SC q24h plus morphine and hospitalized. The next day she developed epigastralgia, blurred vision, HR 117 bpm, BP 113/85 mmHg, and SpO2 93%; enoxaparin was discontinued. Hemoglobin fell from 10.4 g/dL (day prior to admission) to 6.4 g/dL, prompting 2 units of packed red cells. With a working diagnosis of vasculitis, methylprednisolone was started and she was referred for further evaluation.\n\nOn admission she had severe pallor, extensive ecchymosis of the left thigh and lateral knee, and a right thigh haematoma. Hemogram: Hb 9.8 g/dL, normocytic, normochromic. Chemistry notable for glucose 160 mg/dL; AST 52 U/L, ALT 86 U/L. Coagulation profile showed isolated prolongation of the activated partial thromboplastin time (aPTT) to 91.2 s; the remainder of hemogram, biochemistry, electrolytes, liver profile, and coagulation parameters were within reference limits. Soft-tissue ultrasound of the right gluteal region revealed a subcutaneous collection (TCSC) with oedema extending to the upper third of the thigh. Repeat Doppler ultrasound of the left lower limb showed normal flow without thrombosis in the common femoral, superficial, or deep venous systems. Blood and urine cultures were negative. ANA, C3, C4, and ferritin were within reference ranges.\n\nGiven suspected acquired haemophilia, a mixing test demonstrated partial correction of the aPTT. Factor VIII activity was <1.0 U/dL, and a factor VIII inhibitor was detected at 8.64 Bethesda units/mL, confirming acquired haemophilia A, likely postpartum in onset. Therapy included prednisone 50 mg PO at breakfast plus 10 mg at lunch, cyclophosphamide 50 mg (2 tablets) PO q24h, and FEIBA for haemostasis. After 5 days, FEIBA was discontinued due to chest tightness, dyspnoea, and nausea (suspected adverse drug reaction) and replaced with activated recombinant factor VII (rFVIIa; NovoSeven). Clinical evolution was favourable, with decreasing ecchymoses and no new symptoms, and she was discharged.\n\nContext: Postpartum acquired haemophilia A is mediated by autoantibodies to factor VIII and typically presents with isolated aPTT prolongation, low FVIII activity, and an inhibitor measured in Bethesda units. Partial correction on mixing supports an inhibitor pattern. First-line immunosuppression (e.g., prednisone with or without cyclophosphamide) and bypassing agents (FEIBA or rFVIIa) are standard to control bleeding while eradicating the inhibitor.", + "wiki_anchor": "Technique\nResuscitative equipment, monitoring and personnel must be immediately available prior to performance of this block. The retrobulbar block is performed with the patient either seated or supine and looking straight ahead. The head should be maintained in a neutral position. A needle (22\u201327 Gauge, 3\u00a0cm long) is inserted at the inferolateral border of the bony orbit and directed straight back until it has passed the equator of the globe. It is then directed medially and cephalad toward the apex of the orbit. Occasionally a 'pop' is felt as the needle tip passes through the muscle cone delineating the retrobulbar space. Following a negative aspiration for blood, 2\u20134 mLs of local anesthetic solution is injected and the needle is withdrawn. 2% Lidocaine (Xylocaine) and 0.5% to 0.75% bupivicaine (Marcaine) are two commonly used agents. Epinephrine, commonly mixed in with local anesthetics for vasoconstriction, is not used in seeing eyes as this can cause a central retinal artery occlusion. An enzyme, hyaluronidase, is frequently a component of the anaesthetic solution, as it accelerates and improves dispersal of the agent. Akinesia and anesthesia quickly ensue within minutes with a successful retrobulbar injection.\nRetrobulbar block can be used successfully for corneal transplantation but may require a supplemental facial nerve block. Retrobulbar block can block levator palpebrae muscle but not orbicularis oculi. Several techniques for facial nerve block can be used in conjunction with retrobulbar block.", + "doc_fkgl": 11.779287370862324, + "wiki_fkgl": 11.157186158798286, + "doc_tree_depth": 6.208333333333333, + "wiki_tree_depth": 6.0, + "fkgl_delta": 0.6221012120640381 + }, + { + "index": 7, + "label": "low_health_literacy", + "original_doc": "This is about a 2-day-old newborn boy. He was born at full term by C-section at a private hospital. He came to the children\u2019s hospital because the right side of his scrotum (the sack that holds the testicles) was swollen since birth. In the emergency room, he looked well. His skin was pink and warm. His blood flow looked good. On exam, the right testicle was big and tight. It was not sore when touched. The skin was red and looked rubbed. A light test did not shine through the right side. The light did shine through the left side. There were no signs of a hernia. An urgent ultrasound scan was done. The scan showed the right testicle was larger and looked uneven inside. No blood was flowing to it. The doctors took him quickly to surgery to look inside the scrotum. In surgery, the right testicle was dead because it had twisted, like a kinked hose that stops flow. There was a small amount of fluid. They removed the right testicle. They fixed the left testicle in place to help prevent twisting.", + "wiki_anchor": "Prenatal diagnosis\nPKS is commonly diagnosed by detecting its causative sSMC as defined by identifying the overexpression of its genetic material. This method has detected the sSMC and therefore diagnosed a fetus as having PKS based on genomic analyses of fetal skin fibroblasts, placenta chorionic villi, cells isolated from the amniotic fluid, fibroblasts isolated from the fetus's umbilical cord, and cells isolated from the fetus's umbilical cord blood. PKS can also be diagnose using fetal ultasound imaging methods. Ultrasound imaging in PKS commonly find fetuses that are too large for their gestational age, contain polyhydramnios (excess amniotic fluid in their amniotic sacs), and have rhizomelic limbs (shortening of the proximal part of the limbs). Less commonly, the imaging evidences diaphragmatic hernias and/or various other major PKS structural malformations. In most cases, however, the ultrasound findings are not diagnostic of PKS. Furthermore, ultrasound diagnoses is best applied in the second or third pregnancy trimester when structural anomalies are more clearly defined and detectable.", + "doc_fkgl": 3.26104347826087, + "wiki_fkgl": 17.03571428571429, + "doc_tree_depth": 4.0, + "wiki_tree_depth": 7.714285714285714, + "fkgl_delta": -13.774670807453418 + }, + { + "index": 7, + "label": "intermediate_health_literacy", + "original_doc": "A full\u2011term male newborn, 2 days old and delivered by cesarean section, presented with a congenital right scrotal swelling. On arrival he appeared well perfused and stable. Examination showed the right testis was enlarged, tense, non\u2011tender, and visibly reddish with excoriated overlying skin. Transillumination was negative on the right and positive on the left; both hernia openings were normal. Doppler ultrasound showed the right testis was enlarged with a heterogeneous, darker appearance and no detectable blood flow; the left testis looked normal, with only a small amount of fluid. He was taken urgently to surgery. Intra\u2011operatively, the right testis was frankly nonviable due to intravaginal torsion, with minimal hydrocele. Surgeons removed the right testis (orchidectomy) and fixed the left testis in place (contralateral orchidopexy) to reduce the risk of future twisting.", + "wiki_anchor": "Since the left gonadal vein drains via the left renal vein, it can also result in left testicular pain in men or left lower quadrant pain in women, especially during intercourse and during menstruation. Occasionally, the gonadal vein swelling may lead to ovarian vein syndrome in women. Nausea and vomiting can result due to compression of the splanchnic veins. An unusual manifestation of NCS includes varicocele formation and varicose veins in the lower limbs. Another clinical study has shown that nutcracker syndrome is a frequent finding in varicocele-affected patients and possibly, nutcracker syndrome should be routinely excluded as a possible cause of varicocele and pelvic congestion. In women, the hypertension in the left gonadal vein can also cause increased pain during menses.", + "doc_fkgl": 11.784036259541985, + "wiki_fkgl": 13.135081967213118, + "doc_tree_depth": 5.375, + "wiki_tree_depth": 6.333333333333333, + "fkgl_delta": -1.3510457076711333 + }, + { + "index": 7, + "label": "proficient_health_literacy", + "original_doc": "A 2\u2011day\u2011old term male neonate, delivered by cesarean section at a private hospital, was referred for a congenital right scrotal swelling and presented to our children\u2019s hospital one day later. On ED arrival he was well hydrated, pink on room air with good perfusion. Physical exam: right hemiscrotum with an enlarged, tense, non\u2011tender, visibly reddish testis and overlying skin excoriation; transillumination negative on the right and positive contralaterally; both hernial orifices normal. Laboratory studies were obtained, and urgent inguinoscrotal Doppler ultrasonography demonstrated an enlarged right testis measuring 15.6 \u00d7 9.4 mm with heterogeneous hypoechoic echotexture, prominent rete testis, and absent intratesticular color Doppler flow. The left testis was normal in size, shape, and echotexture; there was minimal hydrocele. The patient underwent urgent scrotal exploration. Intra\u2011operatively there was frank necrosis of the right testis secondary to intravaginal testicular torsion, with minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed. Contextually, perinatal testicular torsion often presents at or shortly after birth and Doppler evidence of absent flow with heterogeneous hypoechoic parenchyma correlates with nonviability; salvage rates are low when presentation is delayed. Contralateral orchidopexy is commonly performed to mitigate future torsion risk.", + "wiki_anchor": "Prenatal diagnosis\nPKS is commonly diagnosed by detecting its causative sSMC as defined by identifying the overexpression of its genetic material. This method has detected the sSMC and therefore diagnosed a fetus as having PKS based on genomic analyses of fetal skin fibroblasts, placenta chorionic villi, cells isolated from the amniotic fluid, fibroblasts isolated from the fetus's umbilical cord, and cells isolated from the fetus's umbilical cord blood. PKS can also be diagnose using fetal ultasound imaging methods. Ultrasound imaging in PKS commonly find fetuses that are too large for their gestational age, contain polyhydramnios (excess amniotic fluid in their amniotic sacs), and have rhizomelic limbs (shortening of the proximal part of the limbs). Less commonly, the imaging evidences diaphragmatic hernias and/or various other major PKS structural malformations. In most cases, however, the ultrasound findings are not diagnostic of PKS. Furthermore, ultrasound diagnoses is best applied in the second or third pregnancy trimester when structural anomalies are more clearly defined and detectable.", + "doc_fkgl": 15.11899521531101, + "wiki_fkgl": 17.03571428571429, + "doc_tree_depth": 6.5, + "wiki_tree_depth": 7.714285714285714, + "fkgl_delta": -1.9167190704032784 + }, + { + "index": 8, + "label": "low_health_literacy", + "original_doc": "A 4-year-old boy had blood in his pee and swelling for 5 days. He then had headaches, nausea, and vomiting. He came to the hospital with seizures and very high blood pressure. Blood tests showed a low level of a protein called C3 and signs of a recent strep infection. This meant his kidney filters were inflamed after strep. His brain was affected by the very high blood pressure. Doctors suspected a problem called PRES, which is brain swelling from high pressure. A brain MRI confirmed this. His immune system also attacked his red blood cells. This made his blood level drop very low, to 5 g/dL. He was treated with medicines to lower his blood pressure, steps to protect his brain, and steroid medicines. He left the hospital after 31 days. Six months later, he had no symptoms.", + "wiki_anchor": "Patients often present with headaches, painful cranial pressure, and neck pain early in the progression of the disease. Patients with a more advanced infection have been known to complain of many neurological effects such as dizziness, vertigo, confusion, and slurred speech. Very advanced cases can lead to mental instability, nausea, vomiting, rigors, and temporary loss of consciousness. Many patients with ventriculitis also experience some degree of hydrocephalus, which is the buildup of cerebrospinal fluid due to the inability of the ventricles to reabsorb and correctly circulate the fluid. Brain abscess is another common disorder resulting from the inflammation. If left untreated, ventriculitis can lead to serious inhibition of mental function and even death.", + "doc_fkgl": 4.794388489208632, + "wiki_fkgl": 13.78862831858407, + "doc_tree_depth": 4.923076923076923, + "wiki_tree_depth": 7.666666666666667, + "fkgl_delta": -8.994239829375438 + }, + { + "index": 8, + "label": "intermediate_health_literacy", + "original_doc": "A 4-year-old boy presented after 5 days of visible blood in the urine and leg swelling, plus new headaches, nausea, and vomiting. He developed seizures with a hypertensive emergency. Labs showed low complement C3 and a high anti-streptolysin O (ASO) titer, consistent with acute post-streptococcal glomerulonephritis. He developed encephalopathy, and MRI confirmed posterior reversible encephalopathy syndrome (PRES) secondary to the hypertensive crisis. He also developed autoimmune hemolytic anemia, with hemoglobin falling to 5 g/dL. Treatment included antihypertensive therapy, neuroprotective measures, and corticosteroids. He was discharged after 31 days and remained asymptomatic at 6-month follow-up.", + "wiki_anchor": "Acute proliferative glomerulonephritis is a disorder of the small blood vessels of the kidney. It is a common complication of bacterial infections, typically skin infection by Streptococcus bacteria types 12, 4 and 1 (impetigo) but also after streptococcal pharyngitis, for which it is also known as postinfectious glomerulonephritis (PIGN) or poststreptococcal glomerulonephritis (PSGN). It can be a risk factor for future albuminuria. In adults, the signs and symptoms of infection may still be present at the time when the kidney problems develop, and the terms infection-related glomerulonephritis or bacterial infection-related glomerulonephritis are also used. Acute glomerulonephritis resulted in 19,000 deaths in 2013, down from 24,000 deaths in 1990 worldwide.", + "doc_fkgl": 14.753525835866263, + "wiki_fkgl": 14.346862385321106, + "doc_tree_depth": 6.333333333333333, + "wiki_tree_depth": 6.8, + "fkgl_delta": 0.40666345054515673 + }, + { + "index": 8, + "label": "proficient_health_literacy", + "original_doc": "A 4-year-old male, two weeks post nasal impetigo treated with topical mupirocin and oral cefadroxil (dose/duration/adherence unknown), presented with 5 days of macroscopic glomerular haematuria and lower-extremity oedema, followed by 12 hours of headache, nausea, and vomiting, and arrived to the ED in convulsive status after 20 minutes of generalized tonic\u2013clonic seizures. On ED arrival he was afebrile, with non-evaluable BP, depressed consciousness, generalized hypertonia, and bilateral pretibial oedema. He was intubated and loaded with phenobarbital 10 mg/kg. In the ICU, BP was 134/94 mmHg (p95 for age 108/66; p95+12 120/78), consistent with hypertensive emergency. Initial labs: urinalysis with haematuria (>100 RBC/hpf), proteinuria 3+, leucocyturia 10\u201325/hpf; creatinine 0.3 mg/dL; anaemia Hct 21%, Hb 7 g/dL with normocytic, normochromic indices; leukocytosis 23,900/mm3; thrombocytosis 756,000/mm3; no elevation of acute-phase reactants; hypocomplementemia with C3 25 mg/dL (VN 80\u2013150) and normal C4. Throat rapid antigen for group A Streptococcus was positive and ASO positive. Non-contrast head CT was unremarkable. Renal ultrasound showed bilateral nephromegaly with increased cortical echogenicity and decreased corticomedullary differentiation. The working diagnosis was nephritic syndrome due to complicated GNAPE with hypertensive emergency and status epilepticus. He required mechanical ventilation and phenobarbital; EEG the next day was normal; CSF was normal. Cefotaxime was started for Streptococcus pyogenes eradication and furosemide for diuresis. By day 2 he developed AKI (creatinine 0.99 mg/dL), hypertension, and 24-hour proteinuria 36.6 mg/m2/h without oliguria. Antihypertensive therapy included amlodipine and IV labetalol with initial control. After extubation at 48 hours, he deteriorated neurologically within 24 hours (GCS 8) with BP > p95+12 despite labetalol infusion up to 3 mg/kg/h, amlodipine 10 mg/day, and furosemide, necessitating reintubation and sodium nitroprusside infusion up to 3 mcg/kg/min with a planned gradual BP reduction of 25% per day to mitigate secondary neurologic injury. Given acute neurologic deficits with severe HTN in GN, PRES was suspected and confirmed by brain MRI on day 5 showing increased subcortical T2/FLAIR signal in bilateral symmetric occipital regions without diffusion restriction, consistent with vasogenic edema. Ophthalmologic exam was normal; repeat EEG showed occasional generalized voltage depression. Enalapril was added. Over 10 days, BP normalized with slow pharmacologic weaning; follow-up MRI on day 12 showed radiologic regression, and he was successfully extubated after 5 days. During the ICU course, Hb fell to 5 g/dL with normocytic, normochromic indices and no thrombocytopenia; hemolytic anemia was diagnosed given a positive direct Coombs test and hemoglobinuria. He required two packed RBC transfusions. Methylprednisolone 1 mg/kg/day was given for 72 hours. Stool culture and urinary antigen for Streptococcus pneumoniae were negative. Serologies for EBV and Parvovirus B19, ENA profile, ANCA, anti-dsDNA, anti-\u03b22 glycoprotein I, anticardiolipin, and lupus anticoagulant were all negative; all cultures (blood, urine, endotracheal aspirate, pharyngeal) were negative. ANA was positive at 1:160. Clinical status improved with BP control, rising complement levels, and resolution of proteinuria and haematuria; the direct Coombs remained positive on hospital day 9. He was discharged on day 31 normotensive, non-anaemic, with preserved renal function, no proteinuria or haematuria, normalized C3, and asymptomatic neurologically. Discharge medications: prednisone, amlodipine, enalapril, and folic acid. He remained asymptomatic with no recurrence at 6 months. Overall, the case represents GNAPE with hypocomplementemia (low C3) and elevated ASO complicated by hypertensive emergency causing encephalopathy and secondary PRES, plus autoimmune hemolytic anemia with Hb nadir 5 g/dL, successfully managed with antihypertensives, neuroprotective measures, and corticosteroids, with full clinical and radiologic recovery.", + "wiki_anchor": "In a review of 2081 adult patients participating in a Phase III clinical trial of sparfloxacin in community-acquired, lower respiratory tract infections, sparfloxacin (200 or 400\u00a0mg loading dose then 100 or 200\u00a0mg daily; i.e. 200/100\u00a0mg and 400/200\u00a0mg) had a similar incidence of adverse events as the comparator agents (Rubinstein, 1996). The overall rates of drug-related adverse reactions for sparfloxacin 400/200\u00a0mg versus comparators and 200/100\u00a0mg versus the comparator (amoxicillin/clavulanic acid) were 13.7 versus 17.7%, and 9.5 versus 13.2%, respectively. However, many of these reported reactions were very minor; discontinuation of the antibacterial agent because of drug-related adverse reactions occurred in 1.6 versus 1.6%, and 1) versus 1.1%, respectively. Adverse reactions affecting the nervous system were reported in 5.7% of the sparfloxacin group, with insomnia and other sleep disorders the most common events.\nPhototoxicity was noted in 2.0% of sparfloxacin recipients, with the average delay in onset being 6.3 :t 4.5 days (range 1\u201314 days) after commencing sparfloxacin. Mostly this consisted of erythema on the face and hands which lasted an average of 6.4 :t 4.2 days. The incidence of phototoxicity associated with sparfloxacin appears to be higher than that observed with ciprofloxacin and ofloxacin but less than that reported for fleroxacin, pefloxacin, enoxacin and nalidixic acid.\nMost importantly, features of the hemolytic-uremic syndrome such as that associated with temaflox have not been reported.", + "doc_fkgl": 14.958653673835126, + "wiki_fkgl": 9.68824561403509, + "doc_tree_depth": 5.866666666666666, + "wiki_tree_depth": 8.5, + "fkgl_delta": 5.270408059800037 + }, + { + "index": 9, + "label": "low_health_literacy", + "original_doc": "This 69-year-old man had heart bypass surgery in the past. For 2 months, he got very short of breath with light activity. Tests\u2014a heart tracing, a blood test, and an X-ray movie with dye of the heart arteries\u2014showed heart failure from poor blood flow after a bypass vein to the right heart artery failed. Doctors first opened a totally blocked artery on the left side of his heart. Then they used tiny natural detours between heart arteries to reach the right heart artery from the far end and open it. His breathing was better when he left the hospital. Six months later, his shortness of breath had not come back.", + "wiki_anchor": "While playing catch with a teammate on February 4, , however, his throwing hand spontaneously became pale and his arm lost all circulation from the elbow down. After being placed on blood-thinning medication, he was diagnosed with a torn artery in his right shoulder, which led to arterial bypass surgery later that month. The operation removed an artery from his right and transplanted it into the injured shoulder, re-routing blood around the damaged vessel. It was the first procedure of its kind in the history of Major League Baseball.", + "doc_fkgl": 6.522207792207791, + "wiki_fkgl": 12.567272727272726, + "doc_tree_depth": 5.571428571428571, + "wiki_tree_depth": 7.0, + "fkgl_delta": -6.045064935064936 + }, + { + "index": 9, + "label": "intermediate_health_literacy", + "original_doc": "A 69-year-old man with prior coronary bypass surgery presented with two months of severe shortness of breath with mild activity (NYHA class III). He was diagnosed with heart failure due to ischemia after failure of a saphenous vein graft to the right coronary artery. This was supported by an abnormal ECG, elevated NT-proBNP, and a coronary angiogram; echocardiography also showed reduced pumping function. The team reopened a chronic total occlusion in the native right coronary artery using a retrograde approach through septal channels (septal surfing). To enable that route, they first re-opened the totally occluded left coronary artery. After the procedure, his dyspnea improved before discharge, and at 6 months he had no recurrence of shortness of breath.", + "wiki_anchor": "To achieve this, the patient is first placed on cardiopulmonary bypass. This device, otherwise known as the heart-lung machine, takes over the functions of gas exchange by the lung and blood circulation by the heart. Subsequently, the heart is isolated from the rest of the blood circulation by means of an occlusive cross-clamp placed on the ascending aorta proximal to the innominate artery. During this period of heart isolation, the heart is not receiving any blood flow, thus no oxygen for metabolism. As the cardioplegia solution distributes to the entire myocardium, the ECG will change and eventually asystole will ensue. Cardioplegia lowers the metabolic rate of the heart muscle, thereby preventing cell death during the ischemic period of time.", + "doc_fkgl": 13.480000000000004, + "wiki_fkgl": 12.968529411764706, + "doc_tree_depth": 7.166666666666667, + "wiki_tree_depth": 6.0, + "fkgl_delta": 0.5114705882352979 + }, + { + "index": 9, + "label": "proficient_health_literacy", + "original_doc": "A 69-year-old male with prior CABG presented with 2 months of severe dyspnea on mild exertion (NYHA III). ECG showed ST depression in II, III, aVF, and V4\u20136; NT-proBNP was 2640 pg/mL. Echocardiography demonstrated LV systolic dysfunction with LVEF 30%. His history included an inferior STEMI in 2009 with severe 3-vessel disease (proximal LAD CTO, 90% mid/distal LCx stenoses, 95% mid RCA stenosis) treated with CABG (LIMA\u2013LAD; sequential SVG to OM1, OM2, and PL). Current angiography via 6 Fr left radial access showed patent LIMA\u2013LAD and SVG\u2013OM1/OM2, but complete occlusion of the sequential SVG to PL. The native LM was occluded at the ostium and the native RCA was occluded in the mid segment with bridging collaterals. The strategy was to treat the native RCA CTO. Dual arterial access was obtained with an additional 6 Fr right femoral sheath. The right and left coronaries were engaged with 6 Fr AL 0.75 (Launcher; Medtronic) and 6 Fr EBU 3.5 (Launcher; Medtronic) guide catheters, respectively. An antegrade approach from the left radial artery failed: neither a Fielder XTR nor a Gaia 3 with a Finecross microcatheter could enter the distal true lumen. A parallel wire technique with a Crusade microcatheter and two Gaia 3 wires also failed. The team then switched to a retrograde approach via septal channels from the LAD through the occluded left coronary system. A Gaia 3 crossed the occluded LM and LAD to reach the distal LAD true lumen. A Sion wire was exchanged via a Finecross into the distal LAD, followed by dilation of the LM and proximal LAD with a 2.0 \u00d7 15 mm balloon. Septal surfing technique (SST) was then used to identify a viable septal channel. A Sion wire, supported by a 150-cm Finecross, was advanced retrogradely through a distal septal branch into the distal RCA. A Gaia 3 traversed the RCA CTO retrogradely into the proximal RCA true lumen and was advanced into a Guidezilla guide extension catheter positioned in the antegrade guide. The Finecross was delivered to the antegrade guide and an RG3 wire was externalized. The CTO segment was predilated with a 2.0 \u00d7 15 mm balloon and stented with two overlapping DES (2.5 \u00d7 38 mm and 3.0 \u00d7 38 mm), achieving an excellent angiographic result with TIMI 3 flow in all distal branches. Dyspnea was relieved at discharge, and at 6-month follow-up there was no recurrence of dyspnea.", + "wiki_anchor": "Some examples of reported cardiovascular causes include:\n Congenital abnormalities:\nAtrial septal defect\nAortopulmonary window\nEbstein's Anomaly\nPatent Ductus Arteriosus (PDA)\nSurgical intervention:\nTranscatheter closure of a PDA \nIncidence: due to the close proximity of the LRLN to the aortic arch, transient paralysis can occur in 10% of cases while permanent effects can occur in 1% of cases. This can further be attributed to using metal clips (used to control bleeding) during the surgical procedure and is more common in premature infants.\n Cardiac disease:\nLeft atrial enlargement due to valvular heart disease\nNotable case: A middle-aged male had ongoing cough, hoarseness of voice, and shortness of breath for two years without a history of smoking was found to have mitral valve stenosis due to calcification. This led to left atrial enlargement, elevated pulmonary artery pressure, pulmonary artery hypertension, and right ventricular enlargement. This cardiomegaly, or enlargement of the heart, led to compression of the LRLN.\nAtrial Myxoma\nAorta:\nTraumatic injury\nIncidence: Although injury to the thoracic aorta is often fatal, in 10% of cases that take longer to present, hoarseness may be the first symptom.\nAortic dissection\nMore commonly affects the right recurrent laryngeal nerve as the most common type of aortic dissection is type A (Figure 2).\nPseudoaneurysm\nNotable case: A male with long-standing uncontrolled hypertension and hoarseness of voice attributed to life-long smoking was found to have a pseudoaneurysm of the aortic arch which was compressing the LRLN.\nPulmonary disease:\nPathophysiology: Due to vascular congestion in the lung, the pulmonary artery (Figure 3) becomes dilated and can compress the aorta and the LRLN.\nPrimary pulmonary hypertension\n Pulmonary emboli\nMalignancy (pulmonary, mediastinal)\n Autoimmune:\nMixed connective tissue disease\nNotable case: A young female with a history of mixed connective tissue disease presented with hoarseness of voice and was found to have secondary pulmonary artery hypertension. This was causing right heart enlargement and therefore compression of the LRLN.\nIdiopathic", + "doc_fkgl": 9.065632911392406, + "wiki_fkgl": 17.909027817608266, + "doc_tree_depth": 6.684210526315789, + "wiki_tree_depth": 7.071428571428571, + "fkgl_delta": -8.84339490621586 + }, + { + "index": 10, + "label": "low_health_literacy", + "original_doc": "A 51-year-old man came to us with sudden, painful vision loss in his left eye for three days. His right eye could see clearly (20/20). His left eye could only see hand movements. The back of his left eye showed swelling of the seeing nerve, a bulge in the layer under the retina, several patches of fluid under the retina, and wrinkles in the thin lining there. An MRI scan with contrast dye of the eyes and brain showed a small lump behind the eye where the eye nerve meets the white part of the eye. Tests for cancer and immune diseases were normal. The doctors diagnosed inflammation in the back part of the eye\u2019s white coat that forms a small lump (nodular posterior scleritis). They started high-dose steroid pills by mouth (prednisolone).", + "wiki_anchor": "Adverse events and complications \nEndophthalmitis, or a bacterial infection within the eye causing inflammation of the sclera, is one of the most severe complications due to intravitreal injections. Incidence of endophthalmitis after intravitreal injection per patient has been reported to range from 0.019 to 1.6%. Endophthalmitis can also result in white or yellow discharge inside the eyelid, and a white, cloudy cornea. A layer of white blood cells called hypopyon may develop between the iris and the cornea. Endophthalmitis is considered an ophthalmological emergency and requires immediate treatment in many cases. It is treated with injections of antibiotics and antifungal compounds as appropriate. In severe cases a vitrectomy, or removal of vitreous humor, may be required to surgically remove infectious debris.", + "doc_fkgl": 6.597509398496243, + "wiki_fkgl": 13.713708677685954, + "doc_tree_depth": 5.875, + "wiki_tree_depth": 6.428571428571429, + "fkgl_delta": -7.116199279189711 + }, + { + "index": 10, + "label": "intermediate_health_literacy", + "original_doc": "A 51-year-old man presented with 3 days of sudden, painful vision loss in the left eye. Visual acuity was 20/20 in the right eye and hand motion in the left eye. Left fundus findings included optic nerve head swelling, choroidal bulging, multiple areas of subretinal fluid, and RPE corrugations. Orbital/brain MRI with gadolinium showed a retrobulbar nodular mass enhancing at the junction of the optic nerve and sclera. Oncology and rheumatology evaluations were unremarkable. The clinical diagnosis was nodular posterior scleritis, and oral prednisolone was started.", + "wiki_anchor": "Diagnosis\nOptic nerve gliomas are diagnosed using magnetic resonance imaging (MRI) and CT scans. The tumor adopts a fusiform appearance, appearing wider in the middle and tapered at the ends. Enlargement of the optic nerve along with a downward kink in the mid-orbit is usually observed. While CT scans allow for optic nerve evaluation, MRI allows for intracranial evaluation to observe if the tumor has extended to other regions such as the optic chiasm & hypothalamus.", + "doc_fkgl": 11.54186046511628, + "wiki_fkgl": 12.962500000000002, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.75, + "fkgl_delta": -1.4206395348837226 + }, + { + "index": 10, + "label": "proficient_health_literacy", + "original_doc": "A 51-year-old male presented with acute, painful visual loss of the left eye (LE) for 3 days. Best-corrected distance visual acuity (BCDVA) was 20/20 OD and hand motion (HM) OS. Ocular motility and anterior segment were unremarkable OU. Fundus OS showed optic nerve head (ONH) swelling, choroidal bulging, multiple patches of subretinal fluid (SRF), and retinal pigment epithelial (RPE) corrugations; OD fundus was unremarkable.\n\nMultimodal imaging was obtained: OCT (OptoVue, Inc., Fremont, CA, USA; software version 2018.0.0.18) demonstrated mild RPE and choroidal bulging, RPE hyper-reflectivity with back shadowing, subretinal and intraretinal fluid, and mild retinal thickening. Indocyanine green angiography (ICGA) showed a geographic macular hypocyanescent area OS. Blue-autofluorescence (BAF) revealed a geographic macular area with speckled autofluorescence. B-scan ultrasonography showed optic nerve enlargement. Fluorescein angiography (FA) demonstrated vascular leakage at the ONH (hot disc) and a geographic patchy hypofluorescent area with speckled hyperfluorescent margins measuring approximately three disc diameters. Orbital and brain MRI with gadolinium revealed a retrobulbar nodular enhancing mass at the optic nerve\u2013sclera junction. Oncology consultation was unremarkable.\n\nGiven concern for malignancy and the enhancing orbital nodule, the patient underwent transconjunctival lateral orbitotomy one week after presentation. Intraoperatively, a pink localized scleral nodule with edematous Tenon was identified. With a clinical diagnosis of nodular posterior scleritis, sub-Tenon triamcinolone acetonide was administered. The patient declined admission and intravenous corticosteroids; oral prednisolone 50 mg/Kg was initiated. Rheumatologic and infectious work-up, including PPD (tuberculosis), chest X-ray, serum ACE (sarcoidosis), and C-ANCA (Wegener granulomatosis), was unremarkable.\n\nAt the one-week postoperative follow-up, BCDVA was 20/20 OD and counting fingers at 2 meters OS. SRF had resolved, and the macula was atrophic. Oral prednisolone was tapered over three months.", + "wiki_anchor": "Diagnosis\nSphenoid wing meningiomas are diagnosed by the combination of suggestive symptoms from the history and physical and neuroimaging by magnetic resonance imaging (MRI) or computer averaged tomography (CT). Tumors growing in the inner wing (clinoidal) most often cause direct damage to the optic nerve leading especially to a decrease in visual acuity, progressive loss of color vision, defects in the field of vision (especially cecocentral), and an afferent pupillary defect. If the tumor continues to grow and push on the optic nerve, all vision will be lost in that eye as the nerve atrophies. Proptosis, or anterior displacement of the eye, and palpebral swelling may also occur when the tumor impinges on the cavernous sinus by blocking venous return and leading to congestion. Damage to cranial nerves in the cavernous sinus leads to diplopia. Cranial nerve VI is often the first affected, leading to diplopia with lateral gaze. If cranial nerve V-1 is damaged, the patient will have pain and altered sensation over the front and top of the head. Horner's syndrome may occur if nearby sympathetic fibers are involved.", + "doc_fkgl": 14.661870129870131, + "wiki_fkgl": 12.987341160220996, + "doc_tree_depth": 5.473684210526316, + "wiki_tree_depth": 7.75, + "fkgl_delta": 1.6745289696491348 + }, + { + "index": 11, + "label": "low_health_literacy", + "original_doc": "A 78-year-old man from the Amhara region of Ethiopia had a permanent heart pacemaker because of a complete heart block. He was scheduled for prostate surgery. Before surgery, the anesthesia and heart doctors advised switching his pacemaker to a steady, fixed beat to lower the chance of problems. He could not afford that change. He chose to go ahead with the operation. He signed consent for the plan. After surgery, he also gave permission to share his case. For anesthesia, he got a numbing injection in the lower back (a combined spinal\u2013epidural). The team used 2.5 ml of strong numbing medicine (0.5% bupivacaine) and a tiny dose of fentanyl (50 micrograms). Standard monitors were used, and his heart was watched closely. His vital signs stayed steady, with only small changes. His blood pressure stayed good with IV salt water. After surgery, he went to the recovery room. He got pain medicine after 4 hours and an extra dose through the epidural. Six hours after surgery, he moved to the ward in stable condition. The epidural pain control continued for 72 hours. He went home in stable condition about 88 hours after surgery.", + "wiki_anchor": "Now the diagnosis has been confirmed by either cystoscopy or a prior urethrography, the patient is placed in the lithotomy position, and the urinary meatus is cleansed with an appropriate surgical cleansing agent (scrub), usually containing Povidone-iodine, then surgically draped. An IV antibiotic or other anti-infective medication is administered in conjunction with intravenous normal saline, and allowed to run until administration of the prescribed dose is completed. Most often, procedural sedation will be the chosen adjunct to patient comfort, and the patient will have received intravenous anxiolytic medication at sometime prior to, or during the surgical preparation. This medication is usually a benzodiazepine, often, diazepam or midazolam is employed. The urological surgeon or anesthesia practitioner may also choose to administer a narcotic analgesic such as fentanyl citrate, depending on the level of discomfort anticipated by the surgeon. In some cases, usually where longer strictures are present, a rapidly metabolized hypnotic agent such as propofol may be selected, as this allows for the immediate induction of short-term general anesthesia (note:endotracheal intubation will also be necessary if general anesthesia is administered). Constant monitoring of vital signs including pulse oximetry, cardiac monitoring (ECG), body temperature and blood pressure are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit.", + "doc_fkgl": 6.542719298245618, + "wiki_fkgl": 20.87432595573441, + "doc_tree_depth": 4.823529411764706, + "wiki_tree_depth": 7.142857142857143, + "fkgl_delta": -14.331606657488791 + }, + { + "index": 11, + "label": "intermediate_health_literacy", + "original_doc": "A 78-year-old man from the Amhara region, Ethiopia, with a permanent pacemaker placed for complete heart block was scheduled for retropubic prostatectomy. The anesthesia and cardiology teams recommended switching his dual-chamber, rate\u2011modulated pacemaker to an asynchronous mode perioperatively to reduce the risk of electromagnetic interference during surgery. He could not afford reprogramming and chose to proceed with the existing plan after informed consent; permission to publish the case was obtained after the operation. He received combined spinal\u2013epidural anesthesia at L3\u2013L4 using 0.5% isobaric bupivacaine 2.5 ml (12.5 mg) plus fentanyl 50 \u00b5g. Standard ASA monitoring was applied with special attention to cardiac stability. Intraoperatively, he remained stable with minimal changes in vital signs; blood pressure was supported with isotonic saline as needed. Postoperatively, he was monitored in the PACU, received analgesia at 4 hours with an epidural top\u2011up, and was transferred to the ward about 6 hours after surgery in stable condition. Epidural analgesia was continued for 72 hours. He was discharged at the 88th postoperative hour in good condition.", + "wiki_anchor": "General anesthesia is commonly used in animals for major surgery. Animals are often premedicated intravenously or intramuscularly with a sedative, analgesic, and anticholinergic agent (dogs frequently receive buprenorphine and acepromazine). The next step is induction, usually with an intravenous drug. Dogs and cats commonly receive thiopental (no longer allowed in the UK), ketamine with diazepam, tiletamine with zolazepam (usually just in cats), and/or propofol. Alfaxalone is a steroid anaesthetic used in many practices in the UK to induce anaesthesia in cats and sometimes dogs. It is similar in physiological effect but different in composition to the now withdrawn Saffan. Horses commonly receive thiopental and guaifenesin. Following induction, the animal is intubated with an endotracheal tube and maintained on a gas anesthetic. The most common gas anesthetics in use in veterinary medicine are isoflurane, enflurane, and halothane, although desflurane and sevoflurane are becoming more popular due to rapid induction and recovery.", + "doc_fkgl": 12.910294117647059, + "wiki_fkgl": 14.116666666666667, + "doc_tree_depth": 6.444444444444445, + "wiki_tree_depth": 6.0, + "fkgl_delta": -1.2063725490196084 + }, + { + "index": 11, + "label": "proficient_health_literacy", + "original_doc": "A 78-year-old male from the Amhara region of Ethiopia with a 7-year history of a permanent pacemaker for complete heart block was scheduled for retropubic prostatectomy for BPH after prior TURP 3 months earlier. Comorbidities included long-standing hypertension (amlodipine 5 mg daily, enalapril 10 mg BID, atorvastatin 10 mg daily) and type 2 diabetes mellitus (metformin 500 mg BID; NPH insulin 20 IU AM/10 IU PM). Preoperative evaluation showed complete bundle branch block on ECG; electrophysiology assessment demonstrated LVH due to hypertensive heart disease with mild diastolic dysfunction and an EF of 62%. Abdominal ultrasound showed an 82-ml prostate; AP chest X-ray was normal with a left-sided pacemaker in situ; electrolytes and troponin were normal. He had a frailty score of 5.5, METs 3.4, and an RCRI class III, indicating an estimated 10.1% risk of major adverse cardiac events within 30 days and intermediate surgical risk. Multidisciplinary planning recommended reprogramming the dual-chamber, rate\u2011modulated pacemaker to an asynchronous mode to mitigate intraoperative electromagnetic interference risk. Due to financial and logistical constraints, reprogramming was not performed; risks were disclosed, and he consented to proceed. Preoperatively, usual medications were continued (with a lower morning NPH dose at two\u2011thirds); diazepam 5 mg PO was given at midnight for anxiolysis. On the day of surgery, random blood glucose was checked and managed with a sliding scale. Team communication emphasized CIED precautions (electrosurgery pad positioned away from the device; emergency drugs and defibrillator immediately available). Dexamethasone was given for PONV prophylaxis and paracetamol for preemptive analgesia. ASA standard monitoring was applied and baselines recorded. An L3\u2013L4 combined epidural\u2013spinal anesthetic was performed using 0.5% isobaric bupivacaine 12.5 mg (2.5 ml) plus fentanyl 50 \u00b5g, achieving a sensory level to T7. The procedure used a midline infraumbilical incision; monopolar cautery at low voltage (20 mA) with bipolar low\u2011voltage cautery for hemostasis. Intraoperative hemodynamics remained within 10% of baseline without cardiorespiratory events; blood pressure was maintained with isotonic saline. Postoperatively, he was transferred to PACU with vigilant monitoring; analgesia was administered at 4 hours with an epidural top\u2011up, and he was transferred to the ward approximately 6 hours after surgery in stable condition. Epidural analgesia was continued for 72 hours. He was discharged at the 88th postoperative hour in stable condition, with cardiology follow\u2011up advised. Informed consent was obtained, and permission for case report publication was granted after the operation.", + "wiki_anchor": "The functional significance of the coronary collateral vessels is a matter of continuing experimental investigation although their existence has been known for over three centuries and been documented repeatedly in man and beast over the past seven decades. Although a now-classic series of experiments by Schaper in the late 1960s and '70s expanded our understanding of the mechanisms by which these usually redundant, microscopic (40-10\u00a0um in diameter in their native state) ur-arterioles are transformed by ischemia or stenosis into vessels with life-preserving blood capacity, equally as many studies have denied the function of these vessels to preserve myocardium by salvaging tissue perfusion and maintaining blood pressure as have documented this. It was only during the 1980s that a consensus among researchers was reached that these vessels can preserve as much as 30 to 40% of coronary blood flow to an otherwise-occluded blood vessel, and, while not capable of preventing ischemia in the event of high-output exercise, can nevertheless maintain aortic, pulmonic, and atrial blood pressure, redirect ST elevation into less serious ST depression in ischemia, and prevent infarction and symptoms of infarction, even in the case of complete left main coronary artery stenosis.", + "doc_fkgl": 13.475840409207162, + "wiki_fkgl": 31.8918556701031, + "doc_tree_depth": 6.2631578947368425, + "wiki_tree_depth": 8.666666666666666, + "fkgl_delta": -18.41601526089594 + }, + { + "index": 12, + "label": "low_health_literacy", + "original_doc": "A 52-year-old woman had burning when she peed and had to pee very often for a long time. She tried many treatments for bladder infections, but the problem did not go away. Regular scans and lab tests looked normal. A camera test that looked inside her bladder showed the lining was red and irritated, with tiny bits floating in the urine. Later, the lab saw a live larva (a baby insect) in her urine under the microscope. That finding explained her symptoms. She was told to keep very clean. She was also told to drink plenty of water every day.", + "wiki_anchor": "Larva. \"Cylindrical, with four pairs of long fleshy subdorsal filaments which have pink bases and black tips, three pairs being on the anterior segments and the fourth pair on the 12th segment. Body pinkish white with lateral yellowish blotches, the segments each divided by a black line and anteriorly bordered by a narrow transverse pink band and purple-brown stripes ; spiracles black ; head with a dark red stripe in front and one on each side ; fore legs black, middle and hind legs black ringed with pink\" (Moore, Larva of the Javan form, E. claudia)", + "doc_fkgl": 6.041, + "wiki_fkgl": 19.674032258064518, + "doc_tree_depth": 5.125, + "wiki_tree_depth": 7.0, + "fkgl_delta": -13.633032258064517 + }, + { + "index": 12, + "label": "intermediate_health_literacy", + "original_doc": "A 52-year-old woman had ongoing dysuria and urinary frequency despite multiple treatments for presumed infections. Cystoscopy showed bladder redness and debris, while imaging and routine lab tests were unremarkable. Eventually, a live larva was identified in the urine, confirming the cause of her symptoms. Management focused on better personal hygiene and increased fluid intake.", + "wiki_anchor": "All males with recurrent UTIs (urinary tract infections) or abnormality on ultrasound if first UTI.\nFemales < 3 years of age with their first UTI.\nFemales < 5 years of age with febrile UTIs\nOlder females with pyelonephritis or recurrent UTIs\nSuspected obstruction (e.g. bilateral hydronephrosis)\nSuspected bladder trauma or rupture\n Vesico Vaginal/Vesico Colic fistula\nCystocele", + "doc_fkgl": 12.18240740740741, + "wiki_fkgl": 10.652777777777779, + "doc_tree_depth": 5.5, + "wiki_tree_depth": 7.0, + "fkgl_delta": 1.529629629629632 + }, + { + "index": 12, + "label": "proficient_health_literacy", + "original_doc": "A 52-year-old woman presented with a three-year history of urinary frequency, dysuria, and dribbling, along with intermittent passage of red and black thread-like material in the urine. Episodes with these discharges were associated with headache, fever, and chills, and she reported intermittent periurethral and genital pruritus. She had been repeatedly treated for recurrent urinary tract infections without clinical improvement. She denied recent travel, camping, hiking, farming, swimming, or insect bites. Past surgical history included pilonidal sinus surgery (8 years prior) and hysterectomy (7 years prior). Two years before the current visit, she was hospitalized for evaluation. Examination revealed a well-appearing patient with normal vital signs. Laboratory testing, including complete blood count, urinalysis, and serum chemistries, was within normal limits. Abdominopelvic CT was unremarkable. Cystoscopy demonstrated erythema and hyperemia of the bladder mucosa, suspended intravesical debris, and dilatation of the left ureteral orifice. Schistosomiasis was suspected and she received praziquantel at appropriate dose and duration, without improvement. A second infectious diseases consultation raised suspicion for urinary myiasis, and ivermectin was prescribed, again without benefit. She underwent bladder irrigation with polyethylene glycol; no visible larvae were recovered from the washings, and she experienced self-limited hematuria for two days post-procedure. A subsequent random urinalysis was normal. However, a 24-hour urine collection demonstrated a live larva on light microscopy. The specimen was isolated and identified morphologically by an entomologist as Sarcophaga spp. Final management emphasized personal hygiene measures and liberal oral hydration.", + "wiki_anchor": "Now the diagnosis has been confirmed by either cystoscopy or a prior urethrography, the patient is placed in the lithotomy position, and the urinary meatus is cleansed with an appropriate surgical cleansing agent (scrub), usually containing Povidone-iodine, then surgically draped. An IV antibiotic or other anti-infective medication is administered in conjunction with intravenous normal saline, and allowed to run until administration of the prescribed dose is completed. Most often, procedural sedation will be the chosen adjunct to patient comfort, and the patient will have received intravenous anxiolytic medication at sometime prior to, or during the surgical preparation. This medication is usually a benzodiazepine, often, diazepam or midazolam is employed. The urological surgeon or anesthesia practitioner may also choose to administer a narcotic analgesic such as fentanyl citrate, depending on the level of discomfort anticipated by the surgeon. In some cases, usually where longer strictures are present, a rapidly metabolized hypnotic agent such as propofol may be selected, as this allows for the immediate induction of short-term general anesthesia (note:endotracheal intubation will also be necessary if general anesthesia is administered). Constant monitoring of vital signs including pulse oximetry, cardiac monitoring (ECG), body temperature and blood pressure are carried out by the anesthesia practitioner until the patient is discharged post-operatively to the post-surgical recovery unit.", + "doc_fkgl": 14.957394957983198, + "wiki_fkgl": 20.87432595573441, + "doc_tree_depth": 5.411764705882353, + "wiki_tree_depth": 7.142857142857143, + "fkgl_delta": -5.916930997751212 + }, + { + "index": 13, + "label": "low_health_literacy", + "original_doc": "A 36-year-old woman had a long-term bowel disease (ulcerative colitis). She came in with chest pain that kept getting worse. She also had shortness of breath, sweating, and felt sick to her stomach. For months she had felt very tired and had night sweats. Her heart test (EKG) showed signs of a heart attack in the lower part of the heart. Doctors did a dye X-ray to look at the heart arteries. It showed bad blockages in two heart pipes. They opened the most blocked pipe right away with a balloon and a tiny mesh tube (stent). While looking, the team worried the main body artery (aorta) was swollen. Blood tests showed mild inflammation. A special CT scan showed the aorta wall looked thick and scarred, with tight narrow spots in several arteries. This pointed to a rare illness that causes swollen big arteries, called Takayasu arteritis. She started strong anti-inflammatory and immune medicines (prednisone and methotrexate). Later she had heart bypass surgery to improve blood flow. She did well after treatment.", + "wiki_anchor": "Loeffler endocarditis is now regarded as a manifestation of eosinophilic myocarditis, a disorder that involves the infiltration of the heart's muscular layer by eosinophils that leads to three progressive clinical stages. The first stage involves acute inflammation and subsequent death of heart muscle cells. This stage is dominated by signs and symptoms of the acute coronary syndrome such as angina, heart attack, and congestive heart failure. In the second stage, the endocardium (i.e. interior wall) of the heart forms blood clots which break off and then travel through and block various arteries; this clotting stage may dominate the initial presentation in some individuals. The third stage is a fibrotic stage, i.e. Loeffler endocarditis, wherein scarring replaces damaged heart muscle tissue to cause a poorly contracting heart and/or heart valve disease. Recent publications commonly refer to Loeffler endocarditis as a historical term for the third stage of eosinophilic myocarditis.", + "doc_fkgl": 5.827348837209307, + "wiki_fkgl": 11.956081081081084, + "doc_tree_depth": 5.066666666666666, + "wiki_tree_depth": 8.666666666666666, + "fkgl_delta": -6.128732243871777 + }, + { + "index": 13, + "label": "intermediate_health_literacy", + "original_doc": "A 36-year-old woman with ulcerative colitis developed a week of worsening chest pressure with autonomic symptoms (such as sweating and nausea). Her electrocardiogram showed ST-segment elevation in the inferior leads, consistent with an inferior-wall heart attack. She also reported several months of fatigue and night sweats.\n\nUrgent coronary angiography found severe two-vessel coronary artery disease. The right coronary artery was the culprit lesion and was opened successfully with a stent. Because the interventional team suspected inflammation of the aorta (aortitis), additional workup was done. Inflammatory markers were mildly elevated, and CT angiography showed fibrotic thickening around the aorta with significant narrowing in multiple arteries, pointing to Takayasu arteritis.\n\nShe started treatment with prednisone and methotrexate. After stabilization, she underwent delayed coronary bypass surgery and did well.", + "wiki_anchor": "Signs and symptoms\nThe most common symptom is chest pain or discomfort that occurs regularly with activity, after eating, or at other predictable times; this phenomenon is termed stable angina and is associated with narrowing of the arteries of the heart. Angina also includes chest tightness, heaviness, pressure, numbness, fullness, or squeezing. Angina that changes in intensity, character or frequency is termed unstable. Unstable angina may precede myocardial infarction. In adults who go to the emergency department with an unclear cause of pain, about 30% have pain due to coronary artery disease. Angina, shortness of breath, sweating, nausea or vomiting, and lightheadedness are signs of a heart attack, or myocardial infarction, and immediate emergency medical services are crucial.", + "doc_fkgl": 14.593809523809526, + "wiki_fkgl": 14.780000000000005, + "doc_tree_depth": 5.888888888888889, + "wiki_tree_depth": 7.0, + "fkgl_delta": -0.1861904761904789 + }, + { + "index": 13, + "label": "proficient_health_literacy", + "original_doc": "A 36-year-old female with ulcerative colitis (well controlled on sulfasalazine, ferrous fumarate, and intermittent prednisone for flares) presented with 1 week of progressive oppressive precordial pain associated with dyspnea and neurovegetative symptoms. On admission, the ECG was in sinus rhythm with ST-segment elevation in the inferior wall. She endorsed a 6-month history of general malaise, fatigue, and night sweats, and had experienced exertional precordial pain that progressed to occur at rest. Physical examination revealed no murmurs or peripheral pulse abnormalities.\n\nEmergency coronary angiography demonstrated severe 2-vessel coronary disease: a severe 90% ostial lesion in the left coronary trunk (left main) and a severe 99\u2013100% subocclusive ostial lesion in the right coronary artery (culprit vessel). Primary angioplasty of the right coronary artery was performed with successful placement of a drug-eluting stent. The hemodynamicist noted possible aortitis given arch involvement and vessel friability during balloon advancement and recommended an inflammatory/etiologic evaluation prior to definitive management of the left main lesion.\n\nLaboratory testing showed mild anemia (hemoglobin 11.6 g/dL), mild leukocytosis (13,800/mm3), elevated ESR 42 mm/h, CRP 4.9 mg/L (normal <1), and elevated high-sensitivity troponin. Autoimmunity panel: normal complement C3/C4, negative ANA, anti-DNA, and ENA profile; non-reactive VDRL. Cardiac MRI with contrast demonstrated acute non-transmural infarction of the left ventricular inferior wall and subendocardial ischemia in the anteroseptoapical region at rest, with mild aortic and mitral insufficiency and preserved biventricular systolic function.\n\nComputed tomographic angiography of the chest/abdomen/pelvis showed periaortic fibrotic wall thickening involving the aortic root, arch, and abdominal aorta, with severe left coronary trunk stenosis, mild left subclavian and left vertebral artery stenoses, and severe inferior mesenteric artery stenosis. The differential included IgG4-related disease versus Takayasu arteritis. Total IgG was 1,600 mg/dL (ref 700\u20131,600) with IgG1 1,024 mg/dL (elevated) and normal IgG2 456 mg/dL, IgG3 98.8 mg/dL, and IgG4 13.6 mg/dL, findings not supportive of IgG4-related aortitis. Takayasu arteritis was diagnosed clinically and by imaging.\n\nImmunosuppression was initiated with prednisone 60 mg daily and methotrexate 20 mg weekly (parenteral) with folic acid 1 mg daily. After 3 weeks of therapy, she underwent myocardial revascularization surgery using the left internal mammary artery graft to the descending anterior artery (LAD) and an aortocoronary bypass to the circumflex artery. Intraoperatively, the aortic root and ascending aorta appeared healthy. She was discharged home in good general condition and remains under ambulatory follow-up.\n\nContext: Takayasu arteritis is a large-vessel granulomatous vasculitis affecting the aorta and its major branches that can produce aorto-ostial coronary lesions (as in this case, involving the left main and right coronary ostia), leading to myocardial ischemia/infarction. The mildly elevated inflammatory indices, periaortic fibrotic thickening, and multifocal arterial stenoses on CTA are characteristic, and the lack of IgG4 elevation argues against IgG4-related aortitis. The staged approach\u2014urgent culprit-vessel PCI followed by immunosuppression and delayed CABG\u2014is consistent with management principles aiming to control vascular inflammation before definitive surgical revascularization.", + "wiki_anchor": "Manifestations include:\n Skin: Raynaud's phenomenon is universal and almost always is present at the beginning of the disease course. The absence puts the diagnosis in question. The capillary alterations are similar to that of scleroderma. Other cutaneous alterations can be observed similar to the types observed in LES and scleroderma.\n Arthritis: Swollen fingers and occasionally diffuse edema are distinctive signs. Arthritis usually is more frequent and severe than that observed in SLE. Approximately 60% present with an obvious arthritis, with deformities similar to those observed in rheumatoid arthritis. \u00a0\n Myositis: Myalgias \u2013 muscular aches and pains \u2013 are common, but in the majority of patients muscular debilitation, electromyographic alterations, and elevations in muscular enzymes, like in pure polymyositis are not observed.\n Cardiac disease: Pericarditis is the most common cardiac manifestation, observed in 10\u201330% of patients. Myocardial involvement can also be observed, usually secondary to pulmonary hypertension, as well as conduction anomalies.\n Pulmonary involvement: Is observed in 75% of patients. It can present as pleural effusion, pulmonary hypertension, interstitial lung disease, thromboembolic disease, and others.\n Renal disease: The absence of severe renal disease is a marker of MCTD. Membranous nephropathy can be observed in some cases.\n Gastrointestinal disease: The most common change is the alteration of esophageal motility like that observed in scleroderma.\n Central nervous system involvement (CNS): The original description of this disease stressed the absence of changes to the CNS; however, there have been trigeminal neuropathies (cranial nerve V), sensorineural hearing loss, and headaches observed in patients with MCTD.\n Hematologic anomalies: The presence of mild anemia and hypergammaglobulinemia are common, other hematologic anomalies such as those observed in SLE can also be observed.\n Laboratory value changes: Rheumatoid factor is positive in 50\u201370% of patients, and anti\u2013citrullinated protein antibody is detected in 50% of patients. The universal serological findings in patients with MCTD is the presence of anti-nuclear antibody, with anti-nRNP specificity, especially antibodies against protein 68 kD.", + "doc_fkgl": 16.972754430379748, + "wiki_fkgl": 14.438329156223894, + "doc_tree_depth": 6.380952380952381, + "wiki_tree_depth": 6.7894736842105265, + "fkgl_delta": 2.534425274155854 + }, + { + "index": 14, + "label": "low_health_literacy", + "original_doc": "A 36-year-old woman had trouble swallowing. Tests found she was born with an unusual shape of the main body artery in her chest. The artery curves to the right in a mirror-image pattern. It wraps around a main branch of the airway. The side branches of the artery come off in the reverse order from normal. Most people with this have no symptoms. Problems happen only if the artery squeezes the space in the middle of the chest. This can press on the food pipe or the windpipe. Surgery may be needed if there is strong pressure on these tubes, a bulge or a tear in the chest artery, or a pouch on the artery bigger than 2 cm. There is no one-size-fits-all treatment. Care is tailored to the person\u2019s symptoms and body anatomy. This patient did not receive any treatment.", + "wiki_anchor": "Presentation\nThis condition is usually asymptomatic. The aberrant artery usually arises just distal to the left subclavian artery and crosses in the posterior part of the mediastinum on its way to the right upper extremity. In 80% of individuals it crosses behind the esophagus. Such course of this aberrant vessel may cause a vascular ring around the trachea and esophagus.\nDysphagia due to an aberrant right subclavian artery is termed dysphagia lusoria, although this is a rare complication. In addition to dysphagia, aberrant right subclavian artery may cause stridor, dyspnoea, chest pain, or fever. An aberrant right subclavian artery may compress the recurrent laryngeal nerve causing a palsy of that nerve, which is termed Ortner's syndrome.", + "doc_fkgl": 5.730088652482269, + "wiki_fkgl": 13.150443349753697, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.428571428571429, + "fkgl_delta": -7.420354697271428 + }, + { + "index": 14, + "label": "intermediate_health_literacy", + "original_doc": "A 36-year-old woman had dysphagia due to a congenital right aortic arch with mirror-image branching.\nIn this rare pattern, the aorta runs to the right, wraps around the right main bronchus, and the head-and-arm arteries branch in the reverse order of normal.\nMost people have no symptoms unless the aorta or an associated bulge compresses the esophagus or trachea.\nSurgery is considered for major airway or esophageal compression, aneurysmal disease, thoracic aortic dissection, or a Kommerell diverticulum larger than 2 cm.\nThere is no standard operation; treatment is tailored to the person\u2019s anatomy and symptoms.\nIn this case, imaging showed external compression of the upper esophagus with a small Kommerell diverticulum (about 1.3 cm), so no intervention was performed and her symptoms improved.", + "wiki_anchor": "Presentation\nThis condition is usually asymptomatic. The aberrant artery usually arises just distal to the left subclavian artery and crosses in the posterior part of the mediastinum on its way to the right upper extremity. In 80% of individuals it crosses behind the esophagus. Such course of this aberrant vessel may cause a vascular ring around the trachea and esophagus.\nDysphagia due to an aberrant right subclavian artery is termed dysphagia lusoria, although this is a rare complication. In addition to dysphagia, aberrant right subclavian artery may cause stridor, dyspnoea, chest pain, or fever. An aberrant right subclavian artery may compress the recurrent laryngeal nerve causing a palsy of that nerve, which is termed Ortner's syndrome.", + "doc_fkgl": 11.984808362369339, + "wiki_fkgl": 13.150443349753697, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 6.428571428571429, + "fkgl_delta": -1.1656349873843581 + }, + { + "index": 14, + "label": "proficient_health_literacy", + "original_doc": "A 36-year-old female presented with dysphagia and longstanding cervical and upper thoracic pain; she also had a multinodular goiter with no other significant history. Esophagogastroduodenal transit after barium ingestion showed a posterior and lateral right impression on the proximal esophagus extending 3.5 cm craniocaudally, with an estimated maximal esophageal stenosis of 60%. Cervical and thoracic CT revealed a congenital anomaly of the aortic arch: a right aortic arch with mirror-image branching. The arch originated from the aortic root, coursed above the right stem bronchus, and gave rise to the three supra-aortic trunks as follows: (1) left brachiocephalic artery (giving rise to the left common carotid artery and the left subclavian artery), (2) right common carotid artery, and (3) right subclavian artery. The aortic arch then passed posterior to the esophagus and exhibited a small anterior saccule measuring 1.3 cm, consistent with a Kommerell diverticulum. This configuration formed a vascular ring around the tracheo-esophageal pair, bounded posterolaterally on the right by the aortic arch, posterolaterally on the left by the Kommerell diverticulum, laterally on the left by the arteriosum ligamentum (or arterial ligament), and anteriorly by the left brachiocephalic artery. Gastroscopy confirmed endoluminal impact of extrinsic compression. Given minimal clinical repercussions and absence of nutritional disorders, no surgical cure was performed. The evolution was favorable with patient-reported spontaneous amelioration of symptoms.\n\nContext: Right aortic arch with mirror-image branching is a rare anomaly of embryologic development. The vast majority of patients are asymptomatic unless mediastinal structures are compressed. Indications for surgery include major compression of the esophagus or trachea, aneurysmal disease, thoracic aortic dissection, or a Kommerell diverticulum larger than 2 cm. There is no standardized treatment; management is individualized according to clinical presentation and anatomic configuration.", + "wiki_anchor": "Clinical significance\nThe triangle of auscultation is useful for assessment using a pulmonary auscultation and thoracic procedures. Due to the relative thinning of the musculature of the back in the triangle, the posterior thoracic wall is closer to the skin surface, making respiratory sounds audible more clearly with a stethoscope. On the left side, the cardiac orifice of the stomach lies deep to the triangle. In days before X-rays were discovered, the sound of swallowed liquids were auscultated over this triangle to confirm an oesophageal tumour.\nTo better expose the floor of the triangle up of the posterior thoracic wall in the 6th and 7th intercostal space, a patient is asked to fold their arms across their chest, laterally rotating the scapulae, while bending forward at the trunk, somewhat resembling the fetal position.", + "doc_fkgl": 16.455087719298245, + "wiki_fkgl": 15.278736842105264, + "doc_tree_depth": 7.0, + "wiki_tree_depth": 6.8, + "fkgl_delta": 1.1763508771929807 + }, + { + "index": 15, + "label": "low_health_literacy", + "original_doc": "This story is about a 62-year-old white North African woman. She was diagnosed in 2021 with a rare condition called Von Hippel\u2013Lindau disease. This condition caused growths in several parts of her body. She had a tumor in a bone near her left ear. She had a tumor in the left adrenal gland, which sits above the kidney. She had cancer in her left kidney. Her right kidney had many cysts. She also had growths in her pancreas. She received several treatments. She had radiation treatment. She had surgery to remove the left adrenal gland. She had surgery to remove the left kidney. She had major surgery on the pancreas and nearby small intestine. Later, ultrasound and MRI scans showed a lump with both fluid and solid parts near the left ovary and tube. Keyhole surgery looked inside the pelvis. It found cyst-type tumors in the thin support tissue next to both fallopian tubes. Doctors then removed the uterus and both ovaries and tubes. The lab checked the tissue. It showed tumors of the same type on both sides in the thin support tissue around the tubes and the uterus. These findings fit with Von Hippel\u2013Lindau disease.", + "wiki_anchor": "\u2013 urogenital diseases\n \u2013 kidney diseases, cystic\n \u2013 medullary sponge kidney\n \u2013 multicystic dysplastic kidney\n \u2013 polycystic kidney diseases\n \u2013 polycystic kidney, autosomal dominant\n \u2013 polycystic kidney, autosomal recessive\n \u2013 tuberculosis, urogenital\n \u2013 tuberculosis, female genital\n \u2013 tuberculosis, renal\n \u2013 urogenital abnormalities\n \u2013 bladder exstrophy\n \u2013 epispadias\n \u2013 frasier syndrome\n \u2013 hypospadias\n \u2013 multicystic dysplastic kidney\n \u2013 nephritis, hereditary\n \u2013 sex differentiation disorders\n \u2013 freemartinism\n \u2013 gonadal dysgenesis\n \u2013 gonadal dysgenesis, 46,xx\n \u2013 gonadal dysgenesis, 46,xy\n \u2013 gonadal dysgenesis, mixed\n \u2013 turner syndrome\n \u2013 hermaphroditism\n \u2013 hermaphroditism, true\n \u2013 pseudohermaphroditism\n \u2013 androgen-insensitivity syndrome\n \u2013 denys-drash syndrome\n \u2013 kallmann syndrome\n \u2013 wagr syndrome\n \u2013 urogenital neoplasms\n \u2013 genital neoplasms, female\n \u2013 fallopian tube neoplasms\n \u2013 ovarian neoplasms\n \u2013 brenner tumor\n \u2013 carcinoma, endometrioid\n \u2013 granulosa cell tumor\n \u2013 luteoma\n \u2013 meigs syndrome\n \u2013 sertoli-leydig cell tumor\n \u2013 thecoma\n \u2013 uterine neoplasms\n \u2013 endometrial neoplasms\n \u2013 carcinoma, endometrioid\n \u2013 endometrial stromal tumors\n \u2013 sarcoma, endometrial stromal\n \u2013 uterine cervical neoplasms\n \u2013 vaginal neoplasms\n \u2013 vulvar neoplasms\n \u2013 urologic neoplasms\n \u2013 bladder neoplasms\n \u2013 kidney neoplasms\n \u2013 carcinoma, renal cell\n \u2013 wilms tumor\n \u2013 denys-drash syndrome\n \u2013 wagr syndrome\n \u2013 nephroma, mesoblastic\n \u2013 ureteral neoplasms\n \u2013 urethral neoplasms", + "doc_fkgl": 5.262667512690356, + "wiki_fkgl": 68.26444444444444, + "doc_tree_depth": 5.15, + "wiki_tree_depth": 20.0, + "fkgl_delta": -63.00177693175408 + }, + { + "index": 15, + "label": "intermediate_health_literacy", + "original_doc": "A 62-year-old white North African woman with Von Hippel\u2013Lindau (VHL) disease diagnosed in 2021 developed several VHL-related tumors: a left petrous bone tumor, a left pheochromocytoma, left renal cell carcinoma, a multicystic right kidney, and pancreatic masses. She was treated with radiotherapy to the petrous bone lesion, left adrenalectomy, left nephrectomy, and cephalic duodenopancreatectomy for the pancreatic tumors. During surveillance, ultrasound and MRI showed a solid\u2013cystic mass in the left adnexal (ovary/tube) region. Laparoscopy then identified cystic tumors in the mesosalpinx on both the right and left sides. She underwent hysterectomy with removal of both adnexa. Pathology confirmed bilateral clear-cell papillary cystadenomas of the mesosalpinx and broad ligament, a pattern consistent with VHL.", + "wiki_anchor": "Cystic kidney disease refers to a wide range of hereditary, developmental, and acquired conditions and with the inclusion of neoplasms with cystic changes, over 40 classifications and subtypes have been identified. Depending on the disease classification, the presentation may be at birth, or much later into adult life. Cystic disease may involve one or both kidneys and may, or may not, occur in the presence of other anomalies. A higher incidence is found in males and prevalence increases with age. Renal cysts have been reported in more than 50% of patients over the age of 50. Typically, cysts grow up to 2.88\u00a0mm annually and may cause related pain and/or hemorrhage.", + "doc_fkgl": 13.893053097345135, + "wiki_fkgl": 10.367258687258687, + "doc_tree_depth": 6.666666666666667, + "wiki_tree_depth": 6.0, + "fkgl_delta": 3.525794410086448 + }, + { + "index": 15, + "label": "proficient_health_literacy", + "original_doc": "A 62-year-old Tunisian Arab postmenopausal woman with Von Hippel\u2013Lindau (VHL) disease (diagnosed 2021) had multisystem involvement. In 2021 she had a 6 cm left petrous bone endolymphatic sac tumor managed with radiotherapy; a 6 cm left pheochromocytoma treated with left adrenalectomy (pathology: pheochromocytoma); and a ruptured left renal mass treated with left nephrectomy (microscopy: multifocal clear-cell renal cell carcinoma, nuclear grade 2). In 2022 she underwent cephalic duodenopancreatectomy for a pancreatic mass; histology showed three serous cystadenomas and two well-differentiated neuroendocrine tumors. In January 2021, surveillance abdominal\u2013pelvic CT incidentally identified a 4 cm solid\u2013cystic left adnexal mass suspected to be malignant; this was confirmed on transvaginal ultrasound and pelvic MRI and classified O-RADS 5. Gynecologic exam was unremarkable. At laparotomy via a midline infraumbilical incision, a well-defined solid\u2013cystic mass was found in the left adnexa. There was no ascites, no peritoneal carcinomatosis, and the right adnexa appeared grossly normal without exocystic vegetations. Peritoneal cytology was obtained. Left adnexectomy was performed and the specimen sent for frozen section, which was inconclusive, raising the differential of a borderline tumor versus a VHL-associated tumor. Given her postmenopausal status, total hysterectomy with right adnexectomy was completed. Final histology demonstrated bilateral clear-cell papillary cystadenomas of the Fallopian tubes and broad ligament, measuring 0.5 cm on the right and 4 cm on the left. The tumors were composed of tightly packed papillae with fibrous cores lined by monolayered epithelium, consistent with VHL-associated mesosalpinx/broad ligament lesions. The postoperative course was uneventful; 1-month postoperative evaluation was normal. She has been followed every 4 months with normal pelvic ultrasound for 2 years, and was recently readmitted to neurosurgery for recurrence of a brain tumor.", + "wiki_anchor": "\u2013 urogenital diseases\n \u2013 kidney diseases, cystic\n \u2013 medullary sponge kidney\n \u2013 multicystic dysplastic kidney\n \u2013 polycystic kidney diseases\n \u2013 polycystic kidney, autosomal dominant\n \u2013 polycystic kidney, autosomal recessive\n \u2013 tuberculosis, urogenital\n \u2013 tuberculosis, female genital\n \u2013 tuberculosis, renal\n \u2013 urogenital abnormalities\n \u2013 bladder exstrophy\n \u2013 epispadias\n \u2013 frasier syndrome\n \u2013 hypospadias\n \u2013 multicystic dysplastic kidney\n \u2013 nephritis, hereditary\n \u2013 sex differentiation disorders\n \u2013 freemartinism\n \u2013 gonadal dysgenesis\n \u2013 gonadal dysgenesis, 46,xx\n \u2013 gonadal dysgenesis, 46,xy\n \u2013 gonadal dysgenesis, mixed\n \u2013 turner syndrome\n \u2013 hermaphroditism\n \u2013 hermaphroditism, true\n \u2013 pseudohermaphroditism\n \u2013 androgen-insensitivity syndrome\n \u2013 denys-drash syndrome\n \u2013 kallmann syndrome\n \u2013 wagr syndrome\n \u2013 urogenital neoplasms\n \u2013 genital neoplasms, female\n \u2013 fallopian tube neoplasms\n \u2013 ovarian neoplasms\n \u2013 brenner tumor\n \u2013 carcinoma, endometrioid\n \u2013 granulosa cell tumor\n \u2013 luteoma\n \u2013 meigs syndrome\n \u2013 sertoli-leydig cell tumor\n \u2013 thecoma\n \u2013 uterine neoplasms\n \u2013 endometrial neoplasms\n \u2013 carcinoma, endometrioid\n \u2013 endometrial stromal tumors\n \u2013 sarcoma, endometrial stromal\n \u2013 uterine cervical neoplasms\n \u2013 vaginal neoplasms\n \u2013 vulvar neoplasms\n \u2013 urologic neoplasms\n \u2013 bladder neoplasms\n \u2013 kidney neoplasms\n \u2013 carcinoma, renal cell\n \u2013 wilms tumor\n \u2013 denys-drash syndrome\n \u2013 wagr syndrome\n \u2013 nephroma, mesoblastic\n \u2013 ureteral neoplasms\n \u2013 urethral neoplasms", + "doc_fkgl": 15.117090909090908, + "wiki_fkgl": 68.26444444444444, + "doc_tree_depth": 6.071428571428571, + "wiki_tree_depth": 20.0, + "fkgl_delta": -53.14735353535353 + }, + { + "index": 16, + "label": "low_health_literacy", + "original_doc": "A 59-year-old man with type 1 diabetes came to the hospital with heart failure. A heart ultrasound showed big clumps of germs stuck to two heart valves, the mitral and the aortic valves. His blood test grew a germ called Staphylococcus warneri. This is a kind of staph that usually lives on the skin and is normally harmless. Doctors found he had an infection on his own heart valves (native valve endocarditis). He later had surgery to replace both the mitral and the aortic valves. Looking back, small lab changes and weight loss that began about four months earlier may have been early warning signs. He had not been on immune-weakening medicines and did not have any implanted medical devices.", + "wiki_anchor": "Diseases \nBacterial meningitis; an aminoglycoside can be added to increase efficacy against gram-negative meningitis bacteria\nEndocarditis by enterococcal strains (off-label use); often given with an aminoglycoside\nGastrointestinal infections caused by contaminated water or food (for example, by Salmonella)\nGenito-urinary tract infections\nHealthcare-associated infections that are related to infections from using urinary catheters and that are unresponsive to other medications\nOtitis media (middle ear infection)\nProphylaxis (i.e. to prevent infection) in those who previously had rheumatic heart disease or are undergoing dental procedures, vaginal hysterectomies, or C-sections. It is also used in pregnant woman who are carriers of group B streptococci to prevent early-onset neonatal infections.\nRespiratory infections, including bronchitis, pharyngitis\nSinusitis\nSepsis\nWhooping cough, to prevent and treat secondary infections", + "doc_fkgl": 7.468333333333334, + "wiki_fkgl": 23.348333333333333, + "doc_tree_depth": 6.125, + "wiki_tree_depth": 9.333333333333334, + "fkgl_delta": -15.879999999999999 + }, + { + "index": 16, + "label": "intermediate_health_literacy", + "original_doc": "A 59-year-old man with long-standing type 1 diabetes presented with acute heart failure. An echocardiogram showed large vegetations on the mitral and aortic valves. Blood cultures were positive for Staphylococcus warneri, a coagulase\u2011negative staphylococcus commonly found on the skin. He was diagnosed with native valve endocarditis. After medical stabilization, he ultimately underwent replacement of both the mitral and aortic valves. In retrospect, mild laboratory abnormalities and several months of weight loss beginning about four months earlier were likely early signs of endocarditis. He had no history of immunosuppressive therapy and no implanted medical devices.", + "wiki_anchor": "Pathogenicity\nS. sanguinis may gain entrance to the bloodstream when opportunity presents (dental cleanings and surgeries) and colonize the heart valves, particularly the mitral and aortic valves, where it is the most common cause of subacute bacterial endocarditis. For this reason, oral surgeons often prescribe a short course of antibiotics to be taken a few days before to a few days after oral surgery. Once an infection has occurred, treatment is much more complicated and generally involves the administration of several weeks of penicillin and aminoglycoside antibiotics.", + "doc_fkgl": 12.996079027355623, + "wiki_fkgl": 17.556781609195408, + "doc_tree_depth": 5.714285714285714, + "wiki_tree_depth": 7.666666666666667, + "fkgl_delta": -4.560702581839784 + }, + { + "index": 16, + "label": "proficient_health_literacy", + "original_doc": "A 59-year-old Japanese man with a 28-year history of type 1 diabetes on intensive multiple-dose insulin therapy (BMI 18.4 kg/m2, undetectable C\u2011peptide, HbA1c ~9.0%) and remote, asymptomatic chronic severe (grade III) aortic regurgitation (diagnosed 16 years earlier without subsequent follow\u2011up) presented with acute decompensated heart failure. He had never undergone surgery or prosthetic device implantation and had no history of immunosuppressive therapies.\n\nEight days after a routine visit, he developed dyspnea and fever >38\u2103. On arrival: BP 192/82 mmHg, HR 118/min, orthopnea, SpO2 80%. Exam: Levine 3/6 systolic murmur; no Osler nodes, Janeway lesions, or conjunctival petechiae. Labs: WBC 20,800/\u03bcL, CRP 6.06 mg/dL, CK\u2011MB 6.0 IU/L, troponin T negative. CXR showed pulmonary congestion with cardiomegaly (CTR 55%). ECG had ST elevation in V1\u2013V4, but emergent echocardiography showed no systolic dysfunction. He was diagnosed with acute heart failure due to valvular disease and treated with non\u2011invasive positive pressure ventilation and nitrates.\n\nTransthoracic echocardiography demonstrated severe aortic regurgitation and severe mitral regurgitation with a mobile mitral vegetation. Transesophageal echocardiography identified a 16.5\u00d76\u2011mm mobile vegetation on the anterior leaflet of the mitral valve and an 11.2\u00d75\u2011mm nonmobile vegetation on the noncoronary cusp of the aortic valve, raising strong suspicion for native valve endocarditis (NVE). Head CT and MRI showed no cerebral infarction or hemorrhage.\n\nRetrospective review revealed subtle abnormalities starting four months pre\u2011admission: mildly elevated WBC, albumin decreased to 3.0 g/dL the following month, and gradual hemoglobin decline over two months, with a 4\u2011kg weight loss. EGD and whole\u2011body CT were unrevealing. He partially regained weight and labs nearly normalized except for a CRP of 0.54 mg/dL. At the last pre\u2011admission visit (8 days prior), WBC was 9,300/\u03bcL, Hb 13.1 g/dL, Alb 3.0 g/dL, CRP 4.18 mg/dL, and diastolic BP had fallen; he remained afebrile and asymptomatic aside from weight loss.\n\nEmpiric antibiotics were initiated with ampicillin\u2013sulbactam 12 g/day plus gentamicin 120 mg/day. Three admission blood culture sets all grew Staphylococcus warneri, a coagulase\u2011negative staphylococcus (CoNS) and resident skin flora (MICs: ABPC/S \u22648 \u03bcg/mL; GM \u22641 \u03bcg/mL; CEZ \u22642 \u03bcg/mL), confirming S. warneri IE. Per Japanese Circulation Society guidance, emergency surgery is generally recommended for NYHA III\u2013IV heart failure or urgent surgery for NVE with mobile vegetation >10 mm and severe valve dysfunction. Because heart failure improved rapidly and appropriate antibiotics were started (reducing embolic risk), and given poorly controlled type 1 diabetes increasing operative risk, elective surgery was planned after stabilization of infection and glycemia. Antibiotics were narrowed to cefazolin 6 g/day; dental evaluation showed no periodontitis.\n\nAfter four weeks of antibiotics, surgery revealed a bicuspid aortic valve with intact aortic and mitral annuli and no abscess. Large vegetations were exenterated, and both valves were replaced with mechanical prostheses. The postoperative course was uneventful; he was discharged on postoperative day 22 without apparent embolism and has remained recurrence\u2011free for over two years. This case represents NVE due to the resident CoNS S. warneri in a patient without prosthetic material or immunosuppression, with prodromal laboratory abnormalities and weight loss evident up to four months before presentation.", + "wiki_anchor": "Presentation\nClinically, the syndrome affects at least three organs and may affect many organ systems. The syndrome usually occurs with small vessel thromboses affecting organ systems such as the gastrointestinal tract and manifestations of the acute respiratory distress syndrome (ARDS), a type of systemic inflammatory response syndrome (SIRS). Peripheral thrombosis may be encountered affecting veins and arteries. Intra-abdominal thrombosis may lead to pain. The body contains \u03b22-GPI, a glycoprotein in the blood, which is considered a natural anticoagulant due to its inhibitory effects on certain aspects of platelet synthesis and function. Because the formation of anti-\u03b22-GPI antibodies can occur after exposure to bacteria, the body favors a hypercoagulable state, which has been noted to activate toll-like receptor 4 resulting in what is known as a cytokine storm or a thrombotic storm. A thrombotic storm may also occur due to the following precipitating events: alterations in coagulation and fibrinolysis, which induce high mortality rates, and infections amongst pediatric patients where IgM and IgG anti-\u03b22-GPI antibodies induce an endothelial signal, leading to a procoagulant state. It is also hypothesized that thrombotic storms occur due to prothrombotic genetic risk factors, which trigger a sped-up form of thrombosis after its first occurrence, rather than being caused solely by environmental factors. Cardiovascular, nervous, kidney, and lung system complications are common. More specifically with the heart, Asherson's syndrome can lead to complications such as mitral valve regurgitation (MVR) in which the mitral valve does not shut properly allowing backflow of blood into the heart as well as angina (chest pain) and myocardial infarction (heart attack). Furthermore, complications in the kidneys may occur, including low urine production and high blood pressure, while complications with the lungs can result in rapid breathing (hyperventilation) and low oxygen levels (hypoxemia). The affected individual may exhibit skin purpura and necrosis. Cerebral manifestations may lead to encephalopathy and seizures. Myocardial infarctions may occur. Strokes may occur due to the arterial clotting involvement. Death may result from multiple organ failure.", + "doc_fkgl": 12.497337640821737, + "wiki_fkgl": 15.547597477064219, + "doc_tree_depth": 5.96, + "wiki_tree_depth": 6.75, + "fkgl_delta": -3.050259836242482 + }, + { + "index": 17, + "label": "low_health_literacy", + "original_doc": "A 27-year-old woman had many cancers in her large intestine and rectum. She also had an inherited condition that causes many polyps.\n\nShe had robot-assisted surgery to remove the entire colon and rectum. The team also removed lymph nodes from the whole area. They used a surgical robot called Hugo RAS.\n\nThe robot work had three steps.\n\nStep 1: Her head was tilted down. The team removed the right side of the colon with its nearby tissue, up to the bend near the liver.\n\nStep 2: They removed the left side of the colon with its nearby tissue. They also removed the rectum with the tissue around it. They took deeper lymph nodes.\n\nStep 3: Her body was kept flat. The team tied off the main blood vessels along the main artery that feeds the intestines.\n\nAfter the robot part was finished, they took the removed bowel out through the anus. Through a small cut at the belly button, they made a pouch from the small intestine. They connected this pouch to the anus.\n\nThe surgery took about 10 and a half hours. Blood loss was very small. Recovery after surgery went smoothly.", + "wiki_anchor": "Small bowel resection \nOnce the abdomen is accessed, the surgeon \"runs\" the small bowel, viewing the entire small bowel from the ligament of treitz to the ileocecal valve. This allows for total evaluate of the small bowel to identify any and all pathologic sections. Once the area of concern is located, two small holes are created in the mesentery on either end of the segment. These holes are used to place a surgical stapler across the bowel and separate the segment of injured bowel from the healthy bowel on each end. Then bowel is then dissected away from the mesentery. Following this the remaining bowel is observed to verify continued blood flow. After resection the surgeon will create an anastomosis between the two ends of the bowel. Following this the hole in the mesentery created by removing the section of bowel is closed with sutures to prevent internal herniation. The resected section of bowel will then be removed from the abdomen and the abdomen closed. This concludes the procedure.", + "doc_fkgl": 5.185050449959093, + "wiki_fkgl": 10.202183431952665, + "doc_tree_depth": 4.526315789473684, + "wiki_tree_depth": 5.454545454545454, + "fkgl_delta": -5.017132981993573 + }, + { + "index": 17, + "label": "intermediate_health_literacy", + "original_doc": "A 27-year-old woman with familial adenomatous polyposis and multiple colorectal cancers underwent robot-assisted total proctocolectomy with complete lymph node dissection using the Hugo RAS system. The robotic work was organized into three steps: 1) in Trendelenburg position, ascending colon complete mesocolic excision up to the hepatic flexure; 2) descending colon complete mesocolic excision and total mesorectal excision with D3 lymph node dissection; and 3) in a flat position, central vessel ligation along the superior mesenteric artery. After undocking, the specimen was removed transanally. An ileal pouch was created through a small umbilical incision and then connected to the anus (ileal pouch\u2013anal anastomosis). The operation lasted 632 minutes with minimal blood loss, and the postoperative course was uneventful.", + "wiki_anchor": "Natural orifice transluminal endoscopic surgery (NOTES) is a surgical technique whereby \"scarless\" abdominal operations can be performed with an endoscope passed through a natural orifice (mouth, urethra, anus, vagina, etc.) then through an internal incision in the stomach, vagina, bladder or colon, thus avoiding any external incisions or scars. Memic's hominis robotic system is the first and only FDA-authorized surgical robotic platform for NOTES procedures. The system is currently at use for transvaginal hysterectomies through the Rectouterine pouch - the removal of the uterus, along with one or both of the fallopian tubes and ovaries, in cases where there is no cancer present, as well as with the removal of ovarian cysts", + "doc_fkgl": 16.9342905982906, + "wiki_fkgl": 17.23790540540541, + "doc_tree_depth": 5.8, + "wiki_tree_depth": 8.75, + "fkgl_delta": -0.3036148071148119 + }, + { + "index": 17, + "label": "proficient_health_literacy", + "original_doc": "A 27-year-old woman with multiple colorectal cancers on a background of familial adenomatous polyposis (FAP) underwent robot-assisted total proctocolectomy (TPC) with lymph node dissection of the entire colorectal region using the Hugo RAS system. Preoperative CT showed multiple nodal swellings along the inferior mesenteric artery (IMA) and middle colic artery without distant metastases. After multidisciplinary review, robot-assisted TPC was performed under approvals from the Evaluating Committee for Highly Difficult New Medical Technologies (H-0051) and the Kyoto University IRB.\n\nUnder general anesthesia in lithotomy with arms tucked, a 5-cm vertical umbilical incision was made and a wound protector placed. After pneumoperitoneum, 4 robotic and 2 assistant trocars were inserted. Instruments included a camera, monopolar curved shears (right hand), bipolar fenestrated forceps (left hand), and Cadiere/double-fenestrated forceps (reserve arm). Two table positions (Trendelenburg and flat) were used with specific docking tilts; arm cart angles were unchanged. The robotic procedure comprised three steps, followed by transanal specimen extraction, ileal pouch construction via a small umbilical laparotomy, and ileal pouch\u2013anal anastomosis (IPAA).\n\nStep 1: Ascending colon complete mesocolic excision (CME) from a caudal approach, completed through hepatic flexure mobilization.\n\nStep 2: Central vessel ligation (CVL) of the IMA, descending colon CME to completion of splenic flexure mobilization, and total mesorectal excision (TME) to full exposure of the intersphincteric space. This corresponds to a D3 lymph node dissection of the left colon/rectum.\n\nStep 3: After undocking and repositioning the patient flat, CVL along the superior mesenteric artery (SMA) was performed, ligating the ileocolic, right colic, and middle colic vessels; the inferior mesenteric vein (IMV) was ligated at its root (exposed in Step 2).\n\nTransanal and small laparotomy procedures: After transection of the terminal ileum, a transanal specimen extraction was performed with complete rectal mucosectomy from just below the dentate line due to multiple adenomas in the anal canal. An ileal pouch was constructed via the small umbilical incision, its reach to the anal canal confirmed, and a transanal hand-sewn IPAA was completed. No diverting ileostomy was created.\n\nAll three steps were completed without conversion. Following undocking after Step 3, laparoscopy confirmed hemostasis, specimen extraction, and anastomotic integrity. Total operative time was 632 minutes (Step 1: 36 min; Step 2: 160 min; Step 3: 188 min; positioning/docking/specimen extraction/anastomosis: 248 min). Estimated blood loss was 20 mL. Postoperatively, the course was uneventful: flatus and initiation of liquids on POD 1, advancement to a solid diet on POD 3, with a functional ileal pouch and satisfactory anal function.\n\nFinal pathology identified two sigmoid cancers (S1: Type 0-Ip, 55 \u00d7 50 mm, tub1, T1b, ly0, v0; S2: Type 0-Isp, 55 \u00d7 50 mm, tub1, Tis, ly0, v0) and one rectal cancer (R1: Type 0-Ip, 40 \u00d7 35 mm, tub1, Tis, ly0, v0). Lymph node status: 18/89 positive, all in sigmoid/rectosigmoid stations (#241, #242, #251), yielding UICC pT1bN2b stage.", + "wiki_anchor": "Appendectomy: surgical opening of the abdominal cavity and removal of the appendix. Typically performed as definitive treatment for appendicitis, although sometimes the appendix is prophylactically removed incidental to another abdominal procedure.\nCaesarean section (also known as C-section): a surgical procedure in which one or more incisions are made through a mother's abdomen (laparotomy) and uterus (hysterotomy) to deliver one or more babies, or, rarely, to remove a dead fetus.\nInguinal hernia surgery: the repair of an inguinal hernia.\nExploratory laparotomy: the opening of the abdominal cavity for direct examination of its contents; for example, to locate a source of bleeding or trauma. It may or may not be followed by repair or removal of the primary problem.\nLaparoscopy: a minimally invasive approach to abdominal surgery where rigid tubes are inserted through small incisions into the abdominal cavity. The tubes allow introduction of a small camera, surgical instruments, and gases into the cavity for direct or indirect visualization and treatment of the abdomen. The abdomen is inflated with carbon dioxide gas to facilitate visualization and, often, a small video camera is used to show the procedure on a monitor in the operating room. The surgeon manipulates instruments within the abdominal cavity to perform procedures such as cholecystectomy (gallbladder removal), the most common laparoscopic procedure. The laparoscopic method speeds recovery time and reduces blood loss and infection as compared to the traditional \"open\" method.", + "doc_fkgl": 14.549020678891925, + "wiki_fkgl": 16.59148902821317, + "doc_tree_depth": 6.681818181818182, + "wiki_tree_depth": 7.181818181818182, + "fkgl_delta": -2.042468349321247 + }, + { + "index": 18, + "label": "low_health_literacy", + "original_doc": "A 65-year-old man had a swollen right middle finger after a motorcycle crash 6 months earlier. The middle joint stayed bent, and the fingertip bent backward. He could not fully straighten the finger. An X-ray showed no broken bones. The problem was in the soft tissues and tendon on top of the finger. Before surgery, the middle joint could bend from 45 to 110 degrees but could not straighten. The doctors repaired the top tendon using a small strip from another tendon in the same finger. They put the middle joint in a straight splint for 2 weeks. After 2 weeks, he started gentle bending and straightening exercises for that joint. One month after surgery, the middle joint moved from 0 to 90 degrees. Two months after surgery, movement went back to normal. His hand function score (DASH) improved from 50 to 4.2.", + "wiki_anchor": "A branch of the median nerve, the anterior interosseous nerve (AIN) can be affected by either direct penetrating injury, possibly compression in a fashion similar to carpal tunnel syndrome, but most commonly an idiopathic inflammatory process (referred to an Anterior Interosseous Syndrome). As might be expected, the symptoms involve weakness in the muscle innervated by the AIN including the flexor digitorum profundus muscle to the index (and sometimes the middle) finger, the flexor pollicis longus muscle to the thumb and the pronator quadratus of the distal forearm. AIN also has large sensory nerve to the volar wrist bones and compression of the AIN branch of the median nerve at the elbow can cause referred pain in the volar wrist/distal volar forearm. Non-surgical treatment consists of splinting, proximal tissue massage and anti-inflammatory drugs. Surgical treatment consists of releasing the compression on the nerve from surrounding structures. Pronator Syndrome is similar, but involves both the AIN as well as the median nerve proper.", + "doc_fkgl": 5.560996503496504, + "wiki_fkgl": 15.396739130434785, + "doc_tree_depth": 4.916666666666667, + "wiki_tree_depth": 8.166666666666666, + "fkgl_delta": -9.83574262693828 + }, + { + "index": 18, + "label": "intermediate_health_literacy", + "original_doc": "A 65-year-old man developed persistent swelling and a boutonniere deformity of the right middle finger after a motorcycle fall six months earlier. He could not fully extend the finger. On exam, the finger showed edema with flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Active PIP range of motion (ROM) was 45\u2013110 degrees. X\u2011rays of the right hand (AP/oblique) showed no bone injury, indicating a soft-tissue problem consistent with a central slip injury. The patient underwent reconstruction of the central slip using a partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. A PIP extension splint was used for 2 weeks. Active and passive PIP ROM exercises began after 2 weeks. One month after surgery, PIP ROM improved to 0\u201390 degrees, and by 2 months it returned to normal. Hand function, measured by the DASH score, improved markedly from 50 to 4.2.", + "wiki_anchor": "At the level of the PIP joint the extensor mechanism splits into three bands. The central slip attaches to the dorsal tubercle of the middle phalanx near the PIP joint. The pair of lateral bands, to which contribute the extensor tendons, continue past the PIP joint dorsally to the joint axis. These three bands are united by a transverse retinacular ligament, which runs from the palmar border of the lateral band to the flexor sheath at the level of the joint and which prevents dorsal displacement of that lateral band. On the palmar side of the joint axis of motion, lies the oblique retinacular ligament [of Landsmeer] which stretches from the flexor sheath over the proximal phalanx to the terminal extensor tendon. In extension, the oblique ligament prevents passive DIP flexion and PIP hyperextension as it tightens and pulls the terminal extensor tendon proximally.", + "doc_fkgl": 9.454666666666668, + "wiki_fkgl": 12.781111111111112, + "doc_tree_depth": 5.454545454545454, + "wiki_tree_depth": 6.833333333333333, + "fkgl_delta": -3.3264444444444443 + }, + { + "index": 18, + "label": "proficient_health_literacy", + "original_doc": "A 65-year-old male presented with six months of swelling and boutonniere deformity of the right digit III following a motorcycle accident on January 1, 2023. He initially self-managed with analgesics and did not seek care. He reported inability to fully extend the right middle finger. Examination demonstrated edema and a boutonniere posture (PIP flexion, DIP hyperextension). Active PIP ROM was 45\u2013110 degrees, with passive PIP ROM within normal limits. Radiographs of the right hand (AP/lateral) revealed no osseous pathology, supporting a soft-tissue etiology consistent with a central slip injury. \n\nSurgical technique: Central slip defect reconstruction was performed using the partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. Under anesthesia and tourniquet control in the supine position, a midlateral incision was made on the ulnar aspect of the middle phalanx centered at the PIP joint with dorsal oblique extension, and a transverse incision was made over the MCP flexion crease proximal to the A1 pulley. The ulnar digital neurovascular bundle was identified and protected. Full-thickness dorsal flaps were elevated to expose the central slip and extensor mechanism to the PIPJ. Scar and pseudotendinous tissue were excised. The central slip was not amenable to primary repair; therefore, the ulnar slip of the FDS was selected for reconstruction. The ulnar neurovascular bundle was mobilized to visualize the periosteal insertion of the A3 pulley. The extensor tendon was mobilized and tenolyzed; the dorsal PIP capsule was incised with removal of interposed tissue. The A3 pulley periosteal insertion and the volar capsule of the PIP joint were incised longitudinally. A 2\u20130 non-absorbable monofilament suture was placed around the ulnar FDS slip at the PIP level. Through the proximal incision, the flexor sheath and A1 pulley were incised longitudinally to expose the FDS; the ulnar slip was isolated and transected, preserving the radial slip. The previously placed 2\u20130 suture facilitated delivery of the distally based ulnar FDS slip distally. A 2.8\u2011mm dorsal-to-volar bone tunnel was drilled at the base of the middle phalanx; an elevator protected the FDP, volar plate, and volar structures. With the PIP reduced in full extension, the FDS slip was passed through the tunnel and routed through the intact proximal segment of the central slip/extensor tendon. A tendon weaver completed a Pulvertaft weave under appropriate tension with the PIP in full extension and reduction, secured with 3\u20130 non-absorbable suture. The capsule and central slip reconstruction margins were approximated; adhesions were released and lateral bands mobilized. Tenodesis effect, posture, stability, and motion were assessed. Wounds were irrigated, the tourniquet deflated, hemostasis obtained, and capillary refill confirmed. Skin was closed with horizontal mattress sutures. A sterile dressing and a well-padded PIP extension splint were applied to allow early DIP and MCP motion.\n\nPostoperative course: First wound check at postoperative day 4; the patient received meloxicam 7.5 mg PO BID and doxycycline 100 mg PO BID for 3 days. A second wound visit occurred 3 days later. At 2 weeks, the back slab and external sutures were removed, and active and passive PIP ROM exercises were initiated. By 3 weeks, the wound had healed and PIP ROM was 0\u201390 degrees. At 1 month, PIP ROM improved to 0\u2013100 degrees, with continued functional gains. After 7 weeks of rehabilitation, he returned to work with PIP ROM 0\u2013110 degrees. Overall function improved substantially, with the DASH score decreasing from 50 to 4.2.\n\nInterpretation: Clinical and radiographic findings were concordant with a chronic central slip injury producing boutonniere deformity (PIP flexion, DIP hyperextension due to dorsal apparatus disruption and volar migration of lateral bands). Reconstruction using an ulnar FDS slip via bone tunnel and Pulvertaft weave restored PIP extension and yielded progressive ROM gains and marked functional recovery.", + "wiki_anchor": "Palpation\nPalpation of the knee should begin from the unaffected side first. This will reassure the patient and is useful for comparison with the affected knee. The back of the hand can be used to assess the warmth of the knee. The knee is then flexed 90 degrees and the anterior structures are assessed. Inflammation of the patellar tendon is present if the patellar tendon is painful upon palpation. Radiographic imaging should be done if the examination findings fulfills the Ottawa rules: age 55 years and older, pain at the head of fibula, patellar pain, unable to flex the knee to 90 degrees, and inability to stand and walk at least four steps. If anterior cruciate ligament injury is suspected, radiographic imaging should also be ordered because it is frequently associated with lateral tibial plateau fracture. If there is a painful, reddish, and warm swelling in front of the patella, acute prepatellar bursitis should be considered which may require aspiration or drainage. Those presented with these features usually had history of frequent kneeling and direct trauma over the knee.", + "doc_fkgl": 11.863529411764706, + "wiki_fkgl": 11.877281191806333, + "doc_tree_depth": 5.75, + "wiki_tree_depth": 6.666666666666667, + "fkgl_delta": -0.013751780041626915 + }, + { + "index": 19, + "label": "low_health_literacy", + "original_doc": "A 23-year-old man came to the emergency room with a sudden, very bad headache. He also felt sick, threw up, and felt heavy pressure in his chest. His blood pressure was high and he was breathing fast. A quick heart test looked like a major heart attack. He was rushed for a procedure to check and open the heart arteries. The heart arteries looked normal. A head CT scan then showed bleeding in the space around his brain. A team of specialists cared for him, but he got worse quickly. He went into cardiac arrest and died.", + "wiki_anchor": "Dr. Gillian Hayes is performing heart surgery to attempt to save the patient. Another doctor decides that saving the patient is hopeless. After the patient dies, Dr. Hayes was upset at the other doctor for giving up. The coroner said that it appears as if something had exploded from within the patient's chest. Lt. Tom Royko questioned Dr. Hayes in her office about the patient who died and Dr. Hayes suspected that Lt. Royko considered her to be a suspect. Royko said Hayes was not a suspect.", + "doc_fkgl": 4.0628178694158095, + "wiki_fkgl": 5.299551724137935, + "doc_tree_depth": 4.777777777777778, + "wiki_tree_depth": 5.666666666666667, + "fkgl_delta": -1.2367338547221252 + }, + { + "index": 19, + "label": "intermediate_health_literacy", + "original_doc": "A 23-year-old man came to the emergency department with a sudden severe headache, nausea, vomiting, and chest heaviness. His initial vital signs showed high blood pressure and a fast breathing rate. An emergency ECG showed a heart attack pattern (STEMI), so he was urgently sent for percutaneous coronary intervention; the angiogram revealed normal coronary arteries. Further evaluation with a brain CT identified a cisternal subarachnoid hemorrhage (bleeding around the brain). Despite coordinated care by multiple teams, his condition rapidly worsened, leading to cardiac arrest and death.", + "wiki_anchor": "Incident\nThe incident took place around 15:00 (3 p.m.) on 24 June 2006, when the 54-year-old Demoor was heading to work on a De Lijn city bus in Antwerp. There was a disturbance, involving Demoor and six youths of Moroccan descent (five Belgian citizens, one with Spanish passport). During the incident, Demoor received more than one blow to his body. Near the end of the incident, one of the youths rang the alarm bell, and some or all of them left the bus. Demoor died, after or before the boys left the bus, apparently from a subarachnoid hemorrhage.", + "doc_fkgl": 13.757534883720933, + "wiki_fkgl": 7.757551020408165, + "doc_tree_depth": 6.0, + "wiki_tree_depth": 6.6, + "fkgl_delta": 5.999983863312767 + }, + { + "index": 19, + "label": "proficient_health_literacy", + "original_doc": "A 23-year-old male with a 23 pack-year smoking history, no alcohol use, and no illicit drug use presented with 2 hours of sudden severe frontal headache, nausea, vomiting, and chest heaviness. He was distressed but alert and oriented. Vitals: BP 178/103 mmHg, RR 26/min, T 38.9\u00b0C, HR 87/min, SpO2 94%. Exam: normal vesicular breath sounds; cardiovascular and abdominal exams inconclusive; neurological exam notable for neck stiffness, dilated but light-reactive pupils, normal plantar reflexes, and no focal deficits. ECG showed ST-segment elevation >2 mm in V2\u2013V5, consistent with STEMI; he received a 300 mg aspirin load and was urgently transferred for PCI. Troponin was elevated at 1.48 mg/dl (normal <0.16 mg/dl). Femoral-access coronary angiography demonstrated normal coronary arteries with TIMI 3 flow. Post-angiography ECG showed normal sinus rhythm with LVH; echocardiography revealed normal ventricular function without RWMA. Subsequent workup found lymphocytosis and mildly elevated CRP. Non-contrast CT brain demonstrated a cisternal subarachnoid haemorrhage with extension anterior to the right temporal lobe. Abdominal ultrasound was negative for polycystic kidney disease; cerebral CT angiography was planned to exclude aneurysm. Nimodipine 60 mg q4h was initiated with a BP target of 160/100 mmHg. On day 2, he acutely deteriorated with cardiac arrest; after CPR, GCS was 6, and he was intubated and mechanically ventilated in the ICU. Owing to instability, repeat CT brain and planned cerebral CTA were not performed. He received multidisciplinary ICU care with NG feeding, IV fluids, antibiotics, a proton pump inhibitor, and nimodipine. On day 8, he developed ventricular fibrillation and, despite CPR and more than five defibrillation attempts, could not be resuscitated and died.", + "wiki_anchor": "Manifestations include:\n Skin: Raynaud's phenomenon is universal and almost always is present at the beginning of the disease course. The absence puts the diagnosis in question. The capillary alterations are similar to that of scleroderma. Other cutaneous alterations can be observed similar to the types observed in LES and scleroderma.\n Arthritis: Swollen fingers and occasionally diffuse edema are distinctive signs. Arthritis usually is more frequent and severe than that observed in SLE. Approximately 60% present with an obvious arthritis, with deformities similar to those observed in rheumatoid arthritis. \u00a0\n Myositis: Myalgias \u2013 muscular aches and pains \u2013 are common, but in the majority of patients muscular debilitation, electromyographic alterations, and elevations in muscular enzymes, like in pure polymyositis are not observed.\n Cardiac disease: Pericarditis is the most common cardiac manifestation, observed in 10\u201330% of patients. Myocardial involvement can also be observed, usually secondary to pulmonary hypertension, as well as conduction anomalies.\n Pulmonary involvement: Is observed in 75% of patients. It can present as pleural effusion, pulmonary hypertension, interstitial lung disease, thromboembolic disease, and others.\n Renal disease: The absence of severe renal disease is a marker of MCTD. Membranous nephropathy can be observed in some cases.\n Gastrointestinal disease: The most common change is the alteration of esophageal motility like that observed in scleroderma.\n Central nervous system involvement (CNS): The original description of this disease stressed the absence of changes to the CNS; however, there have been trigeminal neuropathies (cranial nerve V), sensorineural hearing loss, and headaches observed in patients with MCTD.\n Hematologic anomalies: The presence of mild anemia and hypergammaglobulinemia are common, other hematologic anomalies such as those observed in SLE can also be observed.\n Laboratory value changes: Rheumatoid factor is positive in 50\u201370% of patients, and anti\u2013citrullinated protein antibody is detected in 50% of patients. The universal serological findings in patients with MCTD is the presence of anti-nuclear antibody, with anti-nRNP specificity, especially antibodies against protein 68 kD.", + "doc_fkgl": 12.237704402515725, + "wiki_fkgl": 14.438329156223894, + "doc_tree_depth": 5.529411764705882, + "wiki_tree_depth": 6.7894736842105265, + "fkgl_delta": -2.200624753708169 + } +] \ No newline at end of file