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data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1313_en.txt

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+A 9-year-old boy presented to our clinic with myopia, and he had reported a history of myopic progression that had not been arrested using orthokeratology lenses for 23 months. He had no medical history of glaucoma or pigment dispersion syndrome. On ocular examination, his best-corrected distance visual acuity (BCVA) was 20/20 in both eyes. The refractive power was −1.50 Dsph −0.25 Dcyl Axis 110 in the right eye and −2.00 Dsph −0.25 Dcyl Axis 50 in the left eye. The refractive corneal power was 42.18 D in the right eye and 41.77 D in the left eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of active inflammation in the anterior chamber or neovascularization in the iris. Corneal topography showed slight lateral decentration in both eyes (shown in ). The axial length was 25.39 mm in the right eye and 25.24 mm in the left eye, and the anterior chamber depth was 3.79 mm in the right eye and 3.77 mm in the left eye, as measured by AL-Scan (Nidek Co., Ltd., Gamagori, Japan) (shown in ). The intraocular pressure measured using air-puff non-contact tonometer was 20 mm Hg in the right eye and 21 mm Hg in the left eye. An intraocular pressure of between 10 and 21 mm Hg is defined as the normal range, as reported in previous studies.
+On ocular examination 2 weeks after the patient discontinued the use of orthokeratology lenses, his refraction was −2.50 Diopter in the right eye and −3.50 Diopter in the left eye, and the best-corrected distance visual acuity was 20/20 in both eyes. We recommended that the patient’s parents refit the orthokeratology lens; however, the parents wanted to keep the orthokeratology lens because of cost considerations. The patient was prescribed topical 0.125% atropine eye drops two times a day in both eyes to prevent myopia progression and maintain the orthokeratology lenses.
+Three days after the treatment, his intraocular pressure rose to 36 mm Hg in the right eye and 32 mm Hg in the left eye, and the best-corrected distance visual acuity was 20/200 in the right eye and 20/100 in the left eye. On slit-lamp examination, the cornea and conjunctiva were unremarkable, and there was no evidence of active inflammation in the anterior chamber. The patient did not use any eye drops or medications, including steroids, did not eat any unusual foods, and did not exhibit any behaviors that increased intraocular pressure, such as Valsalva.
+Because of the high intraocular pressure, the patient was started on dorzolamide and timolol eye drops twice daily, and 0.125% atropine eye drops and orthokeratology lenses were discontinued. One day later, the intraocular pressure was 26/24 mm Hg, and 2 days later, the intraocular pressure was 21/20 mm Hg. Two months after the discontinuation of all eye drops and orthokeratology lenses, the best-corrected distance visual acuity was 20/20 in both eyes, and the intraocular pressure was 19/20 mm Hg.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1402_en.txt

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+A 66-year-old man underwent high anterior resection for rectal cancer 11 years ago. He had also been diagnosed with an esophageal tumor 15 cm in size at the same time, based on the symptom of mild dysphagia, but had left the tumor untreated. Recently, he presented to our hospital with progressive dysphagia and appetite loss, which had gradually worsened over the course of the previous year. He had no history of smoking or drinking alcohol. His tumor markers were not increased (carcinoembryonic antigen: 2.0 ng/mL, squamous cell cancer antigen: 0.9 ng/mL). Upper gastrointestinal imaging (UGI) and esophagogastroduodenoscopy (EGD) showed a large tumor with a thick stalk arising from the esophageal entrance, extending to the gastroesophageal junction, with a normal surface mucosa . Since we could not identify details of this submucosal tumor (SMT), we considered it a so-called fibrovascular polyp. Furthermore, a localized erythematous lesion and type B1 vessels according to the Japan Esophageal Society classification were identified on the tumor surface, 30 cm from the incisor teeth . Contrast-enhanced computed tomography (CT) showed a large tumor hanging from the cervical esophagus, extending to the gastroesophageal junction . The inside of the tumor was heterogeneously contrasted with a mixture of fatty, fibrous and vascular components. The length of the tumor was about 30 cm, indicating that it had doubled in size over the last 10 years. There were no findings suggesting lymph node or distant metastasis. Three-dimensional CT (3D-CT) revealed that the tumor was an intraluminal polypoid tumor . Our preoperative diagnosis was a so-called giant fibrovascular polyp with superficial carcinoma of the esophagus. From the above findings, we determined that it was possible to achieve radical en bloc resection of the tumor through the cervical approach as a minimally invasive procedure, without lymph node dissection. With the patient under general anesthesia, we made a 7-cm skin incision on the left side of the neck. We cut the lateral side of the anterior cervical muscles, but preserved the sternocleidomastoid muscle and entered the inner side of the common carotid artery. After that, we reached the wall of the esophagus and taped it. After directly incising the esophageal wall at the opposite side of tumor peduncle and encircling the stalk of the tumor, the giant tumor was directly grasped and could be carefully pulled out of the esophageal lumen . We transected the stalk of the tumor arising from the posterior wall and extracted it . The basal mucosal layer of the esophagus was closed using continuous 4–0 absorbable sutures, and the muscle layer was closed with nodal sutures using 3–0 absorbable sutures. The surgical duration was 2 h and 22 min, and blood loss was minimal. The patient had an uneventful postoperative course without any complications, and was discharged on postoperative day 14 without dysphagia.
+The excised specimen consisted of a 23.0 × 8.5 cm polypoid mass and superficial esophageal carcinoma located on it . Histological examination showed proliferation of squamous cell carcinoma in the epithelium and invasion of the stroma in some areas, although there was no lamina muscularis mucosa. The depth of invasion was 930 μm from the surface of mucosa , and there was no vascular or lymphatic invasion. On the other hand, most of the submucosal tumor was composed of adipocytes and spindle cells with atypical nuclei . Immunohistochemical analysis showed that the adipocytes were weakly positive for murine double minute-2 (MDM2) and positive for cyclin-dependent kinase 4 (CDK4) and p16 . The final pathological diagnosis was well-differentiated esophageal liposarcoma together with squamous cell carcinoma. The surgical margin of the tumor was microscopically negative. The patient did not undergo any postoperative adjuvant therapy and gained 10 kg in weight within 3 months postoperatively.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1438_en.txt

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+A 44-year-old female presented with progressive abdominal distension especially after eating, accompanied by anorexia, fatigue and vomiting, was admitted to our hospital. MRI of the upper abdomen revealed an irregular huge cystic-solid mass which located in both Segments V-VI and VII-VIII of the liver. The largest size of each section was approximately 12 cm × 9 cm (S VII-VIII) and 11 cm × 8 cm (S V-VI). The mass consisted of dense calcification, fat and soft tissue, poorly demarcated from the adjacent peritoneum, suggesting the possibility of malignant teratoma. No abnormalities were found during the examination of the uterus and bilateral adnexa. For serum tumor markers, carcinoma embryonic antigen (CEA) and β-human chorionic gonadotropin (β-HCG) levels were normal, but AFP level was elevated to 476 ng/ml (the normal range: 0–20 ng/ml). Then, biopsy specimens were obtained and immature neuroectodermal-like structure was observed , which showed positive staining for spalt like transcription factor 4 (SALL4, Clone#6E3, ZSGB-BIO) and negative for glial fibrillary acidic protein (GFAP, Clone#GA5, Vision BiosytemsTM) . Also, Ki-67 (Clone#MRX002, MXB Biotechnologies) staining showed high proliferative index . Therefore, the tumor was diagnosed as immature teratoma, which was not further graded because of the limited tissues.
+After exclusion of chemotherapy contraindication, a systemic chemotherapy was delivered associating etoposide (75 mg/m2), with ifosfamide (1.2 g/m2) and cisplatin (20 mg/m2) each day, day 1 to day 4, every 3 weeks. After four cycles, MRI of the upper abdomen showed tumor survival and the size of tumor increased to 14 cm × 11 cm (S VII-VIII) and 13 cm × 12 cm (S V-VI) . However, the serum AFP level was nearly normal.
+For further treatment, right hepatectomy, cholecystectomy and partial diaphragmectomy and diaphragmatic repair were performed. During the surgery, the tumor was found to protrude from the liver surface and adhere to the diaphragm, omentum, transverse colon, stomach and duodenum. The tumor size was about 28 cm × 17 cm × 15 cm, and it invaded the abdominal wall and part of the diaphragm. No metastatic tumor was detected in other parts of the abdominal cavity.
+Macroscopically, the resected liver measured 30 cm × 24 cm × 13 cm. Cut sections of the liver revealed a solitary, round and cystic-solid mass with grayish or grey-yellow color, which sized 28 cm × 14 cm × 13 cm. The tumor was well-circumscribed but unencapsulated, adjacent to the liver capsule and about 2.5 cm distant from surgical margin.
+The section was cystic and solid, showing multiple cystic cavities with different sizes (about 2–10 cm in diameter). The inner wall of the cyst was smooth, and the cavity was filled with jelly-like viscous liquid. For the solid areas, hard bone-like tissues, tender brain-like tissues, and multitudes of fat were visible .
+On histologic examination, the tumor contained multiple mature types of tissues derived from three germ layers. Ectodermal derivatives including squamous epithelium, sebaceous glands, eccrine glands and hair follicle could be seen . Also, abundant mature brain tissues such as glia and choroid can be observed . In some areas, these cells were sheet arranged, with layers and polarities, but without significant cellular atypia and neural tube formation . On immunohistochemical staining, those densely cellular regions demonstrated positive for GFAP but negative for SALL-4, and Ki-67 index was low . Moreover, intestinal epithelia and respiratory ciliated epithelium (endoderm), mature cartilage and adipose tissue (mesoderm) could also be observed . The tumor was cut open along its long axis and extensively sampled, and no immature component was found. GTS was diagnosed finally.
+Then the patient continued to receive 2 courses of chemotherapy, with the same type and dose of medications as before. However, after 2 months, a CT scan showed multiple small nodules in the bilateral adnexa, suggesting new-onset lesions . Subsequently, the patient underwent the second surgery to resect total uterus and bilateral adnexa. Multiple nodules (0.5-2 cm in diameter) were found on the surface of the ovary, the front of the rectum, and the pelvis on both sides at surgery. Histologically, a large amount of mature glial was observed, while no immature components such as neural tube existed with all tissues sampled. Based on clinical history, GP should be considered.
+A brief flow chart of clinical diagnosis and treatment was shown in Fig. . The patient was still in follow-up at the outpatient clinic and in good condition .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1439_en.txt

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+A 53-year-old, right-handed male patient presented with sudden onset of right hemiparesis and aphasia. Left middle cerebral artery (MCA) stroke was diagnosed. The patient's medical history included systemic hypertension and dyslipidemia. Previously undiagnosed atrial fibrillation was then identified. Systemic fibrinolytic therapy was administered first without result; local intraarterial fibrinolytic treatment and mechanical thrombectomy were then performed, achieving recanalization of the distal MCA.
+Computed tomography angiography (CTA) that was performed during the diagnosis of the stroke also revealed an aneurysm of the PCoA . No signs of subarachnoid hemorrhage were observed in the basal cisterns, and the patient had no focal cranial nerve deficits prior to the stroke. The aneurysm measured 3 mm and had a posterior orientation. A day after the stroke, magnetic resonance imaging (MRI) showed a mass in the interpeduncular fossa that was larger than expected . The mass measured 14 mm, projected medially, and was compatible with a partially thrombosed aneurysm.
+Bilateral carotid and left vertebral angiography [Figures and ] revealed an aneurysm arising from the left PCoA itself. The saccular-type aneurysm originated 3 mm distal to the ICA bifurcation, with a 3.5 mm dome height and a 1.5 mm neck width. A fetal-type posterior cerebral artery (PCA) was present on the left. We opted for endovascular treatment of the aneurysm because the configuration of the aneurysm was favorable in our opinion, rather than surgical clipping. Endovascular occlusion was performed under general anesthesia in a separate procedure. A guide catheter was introduced to the right ICA. Then a microcatheter was placed into the aneurysm sac in the PCoA. Once the microcatheter was placed three coils were packed (3 × 80, 2 × 60, and 2 × 40 mm) until no additional coil could fit into the lumen. Postcoiling angiogram showed complete occlusion of the aneurysm . The postprocedure course was uneventful.
+At the 6-month follow-up, magnetic resonance angiography (MRA) did not show recanalization. The patient exhibited marked neurological improvement with therapy, presenting with mild right hemiparesis and motor dysphasia with mild nonfluent speech and normal comprehension.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1501_en.txt

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+In this case, a 30–35 year old African American male, with a past medical history of Graves Disease diagnosed in 2020 on methimazole and no past psychiatric history, presented to the emergency department (ED) with altered mental status (AMS). The patient could not provide history at the time of arrival due to AMS and disorganized behavior, so most history was initially provided by the patient’s mother. Per mother, the patient’s behavior over the prior two months was uncharacteristic, including posting threatening messages on social media, purchasing firearms, being incarcerated for stealing work property, and delusions such as believing he was a villain destined to kill superheroes. In addition, the patient had homicidal ideation towards family members, leading his mother to no longer feel safe in his presence. The mother reported a history of abnormal behavior a month before the patient’s diagnosis of Graves’ Disease in 2020 in which the patient was paranoid, anorexic, and had insomnia. At that time, the patient was stabilized with methimazole and had complied with his medication until two months before this admission.
+When the patient arrived at the ED, the patient was agitated, uncooperative, and combative, requiring restraints and sedation by a combination of Haloperidol (Haldol) 10 mg/ Midazolam (Versed) 2 mg intramuscular. Initially, the ED believed the patient’s symptoms were due to a brief psychotic episode or drug-related psychosis, so the patient was transferred to the psychiatric emergency unit. The urine drug screen was positive for cannabinoids with a false positive for benzodiazepines from the required sedation of Haldol 10 mg/Versed 2 mg IM. The patient denied any other history of illicit substance use and no previous, documented records of stimulant use disorder were identified. Overnight, the patient had persistent tachycardia of > 110 heart rate, so a thyroid panel was initiated, which resulted in Thyroid Stimulating Hormone (TSH) < 0.0005 and free T4 (fT4) > 7.770, evidence for a thyrotoxicosis induced psychosis. Other labs included a complete blood count and a complete metabolic panel, which were benign.
+The patient was admitted to the Intensive Care Unit (ICU) to treat his thyrotoxicosis. While in the ICU, the patient reported paranoia, and persecutory delusions causing distress due to concerns that he was the subject of the medical staff’s discussions in the hallway. Nursing reported that the patient was concerned that the medical staff had malicious intentions, so psychiatry started the patient on Olanzapine 10 mg twice a day (BID). Endocrine was consulted and initiated Propranolol 60 mg three times a day (TID) and Methimazole 30 mg BID and noted thyromegaly and peripheral tremors on physical exam. During the two days in the ICU, the patient’s thyroid levels improved with decreased paranoia and combativeness, and he was transferred to the hospital’s internal medicine floor for continued monitoring. The endocrine team recommended a thyroidectomy due to his recent history of noncompliance and the high mortality risk of thyrotoxicosis. Once the patient had a normal fT4 level of 2.27ng/dL, otolaryngology performed a total thyroidectomy, and the patient was transferred back to the inpatient hospital floor for continued monitoring. With no evidence of psychosis and overall improvement in behavior on postoperative day (POD) 1, Olanzapine 10 mg BID was decreased to once nightly.
+On POD 6, the patient’s paranoia towards hospital staff returned even with reassuring labs of parathyroid hormones (PTH) 41.3pg/ml and calcium 8.9mmol/L, good adherence to Levothyroxine (Synthroid) 137 mcg daily, and a benign physical exam. The patient was then transferred to the inpatient psychiatric unit and diagnosed with a psychotic disorder due to hyperthyroidism, with delusional disorder. The patient continued Synthroid 137 mcg/daily in the psychiatric unit and restarted Olanzapine 10 mg BID. Olanzapine 10 mg BID was down-titrated to 10 mg nightly for better patient compliance with a simplified regimen and to avoid oversedation from higher doses of an antipsychotic. After day two on the psychiatric floor, the patient’s psychosis symptoms abated on the antipsychotic. Upon questioning, the patient had no recollection of the past two months, including most of his hospital stay. Ultimately, the patient showed greater insight into his illness and understood the need for strong medical compliance and outpatient follow-up. The patient was discharged on Synthroid 137 mcg daily and Olanzapine 10 mg daily. Post hospitalization, the patient was lost to follow up.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1605_en.txt

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+A 71-year-old man with severe COPD with rapidly progressing dyspnea, low exercise tolerance, and hypoxemia.
+The patient was diagnosed with COPD in 2010. Over the last 5 years, the patient experienced a gradual progression of dyspnea that limited his performance of everyday activities.
+In 2019, the patient underwent Bentall’s heart surgery with resection of the left atrial appendage. The patient did not claim any diseases of affluence.
+The patient has a 30 pack-year history (20 cigarettes a day for 30 years) and has not smoked since 2008. He works as a managing director and denies any risk factors for lung disease from his occupation. His father contracted tuberculosis after the Second World War and died of lung cancer, and his brother has diabetes mellitus.
+The patient was afebrile with alveolar respiration and sinus rhythm, and his lower limbs were without swelling.
+Alpha1-antitrypsin levels were normal. Arterial blood gas examination showed an oxygen partial pressure pO2 = 7.67 kPa; carbon dioxide partial pressure pCO2 = 4.56 kPa; pH = 7.46; and blood saturation SpO2 = 90%.
+Computed tomography results demonstrated centrilobular emphysema bilaterally reflecting a severe obstructive ventilation disorder.
+The patient underwent spirometry and body plethysmography examinations with the following results: forced expiratory volume in 1 s = 1.07 L; forced vital capacity = 1.94 L; inspiratory capacity = 1.57 L; total lung capacity (TLC) = 5.51 L; peak expiratory flow = 3.38 L. Inspiratory muscle performance was examined with the PrO2 device (Design Net, Smithfield, United States), showing the following results: maximal inspiratory pressure (MIP) = 57 cmH2O; sustained maximal inspiratory pressure (SMIP) = 404 PTU (pressure-time unit); inspiratory duration (ID) = 7.7s; and fatigue index test (FIT) = 12.1. Questionnaires assessed the subjective perception of dyspnea with a COPD Assessment Test score of 15 and modified Medical Research Council Breathlessness score of 3. The six-minute walk test (6-MWT) was used to assess exercise tolerance, with the distance walked being 270 m, and the oxygen saturation decreased from 95% at baseline to 75% during the test. The multifactorial body mass index, airflow obstruction, dyspnea, and exercise (BODE) index was used as a predictor of prognosis with an initial score of 5. The Charlson Comorbidity Index calculated the 10-year mortality risk to be 53%.

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+A 76-year-old man presented with a peripheral occlusive disease classified as Fontaine Stage IIB. He had a history of hypertension and dyslipidemia, and was a smoker. Preoperative contrast computed-enhanced tomography (CT) revealed a right SFA occlusion . We initiated antiplatelet therapy (100 mg/day aspirin and 75 mg/day clopidogrel). Angiography revealed a 16-cm chronic total occlusion of the right SFA. Endovascular treatment (EVT) was performed on the right SFA following intra-arterial injection of heparin (5000 units). A 6-French (Fr) guiding sheath was inserted via the left femoral artery. Intravascular ultrasound (IVUS) was used for passing through the true lumen. Thereafter, a 4-mm semi-compliant balloon was used for pre-dilatation and IVUS revealed no major dissections. A 25-cm Viabahn (diameter 5 mm) was implanted and a 5-mm non-compliant balloon was used for post-dilatation. On the final angiogram, no edge dissection was visible, and good flow was confirmed . The patient’s symptoms improved, and he was discharged after 4 days; however, he developed pain and local swelling of the right thigh 6 days after EVT. Venous thrombosis was excluded by ultrasound imaging. He had no fever, negative blood culture findings and negative procalcitonin levels (0.1 ng/ml; standard value is ≤0.5 ng/ml). However, blood analysis revealed elevated inflammatory marker levels: white blood cell (WBC) count was 12,000 cells/μl (standard values are 4500–7500 cells/μl) and C-reactive protein levels were 11.83 mg/dl (standard value is ≤1.0 mg/dl). MRI revealed extensive soft-tissue edema and a high perivascular T2 signal around the right SFA ; however, the stent-graft remained patent. This indicated possible perigraft inflammation. The clinical symptoms were severe and there was a risk of occlusion of the stent-graft. We initiated steroid therapy (prednisolone, 20 mg/day) 2 days after the symptoms started and decreased it as soon as possible. Clinical symptoms resolved within 7 days after initiating steroid therapy, and follow-up MRI revealed regression of soft-tissue edema . Therefore, the prednisolone was decreased to 10 mg/day and tapered by 5 mg per week until it was halted. Follow-up MRI demonstrated marked resolution of inflammation over 3 months .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_1713_en.txt

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+A 40 year-old Nigerian housewife was seen at the oncology clinic of the University College Hospital (UCH) Ibadan, Nigeria in June 2002 with a 1 year 8 months history of painful left breast lump which had been previously excised in another hospital but recurred 8 months before presentation at UCH. There was no information about histological diagnosis of the excised breast lesion from the first hospital. There were no systemic symptoms. She was Para 7+1 and had no family history of breast or ovarian cancer. Physical examination revealed globular enlargement of the left breast measuring 20 cm × 18 cm. The mass occupied the whole breast, was warm, multinodular and fixed to the pectoralis fascia. The ipsilateral axillary lymph nodes were enlarged, but examination of the other systems was normal. A clinical diagnosis of locally advanced cancer of the left breast was made.
+Plain radiograph of the chest and abdominal ultrasound scan were normal. A core-needle biopsy of the mass was done and histology showed a malignant neoplasm comprising islands of chondroblastic and osteoblastic stromal cells, with no normal breast tissue seen. A diagnosis of osteogenic sarcoma was made. The patient had a left modified radical mastectomy and latissimus dorsi musculocutaneous flap to cover an anterior chest wall defect. The mastectomy specimen weighed 350 g. Cut sections revealed areas of cystic degeneration and necrosis, with focal areas that were firm with a cartilaginous consistency. Conventional representative sections were obtained from each of the four breast quadrants, areola region, resection margins and axillary lymph nodes. Microscopic examination of the sections showed a malignant breast neoplasm displaying fibrosarcomatous, chondrosarcomatous as well as osteosarcomatous differentiation. There was metastasis to one of the lymph nodes. She was scheduled for radiotherapy to the chest wall but she defaulted. Contact tracing revealed that she died about 6 months after mastectomy.

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+An 18-year-old male patient presented with symptoms of pain and swelling localized on the medial aspect of his right ankle joint, specifically at the medial malleolus. The patient noted a recent history of a twisting injury of his right ankle 6-months before presentation at our specialty orthopedic clinic. The injury occurred while playing football. Initially, he was treated by his general practitioner, who assumed it to be a severe sprain injury and had placed him on a course of ice compress and anti-inflammatory medication followed by a below knee plaster cast for a period of 3 weeks. Following this treatment protocol, the patient was able to walk but reported on-going pain while walking once the plaster cast was removed. No radiographic imaging was done at the time and was therefore not available for review and comparison.
+On further examination, swelling was observed over the distal aspect of the medial malleolus, along with tenderness over deltoid ligament of the right ankle. There was no bone related tenderness at the distal tibia. Ankle joint movement was also observed to be normal. We proceeded with a thorough radiograph examination including standard X-rays and 3-dimensional computed tomography (CT) scanning of the right ankle, which revealed the presence of a small bone fragment located anterior and distal to the medial malleolus (, ). This fragment was not free floating and rather appeared to be attached to the distal tibia. Furthermore, it was a uni-lateral presentation as the patient’s left ankle anatomy did not reveal the presence of a similar bone fragment and was rather normal in appearance . Based on our findings as well as the findings of previously published reports on this topic, a benefit of doubt was provided, and it was assumed to be a case of acute trauma, leading to a small fracture of the anterior aspect of the distal tibia.
+At first consultation, the patient was explained of his diagnosis and offered a conservative treatment protocol that included a compression bandage and anti-inflammatory medication. Since this had minimal effect on his symptoms, he was placed in a plaster cast for period of 6 weeks thereafter. Following removal of the cast, the patient’s symptoms re-occurred, and at that point, he had been on a conservative treatment regimen for almost 10 months with no significant clinical benefit. Based on this, it was considered that this might be a case of differential diagnosis, with the possibility of it being the case of a symptomatic Os subtibiale. At that stage, a surgery appeared to be the best option to help this patient with his symptoms. It was noted that intraoperatively, this surgery may involve either fixation of the bone fragment if it was deemed to be a fracture, or removal of the same if it appeared to be an Os subtibiale. The patient was then offered a surgical treatment option to which he consented and agreed to proceed as necessary.
+On admission to the operating theater, the patient was positioned supine and administered general anesthesia. An upper thigh tourniquet was used on the patient’s right leg in this case. To gain access to the distal tibia, a 4–5 cm anterior mid-line incision over right ankle joint was performed . The surrounding soft-tissue structures, superficial nerve, and vascular structures were carefully protected and retracted to gain exposure to the distal tibia, which revealed the presence of a smooth and oblong bone fragment attached to the anterior-distal aspect of the medial malleolus, as was observed in the X-ray and CT imaging . Based on its appearance, and the lack of bony fusion like characteristics with the adjacent distal tibia, this bone fragment was deemed to be an Os subtibiale. In addition, the margins of the distal tibia marked with a surgical marker, without considering the Os subtibiale, gave the appearance of a normal medial malleolus. It was also observed that it was pressing directly on the deltoid ligament, which explained the on-going pain that the patient experienced while walking. The deltoid ligament was released and the Os subtibiale was then surgically excised using a small 3 mm osteotome and a small bone rongeur. It was measured to be approximately 2 × 11 × cm3 in size . Following excision, the surrounding bone and soft-tissue structures were carefully examined to ensure that there were no other anatomical bone or soft tissues abnormalities that could be contributing to the patient’s symptoms. On confirmation, the surgical area was thoroughly irrigated with saline, and standard surgical procedures were used to close the incision in a layer by layer fashion. A standard surgical dressing was applied over the operated site, and the foot was placed in a heavy compressive bandage for the next 2 weeks. This was followed by ankle mobilization and stretching exercises as tolerated by the patient. At his latest follow-up of 18 months, the patient reported to be pain free and displayed normal range of motion at the ankle joint compared to his non-operated, contra-lateral left foot. He also consented to participating in this study.

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+A 43-year-old female with no significant past medical history presented with a chief complaint of worsening respiratory symptoms that included purulent nasal secretions, dysphagia, mild dysphonia and dyspnea with chronic cough. The symptoms had begun approximately 2 years previously and had failed to completely resolve in spite of multiple rounds of empiric antibiotic therapy for a presumed bacterial upper respiratory infection. She denied previous tobacco use and had no pertinent family history. Her physical exam was notable for erythematous nasal mucosa and a small anterior septal perforation. Blood work demonstrated a white blood cell count (WBC) of 11,400/uL (neutrophils 93.8%) and an erythrocyte sedimentation rate (ESR) of 11 mm/h. Electrolytes were all within normal limits and a random glucose was 96 mg/dL. Head and chest computed tomography (CT) showed air-fluid levels in the bilateral maxillary sinuses and irregular thickening along the left lateral and posterior tracheal wall just above the level of the medial clavicles but was negative for lung parenchymal changes.
+Given these imaging findings in the setting of worsening dyspnea, the patient underwent a laryngoscopic examination, which revealed subglottic crusting with diffuse purulent secretions, anterolateral cricoid inflammation, and vocal cord inflammation. Her nasal cavity also demonstrated thick purulent secretions in the middle meatus bilaterally extending to the nasopharynx. Biopsies of the trachea, subglottis, and nasal septum demonstrated purulent, atypical squamous epithelium and necrotic tissue with bacterial colonies. Cultures from these sites were positive for methicillin-resistant Staphylococcus aureus (MRSA) and Pseudomonas aeruginosa but showed no fungal growth. As such, the patient was treated with intravenous vancomycin and cefepime in addition to steroids and nebulized treatments. Her breathing significantly improved during the course of her hospitalization and she was subsequently discharged with plans to continue outpatient intravenous antibiotics for an additional 2 months.
+Several months later, the patient returned for follow-up and was found to have similar upper airway symptoms despite completing her antibiotic regimen. She again underwent endoscopic examination that revealed multiple regions of white, friable pseudomembranous patches spanning her mid-trachea, subglottis, and nasopharynx . Biopsies of these sites demonstrated diffuse tissue necrosis in the presence of extensive fungal hyphal infiltration . Cultures from the trachea and sinuses grew Aspergillus fumigatus. Given a new diagnosis of invasive pseudomembranous aspergillosis, the patient was started on oral voriconazole (100 mg, twice daily) with close outpatient follow-up.
+Over the following year, despite continuous antifungal treatment, the patient continued to experience tenacious, mucoid secretions, worsening dysphonia, nighttime pharyngitis, and frequent low-grade fevers. She required two separate inpatient admissions due to symptom escalation requiring endoscopic debridement of her trachea, pharynx, and nasal passages. Repeat tissue biopsies during this time period continued to demonstrate necrotic exudates in the presence of fungal hyphae with cultures continuing to grow pan-sensitive Aspergillus fumigatus. A formal immunological workup during this time was non-revealing with normal immunoglobulin levels, CD4+ T cell counts, absolute neutrophil counts, and complement levels. HIV testing was negative. Given her poor response to antifungal monotherapy, she was initiated on topical amphotericin B (100 mcg/ml) and budesonide (10 mcg/ml) nasopharyngeal rinses twice daily for symptomatic flares in addition to an increased dose of oral voriconazole (200 mg, twice daily).
+The patient continued on this regimen for 2 months and was found to have marked improvement on repeat endoscopic examination, at this point 18 months after her initial diagnosis of invasive aspergillosis. Her larynx and subglottis had near normal appearance; her nasal cavities were dry bilaterally; her nasopharynx demonstrated mild scarring but otherwise demonstrated significantly less mucopurulence than on previous exams. However, in spite of this transient improvement, the patient again began developing upper airway symptoms over the following year, correlating with increased purulence in the nasal cavities along with the reformation of pseudomembranous, brown-mucoid layering in the nasopharynx seen on endoscopic exam. Increases in her voriconazole dosing to as high as 300 mg, twice daily were attempted but did not result in significant improvement and were further complicated by vision changes attributed to supratherapeutic voriconazole trough drug levels. Additionally, while the frequency of mechanical debridement had previously averaged once every four to 6 months, the patient began requiring nearly monthly endoscopic suctioning of her nasal passage and pharynx for symptom control.
+Approximately 6 years after her initial diagnosis of invasive aspergillosis the patient continued to experience chronic symptoms including dysphagia, persistent dysphonia, and purulent secretions. Erosive changes to her posterior nasopharynx resulted in velopharyngeal insufficiency. Of note, serial chest x-rays during the course of her treatment never demonstrated abnormal parenchymal findings suggesting long-standing upper airway disease without progression to lower airway involvement. In the setting of persistently positive fungal hyphae seen on upper airway tissue biopsy, she was continued on oral antifungal therapy in combination with oral rinses and periodic mechanical debridement for symptomatic relief.

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+The case involves Mr. N., a 36-year-old man with no previous medical history, who had returned from a long stay in Ivory Coast for professional activities (about 0–6 months). Since his return to Tunisia, he presented a symptomatology associating fever, headache, asthenia, and diarrhea. A polymerase chain reaction (PCR) test for Covid-19 had previously been performed (before traveling), which was negative. Mr. N. did not seek medical advice and resorted to self-medication including antipyretic and analgesics. On the 5th day, Mr. N.’s condition worsened as he presented a generalized tonic-clonic convulsive seizure, after which he did not regain consciousness. His family members called for medical assistance, but Mr. N. died before the arrival of the emergency units. As a result of an unclear cause of death, a medicolegal autopsy was ordered by the prosecutor, and the body was thus transferred to our department for autopsy. Malaria infection was already suspected at this point upon investigating the death circumstances with his relatives. A postmortem blood sample, on ethylenediamine tetraacetic acid (EDTA) preserved blood sample, was hence referred to the Parasitology Laboratory in order to confirm our assumptions before autopsy. Malaria rapid diagnostic test (RDT) (i.e., rapid diagnostic test for malaria which detects malaria antigens in a person’s blood) was positive. In both thick and thin Giemsa-stained blood smears , numerous Plasmodium falciparum (trophozoites) were found, showing high parasitemia. The percentage of parasitemia was though difficult to assess due to the hemolysis state of the postmortem samples. External examination revealed cyanosis with frank mucocutaneous icterus. Autopsy findings revealed massive congestion and edema of the brain, weighing 1550 g , lungs (weighing 745 g on the right and 640 g on the left), and inner organs. Hepatomegaly was noted (liver weighing 2905 g) with heterogeneous parenchyma on section. The spleen (weighing 385 g) was enlarged with a tense, smooth capsule, and congested parenchyma of brown-black color. Histology showed cerebral gray and white matter with congested capillaries containing numerous parasitized erythrocytes (trophozoites) in each examined brain section. Each cell contained dots of hemozoin pigment (malaria pigment). The same findings were also observed in the histology of the remaining thoracic and abdominal organs . Toxicological analyses did not reveal the presence of any toxic substance that might have been involved in the death.
+Based on histology, autopsy findings, as well as parasitology expertise, the case was considered to have died of fulminant cerebral malaria with multiple organ failure.

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+A 37-year-old woman, G1P1, was referred to our hospital due to an increase in size of a tumor in her vulva. The mass was first pointed out to her during her delivery one year earlier. The patient had no apparent symptoms. Magnetic resonance imaging (MRI) of the pelvis showed a well-circumscribed mass in the vulva . The patient underwent resection of the tumor, and the tumor was subjected to histological examination. There was no apparent evidence of recurrence one year after the resection.
+Grossly, the tumor mass was located in the subcutis and measured 73×29 mm. There was no fibrous capsule, but the tumor was well circumscribed. The cut surface showed a yellowish-white mass with gelatinous change. No hemorrhage or necrosis was observed.
+On histopathological examination , the boundary between tumor and adjacent tissue was clear. Tumor cells were short and spindle-shaped without prominent atypia, arranged in no overt architecture. No necrosis or mitoses were identified. The stroma was edematous and myxoid; fine collagen as well as dense collagen was detected in some regions. The vast majority of blood vessels were small-sized with thin walls. Some medium-sized blood vessels were also identified within the lesion . There was no specific distribution pattern of the vascularity. Immunohistochemical studies were performed using the primary antibodies listed in . On immunohistochemical analysis, most tumor cells showed positivity for vimentin, ER, PgR, and desmin. Some tumor cells showed positive for alpha-SMA and CD34. The tumor cells were uniformly negative for S100 protein . The Ki-67 labeling index was less than 2%.

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+A 60-year-old woman presented to her general practitioner with a decade-long history of chronic dysphagia, with acute deterioration in the past 3 months. She had previously been diagnosed, through her general practitioner, with “oesophageal spasm” on spurious clinical grounds, with no oesophagogastroduodenoscopy (EGD) performed for evaluation of this dysphagia (she had undergone an EGD approximately 20 years prior to this, but on another indication). Having previously tolerated solid foods with some difficulty, the patient could now only take fluids. Her past medical history was significant for mucosal ulcerative LP in the mouth and genitalia for the past 15 years, heterozygotic α1-antitrypsin deficiency, active smoking with 40 pack years, and COPD. The oral LP had been difficult to treat, mainly managed with on-off local group IV steroids. Her hepatitis C status was negative. At the time of her presentation to our clinic, her oral LP was active with painful lesions of the oral mucosa, while her genital LP was entirely quiescent. She was urgently referred to an EGD for suspected oesophageal carcinoma.
+Macroscopically, the oesophageal mucosa was rigid and trachealised with a papier-maché appearance, suspicious for long-standing eosinophilic oesophagitis (EoE) . Biopsies were taken along the length of the oesophagus. Histopathological examination of the biopsy of the distal oesophagus revealed a lichenoid oesophagitis pattern of injury , with a prominent band-like lymphocytic infiltrate involving the interface of the lamina propria and epithelium as well as Civatte bodies – apoptotic keratinocytes considered a hallmark of LP. Additionally, intraepithelial lymphocytes and dyskeratotic keratinocytes were observed. Several biopsies showed hyperkeratosis and granulation. No dysplasia or fungal organisms were identified. The patient was subsequently referred to our clinic at the Department of Gastroenterology, Skåne University Hospital, for further evaluation.
+Given the suspicious histopathologic appearance for LP as well as the significant past medical history of mucosal LP, the patient was diagnosed with ELP over other far less likely differential diagnoses such as Crohn's disease, infections, medication-induced oesophagitis, or pill oesophagitis. A discussion was had as to the best treatment strategy, as no internationally accepted treatment guidelines for ELP exist. Several pharmacological treatment regimens were found in the literature, including oral budesonide formulations, calcineurin inhibitors, mycophenolate mofetil, PDE-4 inhibitors, as well as systemic corticosteroids [–]. As topical corticosteroids are the first line of oral LP, we opted for Jorveza™, a novel budesonide orodispersible tablet (BOT) designed for EoE highly selective to the oesophagus . Prior to the introduction of BOT, EoE treatment was largely based on topical steroid therapies. These are now, however, defunct given the efficacy of BOT for EoE treatment. We found no studies on the efficacy of BOT on ELP, only nondescript topical steroid solutions now defunct in our clinical practice. We opted for BOT as this formulation seemed the most targeted and efficacious approach. The patient gave informed consent and was commenced on oral BOT (Jorveza™) 1 mg BD (twice daily) for 10 weeks.
+Within days of commencement of treatment, the patient experienced a complete remission of dysphagia. She reported no side effects. Surprisingly, she also reported marked improvement in her oral LP, with near-complete healing of ulcerations. A follow-up EGD was performed 2 months post-therapy initiation, which was normal apart from incidental candidiasis (a common side effect of BOT ), after which the patient received fluconazole 200 mg BD for 14 days. Biopsies taken from the length of the oesophagus showed no evidence of existing oesophagitis, with an entirely normal mucosal appearance – apart from diffuse candida hyphae and spores without inflammatory response in the distal oesophagus .
+After 10 weeks of induction therapy, the patient remained completely asymptomatic. The patient’s weight increased from 68 kg (BMI 25.9) pretreatment to a steady state of 72 kg (BMI 27.4). Her serum albumin remained unchanged, ranging between 38 and 42 g/L. We opted to cease active treatment and now plan for renewed EGD in 6 months followed by once yearly for surveillance of subclinical disease and/or SCC of the oesophagus as well as to monitor the possible need for oesophageal dilation. In the event of clinical recurrence, we plan the recommencement of induction dose BOT 1 mg BD for 6 weeks. Alcohol and smoking cessation was advised to further reduce the risk of oesophageal SCC.

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+A 20-year-old man presented to the emergency department after four days of progressively worsening periumbilical pain. He was moving heavy boxes for his job when he began experiencing pain and was unable to finish his work. He reported pain with defecation but denied fever, chills, nausea, emesis, weight loss, and recent travel or illness. Past surgical history included branchial cleft cyst excision as a child. On abdominal exam, a one square-centimeter erythematous infra-umbilical mass was exquisitely tender to palpation. Laboratory data on admission demonstrated a WBC count of 10.7 × 103 cells/μL and urinalysis was unremarkable. Based on history and physical exam, the patient underwent diagnostic evaluation for suspected incarcerated umbilical hernia.
+CT abdomen/pelvis revealed a four-centimeter segment of organized periumbilical inflammation with central lucency passing the ventral abdominal wall into the anterior abdominal compartment . The process was extraperitoneal and there was no evidence of communication with the urinary bladder. These findings were consistent with an inflamed urachal remnant complicated by abscess. Our patient received intravenous antibiotics in preparation for an operation. The following day he underwent abscess incision and drainage followed immediately by urachal cyst excision through a four-centimeter infra-umbilical midline mini-laparotomy. The urachal cyst and remnants were dissected inferiorly to confirm no communication with the urinary bladder before total excision (A). Investigation of the cyst contents revealed white sebaceous material (B). Pathology examined the 4 × 3 x 0.7-centimeter segment of fibromembranous tissue and confirmed intraoperative impressions of the specimen .
+The patient was admitted to the surgical floor where he noted his pain was markedly improved. The next day he was discharged to home on post-operative day two with adequate pain control. Two-week follow up in the outpatient surgery clinic confirmed an uncomplicated recovery.

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+A 65-year-old male patient came to our department in August 2013, with varus deformity at the level of middle third and the distal third junction of left forearm. Detailed history revealed that he sustained fracture both bones forearm due to road traffic accident 15 years back, for which he was treated with open reduction and plate osteosynthesis. 6 months after the surgery, the patient fell accidentally and gradually developed deformity of the left forearm, for which the patient did not approach hospital for treatment.
+Our examination revealed varus deformity of 90° in the middle third and distal third junction of left forearm, shortening of about 10 cm of left forearm, healed surgical scars over radius and ulna. Furthermore, the patient had inability to move wrist and finger joints, probably due to muscle laxity. No neurovascular deficit was encountered. There was 30° fixed flexion deformity at elbow joint with further range of flexion of 80°. Radiological examination revealed nonunion of fractured both bones forearm with broken dynamic compression plate (DCP) at radius and loosened DCP at ulna, with one screw in the subcutaneous plane. The bones were found to be osteoporotic. Our aim was to correct the deformity, achieve union at the fracture site, restore optimal function of the wrist, hand, and elbow. Our treatment strategy was planned to perform the staged procedure.
+Implants were removed, except a screw, which was adherent to the adjacent vascular tissue. Pennig external fixator was applied on radius , and universal mini external fixator was applied on ulna in another surgery. The deformity was corrected by gradually stretching (1 mm/day) the contracted soft tissue over a period of 6 weeks . The neurovascular monitoring done clinically. Then, the external fixator was removed, once full correction was achieved. A long arm slab was applied in fully corrected position for 3 weeks.
+Once the soft tissue healed and infection was ruled out, definitive fixation was done for nonunion radius (nonunion in ulna was left undisturbed, since simultaneous fixation of ulna in a scarified tissue would lead to increase in compartment pressure and difficulty in skin closure) using dual onlay fibular cortical strut grafting (procedure is explained below) with cancellous bone grafting. The fracture ends were freshened until fresh bleeding was seen from the bone ends, and medullary canal was opened with 2.5 mm drill bit before fixation was done. A gap of 2.5 cm was present. The fibular graft was harvested from left leg (direct lateral approach, middle third) leaving 6 cms of lower end of fibula for ankle stability. Cancellous bone was harvested from the left iliac crest.
+The fibular graft was predrilled (with 2.5 mm drill bit), tapped and then split longitudinally into two halves using saw. The two halves of the graft were placed over the radius spanning the fracture; drilling was done through the previously drilled holes in the near onlay graft and then into host radius, and then into the opposite onlay graft . The onlay graft was secured to host radius with 3.5 mm cortical screws, so as to obtain 4 cortical purchases (with each screw). The cancellous graft was placed into the trough lying between fracture ends and between the two onlay grafts. Nonunion in the ulna was left undisturbed .
+The patient was immobilized in long arm cast, in mid prone position, for 6 weeks. Immediate post-operative X-ray shows good deformity correction with graft and implants in situ. After 6 weeks of surgery, the patient underwent protected physiotherapy (with a splint) in the form of active and assisted mobilization of the elbow, wrist, and finger joint. The patient refused another surgery on ulna (because the patient was functionally satisfied and deformity was corrected fully). 1-year follow-up shows union at the graft site.

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+A 64-year old female presented to the emergency department with sharp retrosternal pain and progressive dyspnea. She had a medical history of coronary artery disease, hypertension, atrial fibrillation, rheumatic mitral valve (MV) disease and stroke with residual left-sided hemiplegia. Transesophageal Echocardiography (TEE) revealed severe MV stenosis (MV area 0.9 cm2 [normal >1cm2]), mild mitral regurgitation (MR), no vegetations, minimal leaflet motion with pronounced thickening, extensive valvular calcification and minimal thickening of the sub-valvular apparatus (Wilkins score 14), no thrombus in the left atrial appendage and preserved left ventricular systolic function.
+Left heart catheterization revealed a non-obstructive coronary artery disease. Right heart catheterization (RHC) revealed a mean PAP of 71 mmHg and a PCWP of 15 mmHg (Transpulmonary Pressure Gradient [TPG] of 51 mmHg). Given the degree of her PH and rest of her co-morbidities (Society of Thoracic Surgeons’ Surgical mortality risk 31%), a multidisciplinary team approach consisting on advanced heart failure, cardiac surgery, intensive care and cardiac anesthesia team reached the consensus that the patient was not an appropriate candidate for surgical mitral valve replacement, therefore the decision was to perform a percutaneous mitral balloon valvuloplasty (PMBV) in the cardiac catheterization under general anesthesia.
+The patient was brought to the cardiac catheterization suite, underwent uneventful pre-procedure invasive lines placement (radial arterial line and right internal jugular vein introducer) and induction of general anesthesia with endotracheal tube placement. RHC demonstrated a mean PAP of 61 mmHg and a left atrial pressure of 30 mmHg. TEE revealed a severely dilated right ventricle and MV area of 0.9cm2. Cardiac index by Fick method was 1.97 L/min. Balloon dilation of the MV was performed, improving the effective orifice area to 1.3 cm2, however complicated by severe MR, secondary to a ruptured MV chordae tendineae . The cardiothoracic team was emergently consulted. Once again, the decision was that the patient would not tolerate undergo an emergent mitral valve replacement given her severe PH and other co-morbidities, therefore medical management would be the preferred approach in her case.
+After discussion with the cardiology team, the patient was extubated and transferred to the intensive care unit (ICU) with stable hemodynamics (mean systemic arterial pressure 72 mmHg), unchanged PAP, and no signs of pulmonary edema. A pulmonary artery catheter was placed through the existing right internal jugular introducer.
+Overnight, she developed systemic hypotension, requiring vasopressors (vasopressin), with the goal to increase the systemic pressures above the PAP, and inodilators (milrinone), with the goal to decrease the PAP. Cardiac output was borderline low at 3.8 l/minute. Mechanical support in the form of an intra-aortic balloon pump was placed to attempt decrease the MR severity and improve the cardiac output. The new severe MR further exacerbated her PH, which converted into a supra-systemic PH .
+Right ventricular support was initiated in the form of pulmonary vasodilators (intravenous epoprostenol − 2 ng/kg/min- and inhaled nitric oxide − 40 parts per minute- via high flow nasal cannula) and endothelin receptor antagonists (macitentan 10 mg orally, once a day). Remarkably, the patient’s pulmonary mechanics and oxygenation were preserved. At this point, the patient was managed mostly medically. Aggressive diuresis was added to the above-mentioned treatment. Eventually, given a recalcitrant response to maximal medical therapy, the patient and her family opted for hospice care and comfort measures.

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+A 29-year-old female, gravida 3 para 2 at 29 weeks gestation presented to the emergency department (ED) with left arm and neck swelling. Her pregnancy had been complicated by hyperemesis gravidarum requiring a left-sided PICC. Her medical history was significant for prior pregnancies complicated by hyperemesis and a reported history of opoid use disorder on buprenorphine. The PICC had been removed at another ED approximately three days prior to presentation at our ED after the site had become erythematous and painful. She was placed on oral antibiotics and recommended to follow up with her obstetrician. Despite removal of the the PICC, the site had become severely swollen and erythematous extending over her left neck. In addition, she had begun to experience chest pain, worsening shortness of breath, fever, chills, and left arm paresthesias, which prompted her to seek evaluation.
+On arrival her heart rate (HR) was in the 160s beats per minute (bpm) and blood pressure (BP) 95/67 millimeters of mercury (mm Hg); otherwise, her vital signs were within normal limits. On physical exam, the PICC site was erythematous, swollen, and tender. She had marked swelling involving her left upper extremity, chest, and left side of the neck. Given the patient’s vitals and physical exam, there was significant clinical suspicion for deep venous thrombosis (DVT). We used point-of-care-ultrasound to perform a bedside DVT assessment with noted extensive clot burden extending through the basilic vein into the axillary vein , as well as in the IJ vein . Serum labs were notable for a white blood count of 20.7 × 103 cells per microliter (uL) with 80% neutrophils (reference range: 3.7–11 ×103 cells/uL).
+The findings prompted a recommendation that she undergo a computed tomography (CT) pulmonary embolism protocol, which she consented to. Cross-sectional imaging demonstrated extensive clot burden encompassing the left brachiocephalic, left subclavian, and left internal and external jugular veins . The CT was also concerning for septic pulmonary emboli. Given the combination of extensive clot burden encompassing the IJ, in addition to septic emboli, we were able to confirm the diagnosis of Lemierre’s syndrome. The patient was immediately initiated on heparin and broad-spectrum antibiotics.
+Obstetrics was consulted at the time of the patient’s arrival and was bedside shortly thereafter. She received dexamethasone six milligrams intramuscular in the event of an emergent cesarean section. Fortunately, neonatal stress testing demonstrated no evidence of fetal distress, and the patient continued to improve. She was subsequently admitted to the intensive care unit (ICU) by which time her HR had improved to 116 bpm and BP to 105/52 mm Hg. Interventional radiology was also consulted for possible thrombectomy vs thrombolysis at time of arrival; however, given the patient’s improvement by time of admission to the ICU the recommendation was for conservative therapy. While inpatient, blood cultures resulted positive for methicillin-sensitive Staphylococcus aureus (MSSA).
+Ultimately the patient did very well without requiring procedural intervention or cesarean section. She was continued on enoxaparin and discharged on six weeks of cefazolin.

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+A 9 days-old male neonates weighing 3.60 kg was referred by local hospital to our center (National Cardiac Center Harapan Kita Hospital/NCCHK) and was ventilated because of severe metabolic and respiratory acidosis, circulatory dynamics instability with history of respiratory distress, cyanosis, hyperbilirubinemia and severe infection that present since he was born on year 2011. The perinatal history was unremarkable and at a previous hospital she was born at 40 weeks of gestation by normal labour with a birth weight of 3.85 kg, oxygen saturation 90% and an APGAR score of 9/9. On the 6th day postpartum he presented with feeding difficulty, severe cyanosis and congestive heart failure and was referred to local hospital for further treathment, was ventilated at the emergency room with oxygen saturation 82%, and then transferred to us for possible surgical repair. Stable hemodynamic with oxygen saturation was 75%, while differential oxygen saturation was noted between the both upper and lower limbs (89%; 76% and 97%; 83%, respectively). No apparent cardiac murmur was detected. His chest X-ray showed mild cardiomegaly and congestion of the lungs, and pulmonary edema. Electrocardiogram showed normal rhythm, right axes deviation, and mild right ventricular hypertrophy.
+Admitted to our pediatric cardiac intensive care unit (PCICU) with oxygen saturation between 40% and 70%. Two-dimensional Echocardiography revealed an IAA type A and APW type II with a restricted PDA, pulmonary hypertension but no ventricular septal defect (, ). A PGE1 infusion 10 nano was started to re-open the ductus arteriosus and diuretics were administered. During the following days the baby had severe infection and DIC with increased of leucocyte 28.387, pro-calcitonine 11, D-dimer 4.800. Also had experienced of several epileptic episodes, and a brain sonography showed arachnoiditis, brain edema and no intracranial bleeding. Because of the risk of infection, sepsis and taking into account the good general condition, operation was deferred.
+After improvement of the clinical condition, operation was performed on the 20th days of life. A one-stage surgical correction was performed through a median sternotomy under profound hypothermia (26 °C). Before the administration of heparin, the entire ascending aorta and the arch vessels, pulmonary trunk and both branch were mobilized. The external anatomy confirmed an IAA type A and a large APW type II, and this time the right pulmonary artery (RPA) was recognized to originate from the posterolateral part of the ascending aorta, as well as connection with common pulmonary artery. Aorta and pulmonary arteries (PA) were obvious and intact at their origin. The ascending aorta is then come to end by giving three branches including, brachiocephalic artery, left common carotid artery, and left subclavian artery. There was not evidence of descending aorta. Proximal part of PDA arose from PA trunk which is distally becoming into descending aorta with left pulmonary artery are origin from PA trunk also detected at the same time (, ).
+Cardiopulmonary bypass (CPB) was established by the right hemicerebral perfusion and the bicaval drainage. The right hemicerebral perfusion was obtained via expanded 4-0 mm polytetrafluoroethylene (ePTFE) graft sewn to the right brachiocephalic artery. The aortic cross clamp was applied (one-third flow) and cardioplegia was infused. Aortic arch vessels were clamped at the origin of the brachiocephalic artery, the left common carotid artery, and left subclavian artery. Immediately there after, snaring of both pulmonary arteries precluded overflooding the lungs, and the pump flow was lowered to 10% to perfuse only the myocardium. Ductal tissue was ligated near its pulmonary origin and resected until normal aortic tissue appeared, then the ascending aorta was longitudinally incised. An extended end-to-side anastomosis of the descending aorta to the distal ascending aorta was performed with a continuous 7-0 polypropylene suture. After removal of the aortic cross-clamp and off the snares in the vessels, full flow bypass was resumed and the anastomosis was checked for bleeding and undue tension.
+The aortic cross-clamp was reapplied proximal to the aortic cannula, cardioplegia was infused, and the AP window repair was started. The ascending aorta was transversely incised distal to the AP window. Inspection confirmed the location of the AP window which appeared to be very large 10 mm diameter, as well as aortic origin of the RPA. The left pulmonary artery (LPA) arose from the PA trunk in the normal fashion. The coronary arteries were normally positioned. Becaused of the excessive blood flow distally, the aortic cross clamp was removed and reapplied for right hemicerebral perfusion again (one-third flow). A 4-0 Gore-tex patch was used both to close the aortopulmonary window and separated the right pulmonary artery from aortic origin (B).
+After rewarming, CPB was easily weaned with moderate inotropic support. Total bypass time was 125 minutes, cross clamp time 71 minutes and one-third flow 66 minutes. Peritoneal dialysis was performed post operatively for 3 days and electively switch with lasix intermitten.
+The postoperative recovery was uneventful. Slowly weaning from ventilation and extubated on 7th day post operatively with good clinical condition. No clinical signs of neurologic disturbances were observed and cardiopulmonary function as well as distal perfusion were very satisfactory. Early postoperative echocardiography using colour doppler demonstrated an excellent early surgical result with a minimal pressure gradient of 12 mmHg across the aortic reconstruction with good LV function, no AP window residual.
+Currently on year 2021, the patient has grown up as a cheerful 9 year old child who is growing actively and has entered elementary school in grade 2. There are no abnormalities of the heart and lungs according to the patient's mother and always carries out routinely follow up with the pediatric cardiologist. However, there is still a cerebral palsy sequela which is currently being treated by a pediatric neurologist.

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+An 82-year-old white man with a medical history of paroxysmal atrial fibrillation for which coumarins were prescribed presented with an episode of macroscopic hematuria. A physical rectal examination revealed a diffusely indurated prostate and computed tomography (CT) showed normal aspect of his kidneys and bladder as well as an enlarged prostate. Laboratory analysis showed a white blood cell count within normal limits (6.69×109/L) and a slight increase in prostate-specific antigen from 4 to 9.4 ng/ml. A transrectal US of his prostate revealed a hypoechoic and hypervascular subcapsular area in the peripheral zone of his prostate with a differential diagnosis including diffuse carcinoma or granulomatous inflammation. An uneventful US-guided transrectal biopsy was performed on an out-patient basis, 7 days after anticoagulation therapy was ceased. Pathologic analysis of the biopsy specimen revealed a diffuse carcinoma of the peripheral zone of his prostate. Three days later, a massive rectal hemorrhage occurred, associated with hemodynamic shock (blood pressure 50/30 mmHg, heart rate 100 beats per minute). A good hemodynamic response was obtained after appropriate therapeutic management. A clinical examination revealed a nodular rectal area in the prostate bed without a large hematoma. Endoscopy revealed two active arterial bleeders in his lower rectum but endoscopic clipping failed. He was referred to the angiography suite for emergency interventional treatment. Selective angiography of his inferior mesenteric artery did not reveal any bleeding. Selective catheterization of the anterior division of his right internal iliac artery revealed a prostatic artery with an inferior and superior branch. With a microcatheter (Progreat 2.7, Terumo Europe, Leuven, Belgium), selective catheterization of his internal pudendal artery revealed an arteriovenous fistula (AVF) in the left prostatic body, fed from collaterals originating from his right inferior prostatic artery . No contrast extravasation was noted. Embolization with calibrated microparticles (Embosphere® 300–500 μ, Merit Medical, South Jordan, Utah, USA) was performed, followed by placement of three 4×4 mm microcoils (Target®, Boston Scientific Inc Natick, MA, USA) at the origin of the anastomosis with his left inferior prostatic artery . Control angiography following embolization showed complete occlusion of the treated artery without residual opacification of the AVF. Selective angiography of his left internal iliac artery showed a patent internal pudendal artery with normal opacification of his dorsal penile artery and without opacification of an AVF . He was discharged the next day without clinical signs of postembolization syndrome or lower urinary tract symptoms.

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+A 7-year-old boy was referred to our center due to headache and left limb weakness. Craniocerebral magnetic resonance imaging revealed multiple patchy abnormal signals in the bilateral paraventricular basal ganglia area and the right half oval center. Softening lesions were considered, and no notable abnormalities were observed in the cerebral blood vessels . Transthoracic echocardiography indicated a right to left shunt signal with a width of ~2.5 mm in the middle of the atrial septum. Transesophageal echocardiography revealed a fissure-like echo at the foramen ovale of the atrial septum, with a width of ~2.2 mm and a length of ~15 mm . Right ventricular contrast-enhanced ultrasound indicates that a large amount of microbubble echoes were observed in the second cardiac cycle of the left heart in a resting state. During the Valsalva maneuver, a large amount of microbubble echoes were observed in the first cardiac cycle of the left heart (, Left). The transcranial doppler (TCD) foaming experiment indicated that there was no microbubble echo in the resting state, and a large number of microbubble echoes were observed within 10 s during the Valsalva maneuver. Bilateral lower limb venous ultrasound showed no obvious thrombosis or plaque formation. The laboratory examination (included D-dimer) and electrocardiogram (ECG) showed no abnormalities. Inquire about the patient's medical history. The patient has no family history of coagulation disorders. A detailed medical history inquiry revealed that at the age of 2 years, the child experienced headaches, unclear language, and left limb weakness. Emergency cranial magnetic resonance imaging showed patchy and slightly longer T1 and T2 signal shadows in the bilateral basal ganglia area, with a larger range on the right side and a maximum cross-sectional size of approximately 1.5 × 1.2 cm. Bilateral abnormal signals in the basal ganglia area were observed, indicating demyelination changes. The relationship between recurrent cerebral infarction and abnormal shunting caused by PFO is considered in patients. The PFO closure decision was adopted after a detailed discussion. This procedure was performed under local anesthesia with the implantation of an 18 mm Amplatzer PFO device . The patient was discharged the next day. Antiplatelet therapy was administered 6 months after PFO closure. Follow-up after 1 year did not reveal any further symptoms of headache or limb weakness. After PFO closure, no new infarct was found on cranial MRI. The right ventricular contrast-enhanced ultrasound was negative, and the TCD foaming test was negative (, Right).

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2602_en.txt

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+A 24-year-old male with no past medical history, who had been diagnosed with COVID-19 five days previously, presented with right-sided facial droop, left-sided extremity tingling and weakness, and the sensation of falling to the left when walking. Onset of the left-sided extremity tingling and weakness and ataxia had been three days earlier; the patient had been seen at an outside hospital and prescribed gabapentin without effect. Two days later, our patient experienced right-sided facial droop and again sought emergent care. Although our patient had experienced nausea and vomiting for a week or more prior to his positive test for COVID-19, his only respiratory symptom of COVID-19 on presentation was a dry cough.
+In our Emergency Department, the patient’s vital signs were: temperature 36.7°, heart rate 85 bpm, respiratory rate 20 bpm, blood pressure 139/93, and oxygen saturation 100%. Physical exam was significant for a right-sided lower motor neuron (peripheral) seventh nerve palsy, mild left-sided weakness, ataxia, and increased left-sided reflexes. He was diagnosed with CN VII palsy and started on prednisone.
+Because of the severity of his initial symptoms and the known risk of coagulopathy in patients with COVID-19, our patient also received an emergent MRI without contrast, which showed a T2 FLAIR hyperintensity in the splenium of the corpus collosum, mammillary bodies, periaqueductal gray matter, tectum, and ventral and dorsal medulla, in a pattern concerning for Wernicke's encephalopathy. See Figs. , , , and . He was admitted for workup.
+While admitted, the patient received prednisone with improvement of his CN VII palsy by the next day. The patient also received 300 mg IV thiamine for 3 days, increased thereafter to 500 mg after he reported diplopia, and nystagmus was noted.
+A second MRI of the brain, with and without contrast, four days after his first, showed overall improvement with significant resolution of the T2 FLAIR hyperintensity in the splenium of the corpus collosum, hypothalamus, and dorsal brainstem. Mild enhancement of the mamillary bodies and dorsal pons was present, as was an increase in the T2 FLAIR hyperintensity in the inferior olivary nuclei, which was concerning for hypertrophic olivary degeneration. An MRI of the cervical spine with contrast was unremarkable.
+The balance of our patient’s workup was unrevealing. An MR angiography head without contrast was negative for stenosis, branch occlusion, or aneurysm. A transthoracic echocardiogram was negative. No lumbar puncture was performed. The patient’s thiamine level was high at 266; however, this was not collected until after he had received IV supplementation. Vitamin B12 level was high at 1369, his ALT was mildly elevated at 64, and his ferritin level was high at 406. The remainder of his labs were within normal limits, including his white blood cell count, D-dimer, ANA, rheumatoid factor, CRP, HIV, syphilis, toxicology screen, folate, and TSH.
+Throughout his course, the patient’s only symptom of COVID-19 was a dry cough. His oxygen saturation on room air was within normal limits, and his chest X-ray was negative for an acute cardiopulmonary process. He was not treated for COVID-19 while inpatient.
+Our patient was diagnosed with Wernicke’s encephalopathy and cranial nerve VII palsy and discharged on oral thiamine with outpatient follow-up with neurology. His condition on follow-up was stable. Informed consent for this publication was obtained.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2615_en.txt

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+A 77-year-old Chinese female was admitted to hospital with high-grade fever, sore throat, and swelling of the right knee. The intermittent high fever(> 40 °C), which started 20 days ago, had no obvious cause,and was accompanied by chills, redness, pain and swelling of the left ankle. The severe and unbearable pain often occurred during fever, and was slightly relieved after the fever subsided. However, a few days later, these syptoms disappeared while the right knee showed the same symptoms. The patient initially underwent bilateral TKA six years ago and recovered uneventfully and had well functioning TKAs. She also had a history of Alzheimer’s disease.
+Her initial body temperature was 39.2 °C in the evening of admission. The right knee was swollen, and she experienced pain with tenderness. The floating patellar test was positive on the right knee; and negative on the left. The range of motion was 0–100° for the right knee and 0–120° for the left. There was no obvious instability in either knee joint.
+Laboratory examination results are shown in Table . The abdominal ultrasound showed no signs of hepatosplenomegaly and the X-ray showed no obvious abnormality in both knee joints and chest.
+The right knee was aspirated upon admission, and the aspiration fluid showed a yellowish-green turbid character . Routine examination of the fluid showed inflammatory characteristics . No fungi or bacteria were found in the aspiration fluid. Venous blood culture was negative. Thereafter, blood culture was carried out every time the temperature increased significantly (a total of five times), and the results were all negative. After consultation, the pharmacy department provided diagnoses of erysipelas and knee arthritis, and treated the patient with penicillin. However, the patient’s body temperature still fluctuated above 38 °C over the next two days, so treatment was changed to vancomycin and levofloxacin.
+Considering the patient’s symptoms and test results, acute PJI could not be ruled out. We performed debridement, antibiotics, implant retention (DAIR) for the right knee five days after admission. The grinding tissue fluid was taken for culture and biochemical examination .
+The symptoms and laboratory results were slightly improved postoperatively. But on the fourth day after the operation, the patient’s temperature spiked again, reaching over 39.0 °C. A punctate congestive rash was distributed symmetrically over the neck and trunk. At the same time, the patient developed a cough, expectoration, and wheezing. The leukocytes level and the percentage of neutrophils increased significantly. CT scan showed bilateral lung infection with pleural effusion. It also showed enlargement of mediastinal and bilateral axillary lymph nodes. Echocardiography showed a small amount of pericardial effusion and decreased left ventricular diastolic function. We treated it as pulmonary infection, cardiac insufficiency and drug-borne allergy. The previous antibiotics were replaced with linezolid cefoperazone/sulbactam and furosemide, followed by an intravenous drip of dexamethasone 10 mg for three days. During the use of dexamethasone, the patient’s temperature was normal. The respiratory symptoms improved significantly, and the rash gradually subsided. However, her temperature rose above 37.5 °C again after stopping dexamethasone. The left knee displayed redness, swelling, and pain, and the floating patellar test was positive. Both 1,3-β-D-glucan test (G test) and galactomannan test (GM test) were negative, and the sputum culture showed presence of acinetobacter pittii. Treated with an intravenous infusion of imipenem, linezolid, and fluconazole, the patient reported that pain in both knees and the rash intensified. The aspiration fluid collected from both knees showed no bacteria in the culture but the possibility of suppurative arthritis once again .
+Considering that the infection remained uncontrolled, we removed the right prosthesis again, placed the antibiotic bone cement spacer, and performed DAIR for the left knee. We took synovial grinding tissue fluid from both knees for culture, and found Human staphylococci and Staphylococcus cohnii in the left. The temperature remained abnormal postoperatively and even gradually increased over the next few days, peaking around 14:00 each day. Two weeks later, the patient’s right knee swelled again with sticky secretions, but the culture of the joint aspiration fluid was negative. Subsequent mycoplasma pneumoniae and tuberculosis antibody tests were negative. T-SPOT test was positive, so oral isoniazid was given for treatment. A few days later, the right knee’s symptoms worsened, and a rash appeared.
+Then, the spacer in the right knee was removed, and the knee was fixed by bracing. However, the result of articular fluid analysis remained negative. On the third day after operation, the rash had spread all over the body, and the temperature rose again. After four operations on both knees, the fever and rash got worse and worse, so we thought it might not be a simple PJI and consulted the rheumatic immunology department. After excluding the possibilities of malignancies and hematological diseases, they found the patient’s symptoms matched those of AOSD. According to the Yamaguchi criteria , our patient had four major features (spiking fever, arthralgia, rash, and leukocytosis) and four minor features (sore throat, abnormal liver function, lymph nodes enlargement and negative ANA/RF). Using a combination with antibiotics, we continued to prescribe intravenous infusion of methylprednisolone powder 40 mg once a day for three days, then changed the medication to oral prednisone 50 mg. After treatment, the patient’s temperature returned to normal. Both the rash and symptoms of bilateral knees disappeared. A week later, the CRP level decreased to normal (5.06 mg/L) while ESR level was slightly higher (30 mm/h). The patient was discharged. A brief diagram of the patient’s disease changes is shown in Fig. .
+After discharge, the patient’s right lower limb was fixed with a brace, and she continued taking prednisone 50 mg once a day. The symptoms were well-controlled, and the medication dose decreased gradually after a month. The patient was re-admitted four months later and was re-examined . The X-ray of the knee showed bone defects and reduced space in the distal femur and tibial plateau . We performed a revision of the right knee with ACCK prosthesis (ACCK Knee Prosthesis; AK; Beijing, China).
+At one year follow-up after the operation, her right knee flexion was 100° with 15° extension lag and the HSS score was 76. The patient had discontinued prednisone for one month without any systemic or local symptoms.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2693_en.txt

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+The patient a 52-year-old premenopausal woman, was selected from the mammography screening program for breast cancer, and then was requested to do an ultrasonography and a biopsy of the lesion. A written informed consent was provided by the patient to have the case details published. She had a family history of carcinoma, with her father having non-small cell lung cancer and a brother and a sister having colon adenocarcinoma, and a personal history of mucinous borderline ovarian tumor treated in 2013 with laparoscopic-assisted hysterectomy, adnexectomy, and pelvic lymphadenectomy. The patient had also undergone surgery for colon hyperplastic polyps. At that time, the patient was experiencing a perimenopausal syndrome.
+Physical examination showed a nodule of 1×1 cm at the left breast, which was hard and mobile, not adherent to deep layers, in the retroareolar region, at the union of lower quadrants. Only one adenopathy was palpable in the axilla and it had a noninfiltrative but a reactive aspect. The right breast and axilla were both normal, without showing signs of disease. Mammography of the screening program for breast cancer showed a nodule in the left breast the Breast Imaging Reporting and Data System, category 3. Ultrasonography confirmed it as a retroareolar solid nodule with a maximum diameter of 11.6 mm .
+Initially, the mass was considered breast carcinoma and a biopsy was requested to confirm whether it was breast carcinoma or a benign tumor. A biopsy was carried out and a histologic examination of the biopsy suggested GCT, and deferred immunohistochemi-cal examination showed the typical receptors of this tumor . In our case, GCT showed positive immunoreaction to PAS, PAS diastase and S-100, and calretinin and negative immunoreactivity against cytokeratin, estrogen, progesterone receptors, and also to HER2/Neu receptors; also, negative receptors for cytokeratin confirmed the diagnosis of GCT.,
+Finally, a biopsy of a lymph node in the left axilla, followed by a histologic examination showed no signs of malignant cells.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_2794_en.txt

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+A 57-year-old Caucasian woman presented with a large non-tender submandibular mass. The lesion had been present for about 25 years with a slow increase in size. Our patient's medical history was unremarkable. A physical examination revealed a giant painless, movable, semi-hard elastic mass in her right submandibular region measuring about 8×6 cm. Fine needle aspiration cytology was suggestive of a PA. Contrast-enhancement computerized tomography confirmed a giant well-defined mass without cystic changes in her right submandibular region . No lymph node swelling or other tumorous lesions were detected. Submandibular tumor extirpation was performed under general anesthesia.
+Immediately after removal, samples were obtained in the surgery room following a topographic scheme . Group 1 comprised six samples from the periphery of the tumor, adjacent to the subcutaneous tissue; group 2 comprised six samples from the periphery of the tumor, adjacent to the floor of the mouth; and for group 3, the tumor was opened along the midline, and six deep samples were extracted from the center of the tumor.
+Half of the samples in each group were fixed in 4% buffered formalin, processed and embedded in paraffin according to routine procedures, for histological and immunohistochemical analysis. The remainder of the samples of fresh material for each group were immediately submitted for DNA flow cytometry. The rest of the surgical specimen was routinely studied in the Department of Pathology and diagnosed as a benign PA.
+Samples of each group were minced with a scalpel in phosphate-buffered saline solution. Single nuclear suspensions were prepared by filtering through a 50-μm nylon mesh. The DNA contents were measured in a Cytomics FC500 (Beckman Coulter Inc., Fullerton, CA, USA) flow cytometer. DNA histograms of at least 10, 000 nuclei were plotted. The DNA-diploid cell population corresponding to surrounding normal tissue from the same location was used as an internal reference standard for the identification of DNA-aneuploid clones. The percentages of the cell cycle phases as well as the DNA indices of the aneuploid clones were calculated using the Modfit 5.2 software package. DNA histograms were classified as diploid if there was a single G0-G1 peak and aneuploid if additional G0-G1 peaks were present. The ratio of aneuploid G0-G1 peak values to diploid G0-G1 peak values was expressed as a DNA index. All specimens had a G0-G1 peak coefficient of variation of no more than 4%. The following were taken as cytometric variables: DNA ploidy, DNA index, and S-phase fraction. The cases with DNA indices between 0.9 and 1.10 were considered as DNA diploids, and those less than 0.9 or greater than 1.10 as DNA aneuploids.
+Half of the paraffin-embedded samples of all three groups were routinely stained with hematoxylin and eosin. The rest of the paraffin samples were submitted to the labeled-polymer method of immunohistochemistry using antibodies against α-smooth-muscle actin (α-SMA), cytokeratin (CK) AE1/AE3, CK 8, protein 53 (p53), protein 63 (p63) and antigen Ki67.
+The histogram of Group 1 samples presented a single peak in the G0-G1 area. The cell nuclei population was 5.91% in the G2 region and 91.30% in the G1 area. The proportion of cells in the S-phase was 2.78% and the coefficient of variance (CV) was 3.70%. Samples of this group were considered as being DNA diploid . Group 2 samples also exhibited a DNA diploid pattern with an 88.26% nuclei population in the G1 region and 8.80% in the G2 area. The S-phase fraction was 2.95% and the CV was 3.04% . Group 3 samples showed DNA aneuploidy: 48.70% of the cell population was considered diploid with 4.18% in the G2 region, 91.27% in the G1 area and a CV of 2.17%, whereas 51.30% of the cells analyzed presented an aneuploid pattern with 10.53% in the G2 region, 89.03% in the G1 area and a CV of 7.08%. The total aneuploid S-phase was 0.44% and the total S-phase fraction was 2.45% .
+Histological analysis of Group 1 and Group 2 samples showed ductal structures, cords and islands of polygonal cells without atypia, sheets and strands of hyaline or plasmacytoid cells in a myxoid stroma. These findings were consistent with PA . On immunohistochemistry, slight positivity was observed in the ductal cells with CK AE1/AE3 and CK 8 . The non-luminal cells strongly expressed α-SMA . Occasional cells were positive with proliferation antigen Ki67 and no expression was observed with p53 . Otherwise, myoepithelial cells showed high positive nuclear staining for p63 .
+Group 3 samples exhibited an unusual histological pattern. These hypercellular areas were composed of blocks of round to ovoid epithelial cells without the 'reminiscent' myoepithelium. The epithelial cells were round with pale eosinophilic cytoplasm and round to oval nuclei. Nuclear pleomorphism or atypia, malignant luminal cells and necrotic foci were not observed . The immunohistochemical study showed strong expression of CKs AE1/AE3 and CK 8 in most of the epithelial cells . p63 and α-SMA staining were seen to a lesser degree than in the Group 1 and 2 samples whereas expression of antigen Ki67 was more intense . p53 was expressed in a few epithelial cells .

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3067_en.txt

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+A 13-year-old male presented to the emergency department with a four-day history of right inguinoscrotal pain and nausea. He had no prior medical history. Genital examination revealed a tender, freely movable mass in the right scrotum, positioned above the testicle, while both testes were fully descended and appeared symmetrical in size and structure.
+
+Given the acute presentation, Doppler ultrasonography revealed a 48 × 19 mm heterogeneous soft tissue mass in the spermatic cord adjacent to the right testicle, with no vascular flow. Tumor markers (β-HCG, AFP, LDH, and CEA) were all within normal limits, reducing suspicion of malignancy.
+
+Due to persistent pain, imaging findings of an avascular mass, and the potential risk of testicular compromise, urgent surgical exploration was deemed necessary. The patient, initially apprehensive about surgery and the potential risk of testicular loss, provided informed consent following a detailed discussion of risks and benefits.
+
+Inguinal exploration identified a 5 × 2 cm solid, white mass within the tunica vaginalis. The mass was excised relatively easily after severing its vascular connections to the pampiniform plexus. The testicle was intact, and no additional intervention was required. A right herniotomy and high ligation were performed concurrently.
+
+Postoperatively, the patient was discharged with a structured follow-up plan, including monthly and six-monthly evaluations. Physical examination and ultrasonographic follow-up demonstrated no recurrence. The patient reported no ongoing symptoms during subsequent clinic visits.
+
+Histopathological examination confirmed the diagnosis of fibrolipoma, characterized by collagen-rich stroma enveloping lobules of mature adipose tissue. Macroscopically, the lesion measured 5 × 4 × 2 cm, was partially encapsulated and exhibited a grayish-yellow cut surface. Microscopically, elongated spindle cells were observed within the collagenized stroma, interspersed with mature adipocytes and vascular channels, without evidence of atypia.
+
+Immunohistochemical analysis demonstrated positive staining with CD34 in some stromal areas and negative staining in others. Positive staining with CD117 was rare in mast cells, while positive staining with CD68 was rarely noted in histiocytes. Positive staining with SMA was observed exclusively in vascular walls, while positive staining with S-100 protein was observed in fatty tissues. Negative staining was observed with β-catenin, PanCK, MelanA, HMB-45, and Desmin.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3135_en.txt

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+A 47-year-old Chinese male farmer, with history of contact with soil during farm work 2 days before the onset of illness, was admitted to our hospital with a 2-week history of a high fever, productive cough with purulent sputum, shortness of breath on exertion, and nausea and vomiting. Chest computed tomography (CT) performed at a local hospital before admission to our hospital had shown irregular patchy opacities in the lower lobe of the left lung. He had been treated with levofloxacin for 4 days and then switched to moxifloxacin and meropenem for 10 days at the local hospital. However, as his fever, expectoration, and shortness of breath had not improved, he was transferred to our hospital for further investigation and treatment.
+
+The patient had a 7-year history of dry mouth and dry eyes which had not previously been medically evaluated or treated, but had no history of other possible autoimmune disease such as recurrent oral ulcers, Raynaud’s phenomenon, rash, or arthritis. He was a smoker with a 30 pack-year smoking history. He denied a history of pulmonary disease. He didn’t undergo any previous chest X-ray examination and reported no symptoms and signs of previous interstitial lung disease such as gradually progressive dyspnea on exertion, dry cough, fatigue of unknown origin. He also denied a history of occupational dust exposure, keeping pets and drug abuse. He had no family history of pulmonary disease and cancer.
+
+On admission, he had a temperature of 37.6 °C, pulse of 82 beats/min, respiratory rate of 16 breaths/min, and blood pressure of 123/71 mmHg. The skin on both his legs was dry and rough, but there was no rash or bruising. There were no rales in the lungs on auscultation, and no other obvious abnormalities were noted on physical examination.
+
+The chest CT images on admission at our hospital showed that the patchy opacities in the left lower lobe had extended since the previous chest CT, and there were new small patches in the right middle lobe. Laboratory tests revealed an elevated white blood cell count and neutrophil percentage, elevated levels of procalcitonin and C-reactive protein, an increased erythrocyte sedimentation rate, mild hyponatremia, and elevated levels of liver enzymes. The serum human immunodeficiency virus antibody was negative. No infectious agents were detected in the patient’s blood culture and sputum microbiological examination.
+
+
+Main Laboratory test
+
+Test	Day 1 (admission)	Day 8	Discharge	Reference result/range
+Hematology				
+White blood cell count (× 109 cells/L)	20.59	11.53	5.78	3.5–9.5
+Neutrophil percentage (%)	87	81.7	57	42.5–71.5
+Procalcitonin (ng/mL)	0.117			< 0.05
+C-reactive protein (mg/L)	103	43.1	12	0–8
+Erythrocyte sedimentation (mm/hr)	100			0–15
+Liver enzymes				
+Alanine transaminase (U/L)	101			0–40
+Aspartate transaminase (U/L)	60			5–34
+Alkaline phosphatase (U/L)	463			40–150
+Gama-glutamyl transferase (U/L)	209			9–64
+Serum sodium (mmol/L)	132			136–145
+Infections				
+Legionella urine antigen	Positive			Negative
+Streptococcus pneumoniae Urine antigen	Negative			Negative
+Blood culture	No growth			No growth
+Sputum microbiological examination	Negative			Negative
+Serum anti-Mycoplasma IgM	Negative			Negative
+Serum anti-Chlamydia IgM	Negative			Negative
+Serum anti-Legionella IgG	Negative			Negative
+Serum HIV antibody	Negative			Negative
+Immunological test				
+Tear secretion test (mm/5 min)	Left eye: 3; right eye: 9			10–15
+Antinuclear antibodies	Positive, titer 1:160			Negative, < 1:80
+Anti-SSA/Ro60	5.2 (positive)			< 0.8 negative
+Anti-SSA/Ro52	5.5 (positive)			< 0.8 negative
+Anti-SSB/La	0.8 (weak positive)			< 0.8 negative
+Anti-histone	0.9 (weak positive)			< 0.8 negative
+Rheumatoid factor (IU/mL)	94.5			0–30
+
+
+Because the patient had symptoms and signs of extrapulmonary system involvement, including gastrointestinal symptoms, hyponatremia, and signs of liver damage, we could not rule out Legionella pneumonia and thus we performed a Legionella urine antigen test, which was positive. The patient was treated with moxifloxacin 0.4 g once a day and piperacillin sodium and tazobactam sodium 4.5 g three times a day for 8 days. His white blood cell count, neutrophil percentage and C-reactive protein level had decreased since admission. However, his symptoms of fever, expectoration, and shortness of breath persisted. Thus, the antibiotic treatment was switched to intravenous tigecycline 50 mg twice a day for 5 days after an initial dose of 100 mg. However, his symptoms still did not improve. To confirm the diagnosis, we performed an ultrasound-guided percutaneous needle lung biopsy and tested for markers of autoimmune disease.
+
+The result of a tear secretion test was positive. Salivary gland emission computed tomography dynamic imaging showed impaired uptake in both submandibular glands and parotid glands. Immunological index testing gave positive results for antinuclear antibodies, anti-SSA/Ro60, anti-SSA/Ro52, anti-SSB/La and anti-histone antibody, and the serum rheumatoid factor level was increased. Test for autoimmune liver disease-related antibodies, antineutrophil cytoplasmic antibodies, were all negative, and the serum complement C3 and C4 levels were normal.
+
+Lung histology showed formation of fibrin balls in the alveolar cavities accompanied by changes associated with OP (Fig. 2). No pathogens were detected in the lung tissue using metagenomic next generation sequencing (mNGS). Based on the results of the lung biopsy, antibiotics were stopped and intravenous methylprednisolone 40 mg daily was initiated. The patient’s symptoms improved rapidly, and his body temperature returned to normal on the first day of corticosteroid therapy. He was discharged home 4 days later, and continued oral prednisone 10 mg daily for 20 days followed by 5 mg daily for 5 days. At the follow-up visit one month after discharge, his chest CT showed almost complete resolution of the pulmonary lesions.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3364_en.txt

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+30-year-old male patient from the city of Intuto, located 172 km from the city of Iquitos, in the Peruvian Amazon. He has a history of untreated type 2 diabetes mellitus. He presents to the emergency department of the Regional Hospital of Loreto with convulsions, loss of consciousness and functional limitations, accompanied by chills, headache, feeling of heat and poor general condition. His vital signs at the clinical examination were as follows: BP: 90/60 mmHg; HR: 67/min; respiratory rate: 20/min; T°: 36.5 °C; oxygen saturation: 96%; weight: 60 kg; BMI: 19.6 m². He also presented pallor ++/+++, prostration, general malaise, coldness of extremities, sensory disorder, myalgia and arthralgia.
+
+The illness lasted 14 days and began with convulsions of 1 to 2 minutes with a frequency of 5 to 6 times a day. Two days before admission, he presented loss of consciousness and limited motor function, so he was transferred to the nearest health center, where he was given a thick and extended gout examination, with observation of Plasmodium vivax trophozoites and initiation of treatment. However, the doctor decided to refer him to a health center of greater complexity, so the patient went to the emergency department of the Regional Hospital of Loreto where he was hospitalized.
+
+The patient received intravenous artesunate 14.4 mg at admission, repeated at 12 and 24 h, all doses diluted with 5% dextrose in volume of 5 to 10 ml in a 5 min bolus. Artesunate was continued at 24 mg orally until day 5. Simultaneously with the initiation of intravenous artesunate, 600 mg of clindamycin diluted in 50 ml of 0.9% sodium chloride was infused over 20 to 30 min every 12 h for 5 days. Subsequently, a packed red blood cell transfusion was performed, after which primaquine was continued for 7 days.
+
+After receiving the treatment, the patient underwent a new examination for thick blood without observing the parasite. The laboratory examinations showed a depression of the three series of blood cells with a peripheral sheet extension, typical granulocytes ++, atypical lymphocytes +. In the erythrocytes series, microcytosis with anisocytosis and basophilic punctate was observed. The abdominal ultrasound showed splenomegaly and bilateral pleural effusion. A lumbar puncture was performed with analysis of cerebrospinal fluid. The patient showed clinical improvement with a neurological sequela of monoparesia of the motor nerves in the lower left.

data/test_raw_data/en_test/multiclinsum_test_en/fulltext/multiclinsum_test_3374_en.txt

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+A 27-year-old black (“Habesha”) lactating woman with gravida 2, para 1, and abortion 1 was referred to our hospital from one of the local health centres with the diagnosis of chronic pelvic pain. Over the previous year, she had multiple visits to different health centers, was repeatedly given medications for acute PID, and was also prescribed different anti-pain medications. Her last delivery was one year ago; it was via cesarean section and uncomplicated. A CU-IUD was provided six weeks after her delivery while she was still breast-feeding. The procedure was followed by abdominal cramps and mild bleeding, which lasted several days.
+
+Three months after insertion, she went to the health center because she could not feel the strings. At that time, a presumptive diagnosis of spontaneous expulsion was made. No further attempts were made to confirm its location. She was also not provided with another family planning during that visit. Upon arrival at our hospital, she complained of dull and aching pain in the lower quadrant of eight-month duration. Otherwise, she has no other complaints. Her vital signs were within the normal range; her BMI (20.5) and CBC parameters were within normal limits. A bimanual examination was performed to reveal a tender 3 cm by 3 cm cul-de-sac mass with no clear distinction from the uterus, and a speculum examination was nonrevealing. Pelvic ultrasound showed an undefined posterior cul-de-sac mass. Futher investigation modalities such as laparoscopy and CT were discussed with the patient, but she could not afford them.
+
+Subsequently, suspecting an intraperitoneal IUD from history and the finding of pelvic mass on ultrasound, the radiologist performed an abdominal erect X-ray with a uterine probe inside in the AP and lateral planes, which both showed that the T-shaped CU-IUD is near and posterior (in the lateral plane) to the uterus.
+
+Finally, a laparotomy was decided and the abdominal cavity was accessed by making a 5-cm incision on a previous transverse skin incision. A careful palpation of the pelvic cavity was performed to determine the specific location, and a string was palpated over the posterior wall of the uterus. On close examination, the IUD was found to be enclosed in a mass formed by the left ovary and the left fallopian tube, which adhered to the posterior wall of the uterus at the junction of the body and the cervix.
+
+Considering that part of the string was protruding from the mass, the bowel, vessels, and other pelvic structures were examined for perforation, and there was no perforation. Subsequently, after adhesion was removed, the entire IUD (stem, arms, and string) was retrieved from the mass. The uterus was examined and was in a normal anatomic position. Minor surface bleeding from the posterior wall of the uterus and the adnexa was arrested with pressure. After ascertaining hemostasis, the operation was completed. As part of family planning, she was counseled, provided Implanon-NXT, and discharged without complications two days after surgery. Two weeks following the surgery, she stated that her pain had significantly decreased.

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+A 28-year-old female visited a local hospital for preconception care in June 2019 because spontaneous abortion previously occurred at the 8th gestational week in February 2019. Hashimoto’s thyroiditis and subclinical hypothyroidism were found, and euthyrox was prescribed (25 µg/day). Sex hormones were also tested on the 22nd day of the cycle for irregular menstruation (cycle ranged from 31 to 51 days), and the results were abnormal with no evidence of dominant follicle or ovulation .
+Then she was referred to the reproductive endocrinology outpatient department of a tertiary teaching hospital for further diagnosis. Menarche occurred at 12 years of age. Physical examination showed a well-developed woman with normal breast size and no signs of hyperandrogenism or insulin resistance. Serum testosterone, androstenedione, and adrenal androgen levels were normal. The pelvic ultrasound on the 4th day of the spontaneous cycle showed a normal uterus size with an endometrium measured at 6 mm. The antral follicle count per ovary was > 20, and a cyst (1.6 × 1.3 × 2.2 cm) beside the left ovary was observed. Serum antimullerian hormone (AMH) was 8.33 ng/mL. Polycystic ovary syndrome was primarily diagnosed based on ovulatory dysfunction and polycystic ovarian morphology after excluding other etiologies. Oral contraceptives containing drospirenone and ethinylestradiol were prescribed for 3 cycles.
+After stopping oral contraceptives, the early follicular phase serum estradiol levels persistently increased to between 527 and 642 pg/mL (normal range in follicle phase, 19.5-144.2 pg/mL) during the next 10 months, as illustrated in Table . All estradiol measurements were obtained from the same laboratory, using the same competitive chemiluminescent immunoassay (CLIA, Siemens ADVIA CENTAUR). The patient was further referred to the oncology department. However, the levels of other tumor biomarkers were negative (CA-125 6.8, CA-199 6.9, CEA 0.7, β-HCG 2, a-fetoprotein < 1.3). Radiologic assessment by abdominal and pelvic computed tomography was negative for any significant adrenal or adnexal masses, except for a cyst next to the left ovary. Moreover, any form of hormonal substance or dietary supplement was absent by reviewing the dietary diary. Findings on physical examination were completely normal, with no spider angiomas, telangiectasia, palmar erythema, breast tenderness or varicose veins.
+On the basis of persistent elevated estradiol and the cystic lesion beside the ovary, a granulosa cell tumor of the ovary was suspected. Laparoscopy surgery was performed, but a left mesosalpinx cyst and benign pathological results were found.
+The source of increased estradiol was still unclear after screening for 11 months. The patient was then suggested to monitor the follicle growth by ultrasound and attempt pregnancy. Surprisingly, the follicle would grow slowly and eventually ovulate. An appropriate rise in estradiol was observed with follicle growth (1067.8 pg/mL when the follicle was 1.5 cm in diameter).
+There were discrepancies between the serum estradiol level and the clinical picture (follicle growth and normal follicle stimulating hormone). We suspected a case of falsely elevated estradiol levels. The comparison of samples drawn on the same day (14th day of spontaneous cycle), showed our laboratory and the reference laboratory estradiol values to be 619 pg/mL (Siemens ADVIA CENTAUR) and 60 pg/mL (Beckman, DxI 800), respectively. The latter values of estradiol were in concordance with the clinical situation. Thus, falsely increased estradiol was confirmed, and it resulted from analytic interference. Further treatments, including induced ovulation by using letrozole, ultrasound monitoring and intercourse guidance, were scheduled for her urgent pregnancy demand. Successful clinical pregnancy was achieved after six months of therapy. The patient has given birth a healthy baby on 13th March 2022, and she is satisfied with the treatment.

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+An 86-year-old man with a history of hypertension, Type 2 diabetes mellitus, dyslipidemia, and permanent atrial fibrillation visited our hospital and presented with transient deterioration of mental status and mildly sluggish responsiveness, continuous since the previous day. At examination time, his consciousness level was almost clear, without obviously abnormal neurological findings. Diffusion-weighted magnetic resonance imaging of the brain revealed a new-onset cerebral infarction of the right putamen . MR angiography showed total occlusion of the right internal carotid artery (ICA) and severe stenosis of the left ICA at its cervical portion . T1-weighted black blood MR imaging of the neck showed a markedly bright and massive plaque at the proximal portion of the left ICA with a very high plaque/muscle ratio (3.39), suggestive of its vulnerability . Single-photon emission computed tomography (SPECT) using N-isopropyl-p-[123I] iodoamphetamine (123I-IMP) at a resting state and after an acetazolamide challenge revealed extensive declines in cerebral blood flow (CBF; 22-29 mL/100g/min) and cerebrovascular reactivity (CVR; 7-26%) within bilateral ICA territories [-]. Transthoracic echocardiography to screen for cardiac diseases showed a severe narrowing of the aortic valve area (0.82 cm2) and dobutamine stress echocardiography findings were compatible with a true-severe AS. He was diagnosed with acute ischemic stroke due to total occlusion of the right ICA, asymptomatic severe stenosis of the left ICA, and a concomitant true-severe AS. We then started oral dual antiplatelet therapy (DAPT; a loading dose of 300 mg clopidogrel on admission day followed by 75 mg/day plus 200 mg/day aspirin) and intravenous anticoagulant therapy using a systemic infusion of argatroban, a direct antithrombin agent approved for acute atherothrombotic stroke in Japan, before switching to oral anticoagulant therapy using apixaban (5 mg/day) 5 days later.
+In this case, patient status under medical treatment was considered poor because of misery perfusion in the bilateral cerebral hemispheres but the periprocedural complication risk of extracranial-intracranial bypass surgery for the right cerebral hemisphere was deemed too high. In addition, endovascular revascularization for the totally occluded right ICA was considered to be at very high risk for both ischemic complications and CHS. Since increased blood flow in the leptomeningeal collaterals in the right cerebral hemisphere through the anterior communicating artery would contribute to stroke prevention, we decided to perform a revascularization procedure for the left carotid stenosis. To avoid CHS after the carotid revascularization procedure and periprocedural stroke (resulting from a pronounced CBF decrease during the TAVI procedure), we decided to undergo a staged treatment strategy consisting of SAP for the left carotid stenosis and TAVI.

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+A 71-year-old woman with a pancreatic tumor involving the head and uncinate process was referred to our hospital with symptoms of back pain, weight loss, and diabetes. According to imaging, the tumor was approximately 30 mm in diameter. The patient was diagnosed with pancreatic duct adenocarcinoma based on findings from an endoscopic ultrasound-guided fine-needle biopsy specimen. The tumor was in contact with the right side of the SMV at the level where it received the first jejunal vein tributary. The tumor attachment to the SMV had a longitudinal extent of about 20 mm but involved less than half of the vein’s circumference, so the tumor was considered resectable. However, extension of tumor along the retropancreatic nerve plexus (RNP) approached the superior mesenteric artery (SMA; Fig. ), so based upon the results of the PREP-02/JSAP-05 trial , 2 cycles of gemcitabine and S-1 were administered before surgery.
+Although no radiologically evident changes of tumor status were recognized after chemotherapy, we planned to carry out pancreatoduodenectomy with SMV resection and reconstruction. The first jejunal vein tributary would be resected, provided that a vein-clamping test produced no jejunal congestion. Then the segment of the SMV caudal to its confluence with the inferior mesenteric vein (IMV) would be resected in continuity with the pancreatic tumor. Reconstruction of the SMV by simple end-to-end suturing without a venous graft would be difficult, considering that both the splenic vein and the IMV were to be preserved.
+One notable finding from computed tomography (CT) before surgery was dilation of the right ovarian vein to a diameter of about 10 mm, similar to the SMV diameter where resection was planned . Although the patient had no active symptoms of PCS such as chronic pelvic pain, feelings of heaviness, or urinary urgency at the time of surgery, she had experienced severe dysmenorrhea prior to menopause and still had occasional feelings of pelvic heaviness, suggesting that she was at future risk for PCS. We reasoned that use of the dilated right ovarian vein as a graft might prevent or lessen such occurrences while also offering dimensions favorable for grafting.
+No cancer dissemination was grossly evident at laparotomy; subsequent cytologic examination of abdominal lavage fluid detected no malignant cells. Dissection began with liberal application of the Kocher maneuver to the duodenum and firm retraction of the pancreatic head to the left. The peritoneum at the base of the transverse mesocolon was divided to approach the SMA and SMV, as in the mesenteric approach . When no evident jejunal congestion resulted from clamping the first jejunal vein tributary near the confluence of the tributary and the SMV, the tributary was ligated and divided. We performed the retropancreatic nerve plexus (RNP) hanging maneuver as we previously reported , making sure that the cut end of the RNP was free of cancer invasion. In brief, the RNP hanging maneuver was carried out as follows. The middle colic artery arising from the SMA and the middle colic vein both were ligated and divided, after which the SMA trunk was followed cranially to its origin. The tape for RNP hanging was placed around the RNP, which was divided together with ligation and division of the inferior pancreatoduodenal artery in the plane determined by the hanging tape prior to any division of the pancreatic parenchyma and gastric antrum. A 3-cm minimum length of the dilated right ovarian vein was removed for use as a venous graft. The tumor was removed together with the portion of the SMV that it had invaded. The SMV was reconstructed with no venous bypass, using the right ovarian vein graft. Obvious valves were not recognized within the patient’s graft after harvesting, so we carried out reconstruction in a standard manner: distal end to distal end and proximal end to proximal end. The duration of reconstruction was 38 min , while total duration of the operation was 607 min. Intraoperative blood loss was 390 mL. The pathologic diagnosis was invasive ductal carcinoma; the stage according to the classification of pancreatic carcinoma was pT3pN1b (4/40) M0, pStage IIB, with invasion of the SMV (pPV1). R0 resection status was achieved.
+The postoperative course was uneventful, and the patient was discharged 25 days after surgery. She has finished adjuvant chemotherapy and was free from disease recurrence at 8 months after surgery. PCS symptoms have not occurred. Patency of the venous graft for SMV reconstruction was confirmed by contrast CT carried out with administration of a direct oral anticoagulant 8 months after surgery .

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+A 15-year-old Indian girl was referred to our Department of Pedodontics and Preventive Dentistry with the chief complaint of unerupted teeth. Her medical history revealed delayed closure of the anterior fontanelle, a fracture of her right humerus at three years of age and delayed puberty. Our patient was poorly built, short statured, moderately-nourished with a concave facial profile. She had shrugged shoulders with more than normal mobility of the shoulder girdle. Oral findings include Class III malocclusion with anterior and posterior crossbite and retained deciduous teeth .
+An orthopantomogram revealed multiple unerupted permanent teeth and supernumerary teeth in the mandibular anterior region . A lateral cephalograph revealed wide skull sutures . The posteroanterior view of a chest radiograph revealed the absence of clavicles and a bell-shaped ribcage. Based on these clinical and radiographic findings, a diagnosis of cleidocranial dysplasia was made. However, her chromosomal analysis revealed normal female karyotype 46XX.
+A multidisciplinary dental approach involving oral and maxillofacial surgeons, orthodontists and pedodontists was followed in our case. Space management and proper eruption of her permanent teeth for aesthetic purposes were planned. Under general anesthesia, all her primary mandibular anterior teeth and supernumerary teeth were removed. Permanent anterior teeth were exposed surgically and orthodontic brackets and ligature wires were placed for traction for the permanent teeth to erupt, along with a lingual arch appliance to prevent the arch collapsing . The same procedure was performed in the maxillary anterior region after two months . Our patient's self image was taken care of through behavior management and counseling.
+After six months, the permanent teeth were erupting assisted by the orthodontic brackets and arch wire . Despite thorough oral hygiene instructions and maintenance during every follow-up visit, our patient suffered from poor oral hygiene due to the bonded orthodontic brackets and wires.
+Under an aggressive oral hygiene maintenance program, our patient is followed-up periodically for further treatment.

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+An 82-year-old Caucasian man arrived at the emergency department of our hospital complaining of painless, total, macroscopic hematuria starting 24 hours ago. His medical history includes some lower urinary tract symptoms, starting six years ago, insulin-dependent diabetes mellitus, and an episode of stroke five years ago. Clinical examinations were normal, and digital rectal examination (DRE) was negative for pathologic findings. The estimated prostate volume was 70 ml. The laboratory findings were normal, and total serum PSA was 3.7 ng/ml.
+At the abdominal ultrasound, the prostate volume was calculated as 65 ml, and the residual volume was 45 ml. During cystoscopy, the bladder mucosa had a normal macroscopic appearance and an enlarged prostatic middle lobe with small areas of hemorrhage was noted.
+The patient left the hospital with finasteride, 5 mg 1 × 1, and tamsulosin, 0.4 mg 1 × 1. Three months later, the serum PSA was 2.9 ng/ml.
+Five months later, the patient returned to the emergency department for urinary retention. An 18F Foley catheter was inserted, and 15 days later, the patient had a transurethral resection of the prostate (TURP). During the operation, we found a diffuse redness of the whole prostate, especially at the area of the prostatic urethra proximal to the verumontanum. The redness involved the bladder neck, the area of the triangle, and the left lateral bladder wall. The same area was characterized by diffuse edema. The prostatic lateral and middle lobes were removed and cold-cup biopsies were taken from the edematous area of the bladder neck and lateral wall. The histologic examination showed ductal prostatic adenocarcinoma . The CT scan of upper and lower abdomen and thorax and the bone scan were negative for metastasis.
+The patient was treated with triptorelin, 3.75 mg once/month and bicalutamide, 50 mg 1 × 1. The serum PSA at three, six, and 12 months after TURP was 0.1 ng/ml. The patient remains asymptomatic, and he entered a six-month follow-up protocol.

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+A 54-year-old Caucasian woman complained of an unpleasant taste and pain in the mouth. Her medical history included breast cancer with metastasis, which was diagnosed in 2007. The patient had no comorbidities and no history of smoking. A radical mastectomy with axillary dissection was performed. The patient had no previous history of radiotherapy of the head and neck or use of bisphosphonates. The patient received bevacizumab (400 mg/16 mL every 2 weeks; 32 infusions in total) from 11 April 2014 to 26 October 2016. Docetaxel (30 mg/m2 on D1 and D15 of the cycle) and carboplatin (386 mg on D1 and D15 of the cycle) infusions were started in April 2014 and suspended in September 2016. The patient’s leukocyte count was 4310 cells/mm3 (segmented neutrophils, 1896/mm3; band neutrophils, 0/mm3). At 28 days following suspension of the cancer treatment, intraoral clinical examination revealed drainage of purulent secretion involving teeth 16, 25, 27, 44, and 47 . Cone-beam computed tomography (CT) showed the association of hypodense areas with the remaining roots of teeth 16, 25, and 27, and disruption of the lower cortical regions of the maxillary sinus. Hypodense areas could also be seen associated with the roots of teeth 44 and 47 . The patient did not present with clinical characteristics or radiographic findings to suggest MRONJ, and dental implant was placed on 19 December 2016 (3 months after suspension of her medication). At 54 days after the last dose of bevacizumab, and on completion of 3 months of docetaxel and carboplatin infusions, debridement and dental extractions of teeth 16, 25, 27, 44, and 47 were performed in combination with immediate insertion of Straumann® Bone Level Tapered-BLT® implants (SLActive) in regions of teeth 44, 45, 46, and 47 . Chlorhexidine 0.12% mouth wash and levofloxacin (Levoxin®) were prescribed 5 days before and after the oral implantation surgery and continued 5 days after the implantation surgery.
+Five weeks postoperatively, pain, drainage of purulent secretion, and bone exposure around the implants were observed , although none of the implants showed mobility. Ten ozone therapy sessions associated with levofloxacin were performed. After 4 weeks of therapy with ozone oil (Philozon®, Balneário Camboriú, SC, Brazil), no pain or drainage of purulent secretion were present. Bone sequestration accompanied by implant mobility could, however, be seen. Local debridement and implant removal were performed.
+The material removed consisted of 3 irregular fragments of hard, brown bone tissue, with the largest measuring 1.0 × 1.0 × 0.3 cm and the smallest measuring 0.4 × 0.4 × 0.3 cm. The material was stained with hematoxylin and eosin, and histological sections revealed irregular fragments consisting of devitalized bone and the presence of osteoclasts. Adjacent to the necrotic trabeculae, fibrous connective tissue exhibiting intense mixed inflammatory infiltrates (neutrophils, lymphocytes, plasma cells, and some macrophages) was found. Bacterial colonies and hemorrhagic foci were also noted . Based on these results, the histological examination indicated osteonecrosis, categorized as stage 2 MRONJ .
+At 14 days after debridement, the alveolar ridge was completely covered by soft tissue without bone exposure, and the patient was no longer experiencing pain. In March 2017, after the resolution of the osteonecrosis, the patient underwent the same chemotherapy regimen (bevacizumab, carboplatin, and docetaxel) as administered earlier. In July 2017, the patient was still undergoing chemotherapy. At the 7-month postoperative follow-up, the debrided area presented a healthy mucosal covering without lesions . No signs of bone lysis or sequestration were seen on the panoramic radiograph .

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+A 48-year-old male reported pain in the lateral part of his left lower leg and ankle during a badminton play. He was injured when he attempted to receive a high serve. The shuttlecock came to his left, so he stepped his right foot to the left first and jump to hit it. However, he felt pain at the left lower extremity when his left foot landed on the ground and immediately lost the ability to continue the play. He denied a direct impact injury to the proximal end of the left leg and confirmed no history of trauma or surgical treatment on the lower extremity.
+Physical examination revealed no obvious deformity and intact skin of the left leg with mild tenderness upon palpation of the lateral malleolus, as well as the proximal aspect of the fibula. Medial or posterior tenderness was not presented. The initial motions of the ankle joint were limited and there was no distal neurovascular deficit. There were no other skeletal injuries and the systemic examination was unremarkable.
+Plain radiographs demonstrated a spinal fracture at the proximal fibula with no displacement of fragments. Evidence of a medial, lateral, or posterior malleolar fracture or other defects was not clear . Talar shift or widening of the ankle mortise was not noted.
+Computed tomography (CT) images of the ankle showed an avulsion fracture of the anterior tibia by the anterior inferior tibiofibular ligament (AITFL) with a nondisplaced bony fragment . However, magnetic resonance images suggested no injury of the posterior inferior tibiofibular ligament, interosseous tibiofibular ligament, deltoid ligament, and both the medial and lateral malleoli .
+Considering the ankle was stable, we decided to perform nonoperative management. The injury was treated with rest, ice, and elevation. Immobilization of the left lower leg was done with a short leg cast for 6 weeks. Six weeks later, the cast was removed. After that, gradual resumption of ankle range of motion, leg strengthening exercises, and regular activities began. The patient initially walked with hand support. Three months after the injury, the patient started to walk with full body weight. The patient presented free of pain, good ankle motion, and functional recovery during follow-ups at 6 weeks, 3 months, and 6 months after the injury. Plain radiographs showed successful recovery of the fracture at the proximal fibula . At the final follow-up, his American Orthopaedic Foot and Ankle Society ankle-hindfoot (AOFAS) score was 100 out of 100 total points, and he returned to his regular sport, badminton.

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+A 56-year-old man presented to our department with headache, vomiting, and gait disturbance (for 1 month). He had a past medical history of hepatitis type B virus infection and hepatic failure. He had been medically treated for hypertension and hepatitis for the previous 4 years. On admission, he had an impaired consciousness [Glasgow coma scale (GCS), 14]. Cerebellar ataxia and gait disturbance were evident. Diffusion weighted imaging (DWI) demonstrated multiple cerebellar infarctions at several intensities with perilesional edema of the left cerebellar hemisphere . Brain magnetic resonance imaging (MRI) did not reveal any prominent meningeal gadolinium enhancement or nodule . MR angiography revealed no abnormal findings. The main venous sinuses were confirmed to be patent by 3-dimensional reconstructions of MRI with gadolinium . Chest X-ray did not reveal any abnormal lesions, and the results of serum examination for infectious diseases, including human immunodeficiency virus (HIV), were negative except for hepatitis B virus surface antigen.
+Subsequently, the patient was diagnosed with subacute cerebellar infarction due to arteriosclerosis and was administered glycerol to control the intracranial pressure; however, 1 week after admission, his GCS decreased to 11. Computed tomography confirmed worsened cerebellar edema and hydrocephalus. External and internal decompression surgery were performed to control the intracranial pressure . A section of the swollen cerebellar hemisphere was removed and submitted as a surgical specimen. Additionally, external continuous ventricular drainage was performed to control hydrocephalus. Lumbar puncture to collect cerebral spinal fluid (CSF) was not performed until this time because of the risk of cerebral herniation. CSF from continuous ventricular drainage demonstrated mild inflammation (cell count, 36 /mm3; protein, 16 mg/dl; glucose, 113 mg/dl). C. neoformans was detected in CSF as well as in the surgical specimen of the cerebellum.
+Histopathologic examination of the surgical specimen revealed strong hyperplasia of the arachnoid mater . Fungi were mainly localized in the subarachnoid space and rarely in the parenchyma . Lymphocytes and multinucleated giant cells forming granulomata invaded the arachnoid and subarachnoid spaces and pia with heavy fibrosis . Small arteries were occasionally observed to be occluded with internal endothelial proliferation. While there were arteries in the sample, veins were rarely observed in the subarachnoid space . In addition, venules in the parenchyma were frequently observed to be congested. The patient was diagnosed with granulomatous meningitis due to C. neoformans and was immediately treated using liposomal amphotericin B and fluconazole; however, the ischemic lesion of the cerebellum continued to bilaterally worsen along with worsening perilesional edema . The patient’s course subsequently deteriorated. He developed renal failure and ultimately died 25 days after admission.
+Autopsy confirmed that the pathological changes were confined to the central nervous system and predominantly localized at the surface of the cerebellar hemisphere. Fungal bodies were widely spread along the surface and bilaterally into the deep sulcus of the cerebellum . Few fungi were observed in the supratentorial and intraparenchymal lesions. The lesion in the arachnoid mater of the cerebellum was roughly the same as that in the surgical specimen although it was more deeply spread into the peripheral sulcus and the granulomatous inflammation was not as severe .

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+We present a case of a 54-year-old Chinese man with a history of treated hypertension and diabetes mellitus, referred for suspected spontaneous left dural CCF. The patient complained of a chronically red left eye and double vision in the left gaze. Initial examination disclosed best corrected visual acuity 20/20 in the right eye and 20/25 in the left eye, associated with a left relative afferent pupillary defect and severely reduced color vision on Ishihara testing in his left eye only. Humphrey visual field assessment disclosed diffuse defects in the left eye, but was normal in the right eye. Slit lamp examination disclosed a red left eye with dilated corkscrew vessels, but no evidence of angle closure, blood in the Schlemm canal, or other causes of raised intraocular pressure. Intraocular pressure (IOP) was 28 mmHg in the left eye, and 14 mmHg in the right, healthy eye. Fundoscopy disclosed dilated retinal veins on the left side, but no venous stasis retinopathy, or choroidal detachment. The remainder of the ophthalmic examination disclosed mild left abduction deficit, mild ptosis and 3 mm proptosis on the left side. Partial embolization of the angiographically confirmed left dural CCF resulted in incomplete clinical recovery: despite complete regression of the left optic neuropathy and of the left abduction deficit, the left eye remained red, associated with raised intraocular pressure requiring topical medication. Optical coherence tomography angiography of the anterior segment was performed, using a described technique , with optic disc imaging as well using the AngioVue (Optovue Inc. Fremont, CA, USA). Our study followed the principles of the Declaration of Helsinki, with informed consent obtained and ethics approval obtained from our local Institutional Review Board (CIRB Ref no: 2015/3078). OCTA showed engorged episcleral vessels, which were better delineated than using clinical evaluation alone . The OCTA was able to analyze the location and depth of the tortuous, abnormal vessels, as well as the increased flow detected on the B-scan cross-sectional OCTA scans . Posterior pole OCTA of the affected eye disclosed glaucomatous nerve damage and reduction in the peripapillary flow .

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+A 49-year-old female patient presented to the outpatient clinic with headache for 11 d, and left upper and lower extremity weakness accompanied by fever for 1 wk.
+The patient had persistent pain mainly due to right frontal and parietal headache, which could not be relieved after rest. The patient was hospitalized at the Department of Neurology with a body temperature of 39.2 ℃.
+The patient had type 2 diabetes. A diagnostic consultation did not identify any foci of infection. She had no past history of otitis media, sinusitis, or head trauma.
+The patient denied having any other relevant personal history and her familial history was unremarkable.
+The physical examination revealed intact consciousness with a Glasgow coma scale (GCS) score of 15, a soft neck, left upper and lower extremity muscular strength (1 out of 5), a shallow left nasolabial fold, and intact deep and superficial sensation.
+A complete blood count with differential revealed a white blood cell count of 13.4 × 109/L (normal reference range: 4.0–10.0 × 109/L), 80.0% neutrophils (normal reference range: 50%–70%), 12.1% lymphocytes (normal reference range: 20%–40%), and C-reactive protein level of 50.1 mg/L (normal reference range: 0–10 mg/L). Urinalysis revealed a white blood cell count of 229/μg (normal reference range: 0-26/μg). Urine culture grew Enterococcus faecalis. Blood and sputum cultures were negative.
+No obvious abnormalities were observed in a computed tomography (CT) scan of the chest. Cardiac Doppler ultrasound revealed mild mitral regurgitation. Magnetic resonance imaging (MRI) of the head with and without contrast demonstrated the following: (1) Large-scale abnormal signal lesions in the right frontal lobe and right basal ganglia with low signal on T1-weigted imaging, slightly higher signal on T2-weigted imaging, and high signal on diffusion-weighted imaging (DWI); (2) Enhancement of the gyrus around the lesion without significant space-occupying effect; and (3) Multiple long T2 signals and enhanced DWI signals in the left cerebral hemisphere . CT angiography of cervical arteries demonstrated occlusion of the right internal carotid artery . Further examination of the arteries by magnetic resonance angiography showed that there was no development of the right internal carotid artery skull base and intracranial segments, and the anterior and posterior cerebral arteries were supplied by the traffic branch .
+All available clinical evidence up to this point suggested cerebral infarction, with the only unexplained symptoms being persistent fever and headache. Per antibacterial susceptibility testing of the urine culture, piperacillin and tazobactam were administered intravenously, in addition to the initiation of standard treatment for cerebral infarction. In the following week, the patient's temperature fluctuated between 38 ℃ and 39 ℃, and her headache did not improve significantly. Two consecutive cerebrospinal fluid tests revealed the following: (1) Greater than 100 nucleated cells, most of which were neutrophils; (2) Slightly elevated glucose and protein levels; (3) Normal chloride levels; and (4) Opening pressures of 170 mmH2O and 210 mmH2O. No bacteria or fungi were found in cultures of the cerebrospinal fluid. Considering the possibility of brain abscess, the patient was empirically treated with meropenem and vancomycin. However, as discussed above, a CT scan of the head showed a low-density shadow in the right frontal lobe and right basal ganglia. The right basal ganglia showed focal enhancement, the right lateral ventricle was slightly compressed, and there was slight midline shift to the left. In light of these findings, 100 mL intravenous mannitol, 250 mL intravenous glycerol fructose, and intravenous sodium chloride were infused every 12 h. The patient's temperature continued to fluctuate between 37 ℃ and 38 ℃, and her headache persisted. Approximately 1 wk later, the patient's temperature suddenly rose to 39 ℃. A review of the head CT revealed a large area of infarction corresponding to the right middle cerebral artery. The density of some areas was slightly higher, the midline was shifted, and cerebral palsy developed . Accordingly, right craniotomy and drainage were performed, with turbid serosanguineous fluid and no signs of abscess observed intraoperatively. After 1 wk, the patient's level of consciousness decreased (GCS, E3V4M4). Repeat MRI of the head was still consistent with cerebral infarction . However, after communicating with the patient's family, resection of the right brain lesion was performed and tissue was sent for gross pathologic and histologic examination. Findings reported by pathology included purulent brain tissue with visible fungal structures revealed by special staining to be consistent with mucormycosis . On the 10th d after the brain lesion resection, repeat head CT showed a large low-density shadow, and the midline returned to normal .

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+A 37-year-old woman (gravida 3, para 3) with a history of type 2 diabetes presented with the acute onset of difficulty looking downward. She described that this predominantly occurred during driving, noticing that when she looked up into the rear view mirror she was unable to look back down to the dashboard. Other complaints included new daily holocephalic headaches and a 30-pound weight gain over 3 months, without an obvious increase in appetite. She reported fatigue, but no excessive sleepiness. Her medical history was significant for stage IB1 squamous cell carcinoma of the cervix diagnosed 7 years prior to the onset of neurological symptoms. She was treated with a radical hysterectomy and pelvic lymphadenectomy. Pathology revealed a poorly differentiated tumor with a greatest thickness of 1.5 cm and a total cervical thickness of 1.7 cm, and extensive lymphovascular invasion. She received pelvic radiation with weekly cisplatin followed by brachytherapy, and was then lost to follow-up.
+Neurological complaints began approximately 7 years after completing the above-mentioned treatment. Comprehensive neurological examination was normal with the exception of vertical supranuclear gaze palsy with absent voluntary vertical saccades or pursuit. Downward gaze was more affected than upward gaze. Oculocephalic maneuvers showed full ocular range of motion. Horizontal gaze was unaffected. Brain magnetic resonance imaging (MRI) revealed T2 hyperintensities with contrast enhancement of the hypothalami extending into the mesial temporal lobes and midbrain . Significant laboratory studies included an elevated serum alkaline phosphatase level of 138 U/L (normal range, 39-117 U/L) and an erythrocyte sedimentation rate of 21 mm/h. Cerebrospinal fluid (CSF) exhibited a white blood cell count of 15/µL, a red blood cell count of 10/µL, a protein level of 31 mg/dL (normal range, 15-45 mg/dL), and a glucose level of 106 mg/dL (normal range, 40-80 mg/dL). Cytological analysis of the CSF yielded no malignant cells. Commercial paraneoplastic antibody testing revealed that the following antibodies were absent from the serum and CSF: antineuronal nuclear autoantibody types 1, 2, and 3; Purkinje cell cytoplasmic autoantibody types 1, 2, and Tr; amphiphysin; antiglial nuclear antibody type 1; and collapsin response-mediator protein 5 IgG. Serum striational (striated muscle), P/Q-type calcium channel, N-type calcium channel, acetylcholine receptor (neuronal and muscle), and voltage-gated potassium channel antibodies were also absent. Ma antibodies were absent in initial serum and CSF samples evaluated at a separate commercial laboratory using immunoblot testing (reference value: negative). Anti-Ma2 antibodies were eventually found in the serum during an evaluation at an independent laboratory using immunofluorescence (reference value: negative).
+These findings prompted a systemic search for an occult cancer versus a recurrence of her cervical cancer. Positron-emission tomography (PET) and computed tomography (CT) scans revealed enlarged retroperitoneal and common iliac lymph nodes with avid 18-F fluoro-2-deoxyglucose uptake, consistent with an active malignancy . During staging the patient received intravenous corticosteroids (1 g of methylprednisolone per day for 3 days). Her headaches resolved without a significant change in her vertical gaze paresis. She subsequently underwent a retroperitoneal lymph-node biopsy that revealed squamous cell carcinoma, consistent with her known malignancy of the cervix . She was treated with docetaxel and carboplatin along with directed radiation therapy to the involved lymph nodes. Follow-up MRI of the brain revealed significant improvement of the previously observed abnormal contrast enhancement and T2 hyperintensity , although her neurological findings were unchanged. Follow-up PET/CT revealed new metabolically active retroperitoneal lymph nodes. The patient elected to enroll in a phase I study with the multitargeted kinase inhibitor crizotinib. She completed two cycles of the study protocol, with subsequent progression of disease and evidence of new liver and lung metastases. The patient died 3 months later, 1 year after the presentation of neurological deficits. No autopsy was performed.

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+A 64-year old man was referred to our department for right recurrent pleural effusion. A CT scan showed thickened right parietal pleura with a minimal pleural effusion, but no pulmonary nodules or lymphadenopathies or distant metastases. Because of negative cytology malignancy, the patient underwent a thoracoscopic pleural biopsy on December 2004 that showed an epithelioid monophasic pleural mesothelioma, followed by talc pleurodesis at the end of the procedure.
+Three weeks later the patient underwent a right extrapleural pneumonectomy with coverage of the bronchial stump with a flap of thymic tissue. The pathological examination confirmed a monophasic epithelioid pleural mesothelioma, with lung and pericardial fat infiltration, but no invasion of the diaphragm or pericardium (pT3 N0 M0). The postoperative period was uneventful.
+Ten months later the patient complained of a fever and cough. The diagnosis of broncho-pleural fistula was made immediately after the first appearance of cough and fever by bronchoscopy that clearly showed a 2-mm fistula on the mediastinal side of the stump confirmed by the methilene blue passage from bronchus to the chest tube. Rapid fluid drainage and antibiotic therapy allowed us to cure the infection of the pleural space avoiding the formation of empyema. After chest tube drainage, the attempt to conservatively close the fistula using biological glue was unsuccessful. So we decided to use a modified Y Dumon stent (Tracheobronxane Y; Novatech SA, La Ciotat Cedex France) to exclude the right stump. The right arm of the Y was shortened and the open end was closed with a silicone material from which the stent was fabricated, and then inserted in the tracheobronchial tree trough a rigid bronchoscope. The tracheal part was 18 mm in width and 4 cm in length, while the left bronchial arm was 16 mm in width and 2 cm in length. Under rigid bronchoscopy, we first introduced the biological glue (CoSeal, Baxter Healthcare Corporation, Fremont, CA – USA) all over the bronchial stump that was of 1 cm lenght, followed by the insertion of the modified Y Dumon stent .
+The negative cultures from the pleural fluid allowed us to remove the chest drain and to discharge the patient on the 3rd postoperative day. The patient was uneventful (no empyema or pneumonitis verified) until he died 4 months later for pulmonary emboli. The post-mortem examination showed a massive pulmonary thrombus in the left main pulmonary artery which explain the sudden respiratory insufficiency and death at home and an initial relapse of mesothelioma in the posterior part of chest wall, without signs of infections.

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+A 72-year-old Japanese male was transferred to our hospital with mildly impaired consciousness and gait disturbance. He was healthy until the morning of that day, but his wife found him injured in front of his house upon returning home. He had a subcutaneous hematoma in his occipital region, and seemed to have slipped by accident. In our initial evaluation, his Glasgow Coma Scale score was 13 (E3V4M6). He was unable to raise his legs or stand. A neurological examination revealed pure motor paralysis of the legs. There were no sensory disturbances. Manual muscle testing revealed scores of 5/5 for the upper limbs. However, these scores were 0/5 for the bilateral iliopsoas, tibialis anterior and tibialis posterior, 3/5 for both adductors and hamstrings, and 1/5 for both quadriceps femoris. Deep tendon jerks in both the lower and upper limbs were slightly diminished and without laterality. No significantly abnormal laboratory findings, including hypokalemia or an inflammation response, were noted in a general blood exam. Computed tomography (CT) of the brain revealed a subarachnoid hemorrhage, subdural hematoma, and contusions in his basal frontal lobes and superior frontoparietal lobes [Figure and ]. Magnetic resonance imaging (MRI) of his spine revealed cervical spinal canal stenosis and lumbar spondylolisthesis; however, these lesions could not account for the pure motor paralysis of both legs . Further brain MRI investigations were performed. Axial T2*-weighted MRI revealed contusions in both basal frontal lobes and bilateral parasagittal regions . Axial, coronal, and sagittal fluid-attenuated inversion recovery (FLAIR) MRI images clearly demonstrated white matter lesions in the bilateral precentral gyri [Figures and ]. He exhibited pure motor paralysis of both legs without sensory disturbances, such as paraesthesia, and the lesions of the bilateral precentral gyri accounted for this symptom. We concluded that the cerebral contusions caused the paraplegia because his pure motor paralysis occurred rapidly, and he had a subcutaneous hematoma in his occipital region. He was treated conservatively. The deep tendon reflexes of lower extremities increased during hospitalization. He received rehabilitation, but apathy and executive dysfunction slowed improvements in his gait. At 2 weeks after hospitalization, he was able to raise his knees. Coronal and axial FLAIR MRI image at that time revealed areas of high intensity in bilateral precentral gyri that were broader than those observed on the initial MRI [Figures and ]. As rehabilitation continued, his consciousness improved modestly, and the paraplegia also gradually improved. At 7 weeks after hospitalization, manual muscle testing of his lower limbs revealed improvements to almost 4/5 in both legs. He received gait training and was able to walk approximately 20 m with a walker. At this time, the total size of the lesion on FLAIR MRI was significantly reduced [Figures and ]. He was discharged to a subacute rehabilitation hospital 8 weeks after hospitalization.

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+A 38-year-old female underwent a medical check-up at our institution. The patient’s medical profile had no history of weight loss, anorexia, or weakness. She had had a splenectomy 20 years prior for traumatic splenic rupture. Laboratory tests, including complete blood count, liver function test, and alpha-fetoprotein levels, were within the normal range. An abdominal CT scan without contrast enhancement revealed the absence of a normal spleen, with a homogeneous mass situated at the site (A and B). The mass exhibited heterogenous enhancement in the arterial phase (C), but homogeneous enhancement in the venous phase (D). The mass was suspected to have originated from the pancreas tail (A and C). There was no fat stranding surrounding the mass . Coronal CT image revealed that this mass compressed the left renal (A). The mass was fed by several branches of the splenic artery (B). An abdominal MRI was performed. This confirmed that the mass was located in the normal site of spleen and compressed the left kidney (A) and that the mass was round, with well-defined borders and without fat stranding. The mass presented as hyperintense compared to liver parenchyma on T2-weighted image (B). T1-weighted images showed that the mass was hypointense compared with liver parenchyma and did not lose signal on T1 out-of-phase images . Part of the mass was suspected to be connected to the pancreas tail (A and C). T1-weighted image in the arterial phase revealed that the mass enhanced markedly and inhomogeneously (A). The normal left adrenal gland was observed clearly (B). The mass exhibited homogeneous enhancement in the venous phase (C). It was clear that the mass showed restricted diffusion, since it was hyperintense on diffusion-weighted image (DWI) and had hypointense apparent diffusion coefficient (ADC) values on an ADC map compared to liver parenchyma . The preoperative diagnosis was a tumor of the pancreas tail. The patient underwent an operation to remove the mass by a general surgeon with 10-year experience. Histopathology showed white and red pulps, as well as connective tissue that presented within the mass as trabeculae that carry the arteries and veins (A). The white pulps included periarterial lymphatic sheath, lymphatic follicles, and the marginal zone (B). It was surrounded by a capsule composed of dense fibrous tissue (C). The lymphatic follicles contained benign lymphocytes (D). Histopathology of the mass revealed the appearance of a spleen parenchyma. The final diagnosis was an enlargement of AS after splenectomy. This patient was discharged from the hospital 4 days after surgery without further complications or treatment. The patient was lost to follow-up later. This case was reported in line with the SCARE 2020 criteria .