{"generated_text": "A 20‑year‑old woman had been followed since age eight for idiopathic nephrotic syndrome (NS) inaugurated by cerebral venous thrombosis extended to the right jugular vein with a massive pulmonary embolism, without sequelae and without personal or family thrombotic history. Kidney biopsy was deferred because there was no kidney failure, gross hematuria, hypertension, or extra‑renal signs suggestive of secondary NS at presentation. She was treated with an oral vitamin K antagonist and oral corticosteroids with good evolution. Subsequently, she had multiple steroid‑dependent relapses and was started on mycophenolate mofetil (MMF) as background therapy to spare corticosteroids and ensure normal growth. An exhaustive thrombophilia assessment was negative: homocysteine, fibrinogen, protein C, protein S, antithrombin III, factor V Leiden, JAK‑2, cryoglobulins, anticardiolipin antibodies, lupus anticoagulant, and anti‑β2‑glycoprotein I antibodies were all normal. Anticoagulation was stopped after nine years. Several relapses occurred but were controlled with oral corticosteroids. NS remission was documented from 2017; MMF was gradually discontinued in 2019, and she remained asymptomatic without relapse.\n\nOne year later, she presented to the emergency department with acute intense diffuse abdominal pain without irradiation, associated with postprandial vomiting and bilateral lower‑limb edema for six hours. Examination showed intense epigastric tenderness with normal vital signs (BP 120/70 mm Hg, HR 83 bpm, SpO2 100% on room air) and no fever or neurological impairment. Urinalysis detected proteinuria. Hemogasanalysis showed metabolic acidosis with respiratory compensation. Labs revealed hypoalbuminemia, hypercholesterolemia, prothrombin time 90%, elevated D‑dimer, LDH, and creatine phosphokinase, with inflammatory markers (CRP 37 mg/L) and leukocytosis (26.4 × 10^3/µL); renal and liver function were normal. Urgent abdominal ultrasound showed a low‑to‑moderate intra‑abdominal effusion. Contrast‑enhanced CT demonstrated acute thrombosis of the superior mesenteric artery with acute mesenteric ischemia. She underwent emergency laparotomy: intraoperative exploration confirmed mesenteric ischemia with extensive necrosis of almost the entire small bowel, rendering resection incompatible with life. She died 48 hours later.\n\nThis case illustrates catastrophic arterial thrombosis in the setting of NS despite a negative thrombophilia work‑up. NS is a hypercoagulable state with multifactorial mechanisms, including urinary loss of anticoagulant proteins (e.g., antithrombin III, protein S), increased fibrinogen, hemoconcentration, dyslipidemia, and systemic inflammation. While venous thromboembolism is more common in NS, superior mesenteric artery thrombosis is rare but often fatal, underscoring the need for high clinical suspicion and rapid imaging when severe acute abdominal pain occurs in patients with active or relapsing NS.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 65-year-old man developed persistent swelling and a boutonniere deformity of the right middle finger after a motorcycle fall six months earlier. He could not fully extend the finger. On exam, the finger showed edema with flexion at the proximal interphalangeal (PIP) joint and hyperextension at the distal interphalangeal (DIP) joint. Active PIP range of motion (ROM) was 45–110 degrees. X‑rays of the right hand (AP/oblique) showed no bone injury, indicating a soft-tissue problem consistent with a central slip injury. The patient underwent reconstruction of the central slip using a partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. A PIP extension splint was used for 2 weeks. Active and passive PIP ROM exercises began after 2 weeks. One month after surgery, PIP ROM improved to 0–90 degrees, and by 2 months it returned to normal. Hand function, measured by the DASH score, improved markedly from 50 to 4.2.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "We report a unique case of a 13-year-old boy who presented with a palpable, painless mass in the left inguinal (groin) area and no other constitutional symptoms. His medical history included prior spinal surgery with resulting immobility and a pressure sore on the left foot, but otherwise he was well. Routine blood tests were normal except for a very high erythrocyte sedimentation rate (ESR 119 mm/h), and CT scans of the chest, abdomen and pelvis showed enlarged lymph nodes below the inguinal ligament, the largest about 3.5 × 2.4 cm. Because imaging and blood tests could not rule out malignancy (for example lymphoma or leukemia), the enlarged nodes were surgically removed for definitive diagnosis. Pathology showed features consistent with unicentric Castleman disease, plasma-cell type — one of the rarest forms in children and, to our knowledge, the first reported unicentric Castleman case in the inguinal area. The patient was discharged after 14 days with a course of oral prednisolone and was followed with clinical exams, laboratory tests and whole-body CT scans every three months. After 12 months of follow-up there were no new symptoms, no new enlarged lymph nodes on exam or imaging, and no abnormal laboratory findings.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 40-year-old HIV-positive man with reported regular ART adherence (prior year viral load 4,500 and CD4 70/mm3) presented with a two-year history of intermittent, noncyclical febrile episodes that transiently responded to NSAIDs. Over the preceding two months, he developed progressive, diffuse abdominal pain and generalized adenomegaly. Laboratory evaluation showed pancytopenia, coagulopathy, hypoalbuminemia, and elevated acute phase reactants. Initial CT of the thorax, abdomen, and pelvis demonstrated hepatosplenomegaly and generalized adenomegaly without additional parenchymal findings. A broad microbiologic workup was undertaken, including mycobacterial cultures from multiple specimen types; all were negative except an RT-PCR positive for HHV-8. Excisional biopsy of a left iliac lymph node showed features consistent with Castleman’s disease. Despite reinitiating antiretroviral therapy, clinical status deteriorated, prompting initiation of corticosteroids and ganciclovir. After approximately one week, the patient developed multiorgan failure with anasarca, rendering the instituted therapies contraindicated and necessitating discontinuation. Repeat chest CT revealed right upper lobe tree-in-bud infiltrates with bilateral pleural effusions. Concurrent abdominal imaging showed progression of hepatosplenomegaly and new-onset ascites. Forty-eight hours later, he developed fulminant hepatic failure and was transferred to the intensive care unit. He expired within hours. Tracheal aspirate culture, finalized postmortem, grew Mycobacterium tuberculosis. A percutaneous liver biopsy performed with transfusion support demonstrated non-necrotizing granulomas with otherwise preserved parenchyma. The case management and reporting adhered to the ethical principles of the WHO/Declaration of Helsinki.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 77-year-old man has memory and thinking problems. He had a big seizure. Both hip joints popped inward into the pelvis. In the emergency room, his right leg looked shorter than the left. Both legs were turned outward. Both hips were stuck when staff gently rolled his legs. Scans and medical checks were done to get him ready for surgery. The surgeries were done in two steps. The left hip was done on day 8. The right hip was done on day 15. In both surgeries, doctors put in a support ring and a special hip socket that helps keep the joint stable. They also put in a new thigh-bone piece that does not use cement. Right after surgery, there were no problems from the operation. At 12 months, he could put full weight on his legs. His right hip score was 77. His left hip score was 79. His WOMAC score was 12. He has had no problems since the surgery.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 16-year-old girl has a depressed gray plaque on the lower outer (lateral) part of her left thigh, about 10.5 × 8.0 cm. The area includes lighter patches and small dilated surface blood vessels (telangiectasias) around the edges, and some nearby veins are visible. The lesion has been present since birth—it was initially purplish (violaceous) and over the years became lighter and sunken. There is no difference in leg length. Vascular imaging (angioresonance) shows a vascular malformation involving the skin and the fat under the skin in that area, supplied by branches of the popliteal artery. The scan showed early filling of veins, which suggests early venous shunting; no markedly dilated draining veins were found except for a superficial draining vein along the front of the thigh. The subcutaneous tissue beneath the plaque is thinner, and there is no extension into muscle or bone.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A.P. is a 38‑year‑old woman. At age 17, her heart became big and weak. This may have started after a bad throat infection.\nShe stayed in the hospital for 10 months and 10 days. She was very sick and waiting for a new heart. Her heart rhythm was not dangerously abnormal. Her heart’s pump was very weak.\nDoctors treated her heart failure. They also tried to prevent dangerous heart rhythms and blood clots.\nHer heart got better. This kind of recovery happens in about 16 out of 100 people. The better phase lasted 4 years.\nThen the disease got worse for 2 years.\nAfter that, she was stable. She had her first baby, and the pregnancy was normal.\nIn the middle of her second pregnancy, her heart got worse again. It improved a few months after the birth.\nIn May 2017, she was doing well on medicines. These medicines relax blood vessels, slow the heart, help the body get rid of extra water, and slow the heart’s natural pacemaker. She had no limits in daily activity. She is a mother of two. She did not have a job.", "literacy_label": "low_health_literacy"}
{"generated_text": "An 18-year-old man came to the emergency room with new chest pain, fever, and trouble breathing when he lay down. A blood test showed strain on his heart. His heart tracing had changes that can happen when the heart is irritated. His chest X-ray made the heart look bigger than normal. An ultrasound showed the heart muscle was very thick on both sides. It also showed fluid around the heart. Blood tests pointed to a common virus called Coxsackie, which can inflame the sac around the heart. Doctors treated him, but he got worse with shortness of breath and very low blood pressure. A new heart ultrasound showed the fluid was starting to squeeze his heart, like a tight jacket. Doctors drained the fluid, but his heart stopped, and he needed a heart-lung machine to stay alive. A small piece of heart tissue did not show infection. A small skin lump on his right arm was tested. It showed a rare blood cancer linked to the Epstein–Barr virus. He started cancer medicines. His heart pumping got better. The fluid around his heart went away. The thick heart muscle slowly went back toward normal.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 59-year-old woman has multiple sclerosis. She started a new seizure medicine called levetiracetam. A few weeks later, her vision in both eyes became blurry. The eye doctor found swelling in the clear front window of both eyes. A special eye scan confirmed the swelling. They lowered the dose of the new medicine. Her vision started to get better. They then stopped the medicine. Her vision went back to normal. The swelling went away.", "literacy_label": "low_health_literacy"}
{"generated_text": "A baby boy was 4 months old. He lived with his mother in a prison cell. A painful lump grew in his left armpit. A chest X-ray looked like some ribs were broken. Doctors worried he might have been hurt. The pictures also showed a pocket of pus in his armpit, damage to his ribs, a lung infection, and small spots in his lungs. He got strong antibiotics. He went home. When he was 8 months old, he got a fever. The pus spread toward his left shoulder. New chest pictures looked worse. Tests found a mold called Aspergillus fumigatus in the pus. The doctors said he had a serious mold infection. He took a strong antifungal medicine called voriconazole for 28 days. A special blood test showed his germ-fighting cells did not work well. He had a rare immune problem called chronic granulomatous disease. It was caused by a change in a gene called CYBB. His mother carried this gene change. When he was 12 months old, the mold infection came back. The treatments did not work. He died.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 40-year-old man has HIV and takes his medicines regularly. For two years, he had fevers that came and went. In the last two months, he also had spreading belly pain and many swollen glands. Blood tests showed very low blood cells, blood that did not clot well, low blood protein, and strong signs of inflammation. A body scan showed a big liver and spleen and many swollen glands. Many germ tests were done and were negative, except one that found the HHV-8 virus. A gland sample showed a rare illness called Castleman’s disease. Even after restarting his HIV drugs, he got worse. Doctors tried steroids and an antiviral called ganciclovir. A week later, many organs started to fail and he swelled all over, so those drugs had to be stopped. A new chest scan showed small branch-like spots in the right lung and fluid around both lungs. The belly scan showed the liver and spleen got bigger and there was fluid in the belly. He went to intensive care because his liver suddenly failed. He died soon after. After his death, a lung sample grew tuberculosis. A liver sample showed tiny immune lumps called granulomas.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 15-year-old male with no prior surgeries developed four days of abdominal pain and vomiting. CT suggested a small-bowel obstruction from an internal hernia through the foramen (hiatus) of Winslow, an opening behind the stomach. He underwent urgent surgery that began as a diagnostic laparoscopy but was converted to a supraumbilical midline laparotomy because the view was poor. The surgeons reduced a herniated ileal loop; the bowel looked viable, so no resection was needed. They did not perform a preventive maneuver to lower the risk of recurrence. After surgery, he developed a pelvic fluid collection that was managed with antibiotics alone. He is currently followed in the outpatient pediatric surgery clinic.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 19‑month‑old boy went to the emergency room because he hit his head. Doctors saw that he was fighting to breathe. They put in a breathing tube to help him. The team believed the breathing problem likely started first. It may have made him less alert, and then he fell and hit his head. Scans showed the left lung was not filling with air, like a balloon that stays flat. This made doctors think something was stuck in his airway. A CT scan showed a sudden stop in the main airway to the left lung. Doctors used a small camera to look inside. They found and removed a 2‑cm almond that was blocking the airway.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 42-year-old woman with primary cough headache (PCH) could not tolerate oral preventive medicines because of side effects. She developed more than ten short, severe headache attacks a day after a bout of bronchitis; each attack lasted about 30 minutes, was triggered by coughing, straining or lifting, and reached 9/10 on a pain scale. Neurological exam and brain and neck imaging were normal, and she declined a lumbar puncture. Because she could not keep taking indomethacin and could not use other oral options, we offered an ultrasound-guided proximal greater occipital nerve block (PGONB) using bupivacaine. After a single, unilateral block the pain fell from 9/10 to 2/10 within 20 minutes. The block was repeated once weekly for a month; at two months both the number of attacks and their intensity had declined (about two attacks per month at 4/10), and by six months she reported no attacks. No adverse effects from the nerve blocks were observed, suggesting ultrasound-guided GON blockade can be an effective option when oral drugs are not tolerated.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 77-year-old woman was admitted with haematemesis. CT scans showed that the third part of her duodenum bent sharply on the right side of the aorta and ran downward without crossing in front of it; the duodenojejunal junction and much of the jejunum were located on the right side of the abdomen. Upper GI endoscopy found a mucosal tear at the gastric cardia consistent with Mallory–Weiss syndrome. Seven days after the first scan the abnormal right-sided position resolved on CT, but two months later the patient had another episode of haematemesis and the duodenojejunal junction and jejunum had again shifted to the right. Because the small bowel moved back and forth rather than staying in the wrong position, true intestinal malrotation was considered unlikely. The working diagnosis was dysplasia (abnormal development) of the ligament of Treitz, meaning the ligament that normally helps fix the upper small intestine was not holding the jejunum securely. At laparotomy the ligament of Treitz was present but did not fully fix the upper jejunum to the back wall of the abdomen (retroperitoneum); the pararenal area also appeared loosely fixed and mobile on CT. These factors probably allowed the jejunum to fold and deviate to the right. Surgically the upper jejunum was tacked to the left retroperitoneum with sutures, the postoperative course was good, and the patient has remained symptom-free.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 10-year-old boy was getting cancer medicine for leukemia. During the first phase of treatment, he got a pocket of infection in his brain. The germ was called Bacillus cereus. Doctors found it with brain scans and by testing the fluid around his brain and spine. He got better after taking antibiotics.", "literacy_label": "low_health_literacy"}
{"generated_text": "This is the story of a 35-year-old man with a rare condition called Carney syndrome. This condition led to a growth in his heart (a myxoma) and made his heart large and weak (dilated cardiomyopathy). Three years ago, he went to the hospital for sudden chest tightness and shortness of breath. Heart pictures showed the growth. Exams and genetic tests confirmed Carney syndrome. His symptoms got better with medicines, and he went home. No surgery was done then. Later, his chest tightness and shortness of breath got much worse. Doctors said he had very severe heart failure. Tests showed the weak, enlarged heart was still there along with the heart growth. He received a heart transplant. The transplant successfully treated his heart failure.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 12-year-old boy with Down Syndrome and motoric disorders (diagnosed with myeloradiculopathy) was referred from Pediatrics to the Oral Medicine Department (RS Hasan Sadikin Bandung) for oral evaluation. The mother reported hospitalization for weakness of both hands and feet and difficulty maintaining the child’s oral hygiene; there was a history of a fall approximately one year prior. Extraoral findings: dysmorphic facies; cracking and desquamation of the vermilion border; cervical collar in place, precluding lymph node assessment. Intraorally, there was an irregular 1×0.7 cm ulcer with an indurated margin and a white‑yellowish base on the right lateral tongue. Additional findings included dentinal caries on tooth 63 and tooth remnants on 55, 62, 74, and 85. The 55 tooth had a sharp cusp causing occlusal trauma to the right lateral tongue. Pediatric dentistry recommended extraction of the upper and lower tooth remnants with subsequent space maintenance. Laboratory data: hyponatremia (Na 130 mEq/L) and relative lymphocytosis (46%). MRI of the cervical spine demonstrated dislocation; the mother provided informed consent for publication. Working diagnoses, based on history, clinical examination, and investigations: chronic traumatic ulcer mimicking OSCC (clinical diagnosis; indurated margin raised concern for oral squamous cell carcinoma), exfoliative cheilitis, reversible pulpitis of 63, and radix gangrene on 55, 62, 74, and 85. The patient had been hospitalized for 4 days and received paracetamol 120 mg/5 mL oral suspension and amoxicillin 125 mg/5 mL oral suspension from Pediatrics. Oral Medicine management included sodium chloride 0.9% solution, 1% povidone‑iodine mouthwash, and petroleum jelly. Caregiver instructions: cleanse the oral cavity with gauze soaked in 0.9% saline; apply 1% povidone‑iodine compresses to the ulcer three times daily as an antiseptic/anti‑inflammatory; apply petroleum jelly to moisturize the lips. Extractions of 55, 62, 74, and 85 were advised. Follow-up: at 3 days, oral lesions showed improvement; at 1 week, the lateral tongue ulcer decreased in size and lip lesions improved; at 10 days, the ulcer showed significant improvement. Two days later, the patient underwent neurosurgery and was observed in the Pediatric ICU. After two weeks in the ICU, he developed respiratory failure and died.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 13-year-old boy presented with acute pleuritic chest pain but no other systemic symptoms. On exam, he had diminished breath sounds over the lower two thirds of the chest, and his oxygen saturation was normal (98% on room air). Chest X-ray showed a marked interstitial infiltrate similar to an image taken 4 years earlier during an illness treated presumptively with azithromycin. Chest CT demonstrated multiple bilateral ground-glass opacities with areas of “crazy paving,” involving more than 65% of the lung, which raised concern for pulmonary alveolar proteinosis (PAP). Respiratory viral testing, including SARS-CoV-2, was negative. Bronchoalveolar lavage yielded milky fluid with positive periodic acid–Schiff staining. Pulmonary function testing showed a mild restrictive pattern (FVC 77%) and a moderately reduced diffusing capacity (DLCO 48.6%). A genetic panel found no mutations linked to surfactant dysfunction. Anti–GM-CSF antibodies were strongly positive, supporting autoimmune PAP. At 20 months, he remains asymptomatic, and spirometry has normalized.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 28-year-old male with no significant past medical history presented with a 48-hour history of two erythematous plaques with central vesicles and superficial ulceration on the flexor surface of the right arm and forearm, equidistant from the antecubital crease, associated with burning and pruritus. He denied systemic symptoms and had not self-medicated. He reported being on vacation in coastal Ecuador at the time of onset. Incisional biopsy demonstrated epidermal acanthosis, parakeratosis, and spongiosis, neutrophils within the stratum corneum, and perivascular lymphocytic infiltrates in the superficial, mid, and deep dermis. Integrating the clinical morphology, tropical travel history, and histopathology, the diagnosis of Paederus dermatitis was made. Management included antihistamines, topical corticosteroids, and cold compresses. By day 8, the eruption resolved, with residual post-inflammatory hyperpigmentation. Paederus dermatitis is an irritant contact dermatitis due to exposure to Paederus species toxin (pederin), typically producing burning, vesiculation, and superficial erosions; the histologic pattern here (spongiotic dermatitis with mixed inflammatory infiltrates) is consistent with this mechanism.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "This 69-year-old man had heart bypass surgery in the past. For 2 months, he got very short of breath with light activity. Tests—a heart tracing, a blood test, and an X-ray movie with dye of the heart arteries—showed heart failure from poor blood flow after a bypass vein to the right heart artery failed. Doctors first opened a totally blocked artery on the left side of his heart. Then they used tiny natural detours between heart arteries to reach the right heart artery from the far end and open it. His breathing was better when he left the hospital. Six months later, his shortness of breath had not come back.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 12-year-old boy with Down Syndrome and movement problems went to the mouth doctor. His face looked different. His lips were very dry. The doctor could not feel the neck glands because he wore a neck brace. Inside his mouth, there was a sore on the right side of his tongue. It was about 1 by 0.7 centimeters. The edge felt hard. The bottom looked white-yellow. A sharp baby tooth kept rubbing and biting that spot on his tongue. This made a long-lasting injury sore that can look like mouth cancer, but it was from repeated rubbing. The team gave 0.9% salt-water solution, 1% iodine mouthwash, and petroleum jelly for his lips.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 36-year-old woman had trouble swallowing. Tests found she was born with an unusual shape of the main body artery in her chest. The artery curves to the right in a mirror-image pattern. It wraps around a main branch of the airway. The side branches of the artery come off in the reverse order from normal. Most people with this have no symptoms. Problems happen only if the artery squeezes the space in the middle of the chest. This can press on the food pipe or the windpipe. Surgery may be needed if there is strong pressure on these tubes, a bulge or a tear in the chest artery, or a pouch on the artery bigger than 2 cm. There is no one-size-fits-all treatment. Care is tailored to the person’s symptoms and body anatomy. This patient did not receive any treatment.", "literacy_label": "low_health_literacy"}
{"generated_text": "A male infant was delivered at 40 weeks via emergency cesarean section for fetal distress to a 33-year-old G1P1 mother. Family history was negative for congenital anomalies, aortic disease, or sudden death. Prenatal imaging showed advanced femur length (by 1–3 weeks), cardiomegaly with a cardiothoracic circumference ratio ≥0.5, an enlarged foramen ovale, and left aortic constriction near the subclavian artery basin; no other anomalies were noted. Birth measurements: 3560 g (75th percentile), length 56.5 cm (>90th), head circumference 36 cm (>90th). Apgars were 4 and 6 at 1 and 5 minutes. In the delivery room he had no spontaneous respirations, bradycardia, and cyanosis, prompting NICU admission. Physical exam revealed multiple musculoskeletal and craniofacial anomalies: severe arachnodactyly and camptodactyly of all extremities with flat soles; elbow and knee contractures; malar hypoplasia with senile facial appearance; deep-set eyes with down-slanting palpebral fissures; hypoplastic, crumpled auricular cartilage; sagging mouth; prominent coronal suture; and brachycephaly. A grade V/VI systolic murmur was audible at both upper sternal borders and the left lower sternal border with a grade III parasternal heave. The Ghent systemic score for musculoskeletal features was 11. Echocardiography demonstrated poor contractility, severe pulmonary hypertension, a dilated aortic sinus measuring 20.2 mm (Z-score 8.08 Boston, 6.37 Detroit, 5.97 Halifax), and multivalvular prolapse with dysfunction: moderate aortic regurgitation, severe mitral regurgitation, moderate tricuspid regurgitation, and moderate pulmonary valve regurgitation. Ophthalmology confirmed bilateral ectopia lentis with lens subluxation. Abdominal radiography and ultrasound identified liver herniation.\n\nMolecular testing (Sanger sequencing/PCR) of FBN1 detected a heterozygous donor splice-site variant, c.3964+1G>T in intron 32, classified as likely pathogenic per the 2015 ACMG/AMP guideline. The variant resides within the established neonatal region of FBN1 (exons 24–32) associated with the severe neonatal Marfan phenotype. Mechanistically, splice-site variants at this locus are expected to disrupt normal FBN1 splicing, compromising microfibril integrity and driving the aggressive cardiovascular phenotype observed in neonatal MFS (notably early aortic root dilation and severe atrioventricular valve regurgitation).\n\nOn day 1, he exhibited differential cyanosis with refractory hypoxemia despite >60% oxygen and clinical signs of low cardiac output. Medical management targeted afterload reduction (continuous milrinone infusion), full sedation (continuous fentanyl infusion), and diuresis to address oliguria and heart failure. Despite these measures, he progressed to respiratory failure and severe pulmonary hypertension requiring continuous invasive mechanical ventilation. Aortic and mitral regurgitation worsened, pulmonary hypertension escalated, and cardiac contractility deteriorated. Given the grave trajectory and the expectation that surgical intervention would be essential to prolong life but with limited prospects in the face of rapid progression, the family elected palliative care after multidisciplinary discussions. He developed hepatic and pulmonary congestion with pulmonary hemorrhage, progressed to multiple organ dysfunction syndrome, and died 32 days after birth.\n\nThis case documents a novel FBN1 c.3964+1G>T splice-site variant in the neonatal region, concordant with the classic neonatal MFS phenotype: severe early valvulopathy, aortic root dilation, ectopia lentis, characteristic skeletal/craniodysmorphic features, and a fulminant cardiorespiratory course with death in early infancy.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 22-year-old woman presented with a month of painful stomatitis that made eating and drinking difficult. The illness began with a fever and pimple-like lesions on the lips. She had been vaping regularly for about one year. Examination showed no skin lesions elsewhere. The lips had serosanguineous crusts and erosions at the labial commissures that tended to bleed. Intraorally, there were multiple irregular white ulcers with yellowish borders on several sites of the oral mucosa. Anti–HSV-1 IgG was non-reactive. The diagnosis was oral erythema multiforme, likely related to vaping. Management included normal saline compresses to the lips, a dexamethasone mouth rinse mixed with hyaluronic acid, 2% miconazole cream applied to the lip corner, petroleum jelly for dry lips, and stopping vaping. Her oral condition improved within one week.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 19-year-old woman came to the emergency department with a dangerous arrhythmia and signs that her heart was failing to pump well (cardiogenic shock). An ECG ruled out an acute heart attack, and cardiac MRI did not show cardiomyopathy. Because a hidden congenital issue was suspected, she underwent cardiac CT angiography. The scan showed ostial atresia of the right coronary artery—the opening of the right coronary artery was absent. She was referred to a specialized congenital heart disease center. An electrophysiology study pinpointed the arrhythmia to the posteromedial papillary muscle, and the focus was treated with catheter ablation. She has remained symptom-free since.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A term newborn boy had neonatal Marfan syndrome with severe heart involvement. He showed typical features: very long fingers and toes (arachnodactyly), bent fingers and toes (camptodactyly), elbow and knee contractures, an aged facial appearance, deep-set downward-slanting eyes, underdeveloped ear cartilage with a sagging mouth, a short-wide head shape (brachycephaly), and ectopia lentis (displaced eye lenses). Genetic testing identified a new FBN1 mutation affecting a splice site (c.3964+1G>T in intron 32) within the known neonatal region (exons 24–32). He developed low cardiac output due to severe mitral and aortic regurgitation and also had pulmonary hypertension. Medical management focused on afterload reduction, deep sedation to lessen cardiac work, and diuretics to treat fluid overload and low urine output. Despite treatment, the valve regurgitation, pulmonary hypertension, and poor heart pumping worsened. Surgery would likely have been required to extend survival, but given the rapid and grave progression, the family chose palliative care. Within a few months after birth, he experienced rapidly progressive heart failure and died.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 65-year-old male presented with six months of swelling and boutonniere deformity of the right digit III following a motorcycle accident on January 1, 2023. He initially self-managed with analgesics and did not seek care. He reported inability to fully extend the right middle finger. Examination demonstrated edema and a boutonniere posture (PIP flexion, DIP hyperextension). Active PIP ROM was 45–110 degrees, with passive PIP ROM within normal limits. Radiographs of the right hand (AP/lateral) revealed no osseous pathology, supporting a soft-tissue etiology consistent with a central slip injury. \n\nSurgical technique: Central slip defect reconstruction was performed using the partial ulnar slip of the flexor digitorum superficialis (FDS) tendon. Under anesthesia and tourniquet control in the supine position, a midlateral incision was made on the ulnar aspect of the middle phalanx centered at the PIP joint with dorsal oblique extension, and a transverse incision was made over the MCP flexion crease proximal to the A1 pulley. The ulnar digital neurovascular bundle was identified and protected. Full-thickness dorsal flaps were elevated to expose the central slip and extensor mechanism to the PIPJ. Scar and pseudotendinous tissue were excised. The central slip was not amenable to primary repair; therefore, the ulnar slip of the FDS was selected for reconstruction. The ulnar neurovascular bundle was mobilized to visualize the periosteal insertion of the A3 pulley. The extensor tendon was mobilized and tenolyzed; the dorsal PIP capsule was incised with removal of interposed tissue. The A3 pulley periosteal insertion and the volar capsule of the PIP joint were incised longitudinally. A 2–0 non-absorbable monofilament suture was placed around the ulnar FDS slip at the PIP level. Through the proximal incision, the flexor sheath and A1 pulley were incised longitudinally to expose the FDS; the ulnar slip was isolated and transected, preserving the radial slip. The previously placed 2–0 suture facilitated delivery of the distally based ulnar FDS slip distally. A 2.8‑mm dorsal-to-volar bone tunnel was drilled at the base of the middle phalanx; an elevator protected the FDP, volar plate, and volar structures. With the PIP reduced in full extension, the FDS slip was passed through the tunnel and routed through the intact proximal segment of the central slip/extensor tendon. A tendon weaver completed a Pulvertaft weave under appropriate tension with the PIP in full extension and reduction, secured with 3–0 non-absorbable suture. The capsule and central slip reconstruction margins were approximated; adhesions were released and lateral bands mobilized. Tenodesis effect, posture, stability, and motion were assessed. Wounds were irrigated, the tourniquet deflated, hemostasis obtained, and capillary refill confirmed. Skin was closed with horizontal mattress sutures. A sterile dressing and a well-padded PIP extension splint were applied to allow early DIP and MCP motion.\n\nPostoperative course: First wound check at postoperative day 4; the patient received meloxicam 7.5 mg PO BID and doxycycline 100 mg PO BID for 3 days. A second wound visit occurred 3 days later. At 2 weeks, the back slab and external sutures were removed, and active and passive PIP ROM exercises were initiated. By 3 weeks, the wound had healed and PIP ROM was 0–90 degrees. At 1 month, PIP ROM improved to 0–100 degrees, with continued functional gains. After 7 weeks of rehabilitation, he returned to work with PIP ROM 0–110 degrees. Overall function improved substantially, with the DASH score decreasing from 50 to 4.2.\n\nInterpretation: Clinical and radiographic findings were concordant with a chronic central slip injury producing boutonniere deformity (PIP flexion, DIP hyperextension due to dorsal apparatus disruption and volar migration of lateral bands). Reconstruction using an ulnar FDS slip via bone tunnel and Pulvertaft weave restored PIP extension and yielded progressive ROM gains and marked functional recovery.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 39-year-old woman with peripartum cardiomyopathy underwent orthotopic heart transplantation in October 2014. Induction was basiliximab plus methylprednisolone. Maintenance immunosuppression included tacrolimus XL 7 mg daily, everolimus 1 mg twice daily, and prednisolone 5 mg/day. She had two episodes of acute rejection in the first post-transplant year, managed with methylprednisolone pulse therapy. Baseline renal function during year one was normal (creatinine 0.88 mg/dL; eGFR 102 mL/min/1.73m2). Follow-up was by the heart transplant team; routine BK polyomavirus screening (plasma PCR or urine cytology) was not performed.\n\nIn 2016, creatinine rose to 1.9 mg/dL (eGFR 32.6), with tacrolimus trough 7.2 ng/mL and everolimus 5.2 ng/mL. Calcineurin inhibitor toxicity was suspected; tacrolimus was reduced to 4 mg daily, and creatinine improved to 1.25 mg/dL (eGFR 54.1); no biopsy was obtained. In March 2017, creatinine increased to 2.69 mg/dL (eGFR 21.4) without symptoms. Vitals and exam were unremarkable; renal ultrasound showed normal size with increased echogenicity; urinalysis/culture were negative (no hematuria, pyuria, or casts); echocardiogram showed adequate cardiac function; HIV, syphilis, HBV, and HCV serologies were negative. Tacrolimus and everolimus troughs were 5.2 ng/mL and 5.98 ng/mL, respectively. Despite IV hydration and reducing tacrolimus XL to 2 mg daily, renal function did not improve, prompting biopsy.\n\nRenal biopsy demonstrated active chronic interstitial (tubulointerstitial) nephritis associated with advanced polyomavirus nephritis. Plasma BK virus PCR was positive at 33,800 copies/mL (log 4.5). Tacrolimus was discontinued; creatinine stabilized between 2.2 and 2.4 mg/dL with declining BK viremia to undetectable. Over three years, there were no further cardiac rejection episodes. At two years of follow-up from diagnosis of BKVN, renal function was stable with creatinine 2.5 mg/dL (eGFR 23.4 mL/min/1.73m2).\n\nContext: BK polyomavirus nephropathy, while classically described in kidney transplant recipients, can occur in non-renal solid organ transplant recipients under potent immunosuppression. Management centers on reduction of immunosuppression; maintaining an mTOR inhibitor (everolimus) while withdrawing the calcineurin inhibitor can aid viral clearance, at the potential cost of rejection risk, which was not observed here. Plasma BK viral load (log 4.5) plus biopsy-proven late-stage BKVN established the diagnosis and guided therapy.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "We report a 49-year-old woman with end-stage renal disease and advanced heart failure secondary to long-standing systemic lupus erythematosus (SLE, onset at age 13) and lupus nephritis (LN class III, then IV). Childhood LN was treated with steroids plus cyclophosphamide, later transitioned to methotrexate and then azathioprine, achieving partial remission of nephrotic syndrome; she had no immunosuppression after 2002. She was HBV- and HCV-positive. Cardiovascular SLE involvement included early coronary atherosclerosis, ischemic heart disease, and myocardial infarction at age 20. In 2007, with creatinine 2.2 mg/dL and proteinuria 2 g/day, kidney biopsy showed active and sclerotic focal proliferative LN; immunosuppression was withheld due to active HCV replication. Renal function progressively declined. Despite PCI to the RCA, she developed severe post-infarction and dilated cardiomyopathy, requiring primary-prevention ICD implantation in 2009. On a lupus and secondary cardiomyopathic background, she developed severe mitral and tricuspid regurgitation. In 2014 she underwent mitral and tricuspid valve repair and left ventricular volume reduction surgery, complicated by low cardiac output syndrome necessitating intra-aortic balloon pump support. Postoperatively, renal function worsened, prompting initiation of renal replacement therapy; she remained on dialysis for four years.\n\nWhile listed for kidney transplantation, laboratory indices indicated lupus remission (C3 0.93 g/L, C4 0.4 g/L, ANA negative) but persistent circulatory insufficiency with markedly reduced functional capacity (limited to one flight of stairs) and elevated BNP 619 pg/mL (n 0–100). Pre-transplant transthoracic echocardiography demonstrated markedly enlarged LV and LA, severely reduced LV systolic function (LVEF 26%, GLS −3). Mitral ring precluded diastolic assessment. High tricuspid regurgitant flow gradient with a dilated, poorly respiratory mobile IVC suggested high probability of pulmonary hypertension.\n\nGiven the extremely low ejection fraction, cardioprotective therapy with levosimendan (a calcium sensitizer/inodilator) was instituted perioperatively. Due to transplant timing constraints, infusion (0.1 μg/kg/min) began as soon as crossmatch results were available, immediately post-dialysis, and was continued through the operation for a total of 24 h. Anesthetic management prioritized optimization of allograft perfusion, avoidance of nephrotoxins and renally excreted agents, and use of nephroprotective measures. Because of recurrent extrasystoles with prior decompensation and the need to deactivate the ICD during transplantation, a Swan-Ganz catheter was not placed. Monitoring included ECG, central venous catheter with CVP, invasive arterial blood pressure via radial arterial cannula, and cardiac ultrasound. CVP guided intravascular volume during anesthesia, and postoperative assessments incorporated focused cardiac ultrasound with IVC diameter and respirophasic variability. Fluid management followed a Goal Directed Therapy paradigm. Agents included fentanyl, triacrium, propofol, desflurane, antibiotic prophylaxis, standard immunosuppression, mannitol 25 g for nephroprotection, and 0.9% NaCl for fluid therapy.\n\nPostoperatively, immunosuppression comprised steroids and tacrolimus; mycophenolate mofetil was discontinued due to persistent leukopenia and cytomegalovirus infection. Delayed graft function occurred, necessitating hemodialysis for almost six weeks (largely due to fluid retention). BNP rose to 2996 pg/mL and then gradually declined. Allograft biopsy at postoperative week two revealed acute rejection (AR II B, Banff 2015) with acute tubular necrosis. She was discharged on postoperative day 67 with serum creatinine 1.4 mg/dL and BNP 1794 pg/mL.\n\nAt one month post-transplant, echocardiography showed reduced LV dimensions and improved systolic performance (EF increased to 30%, GLS to −6). Tricuspid regurgitant gradient decreased, and IVC caliber and respirophasic motion normalized, indicating low probability of pulmonary hypertension. Functional status improved from NYHA III/IV to NYHA II. At five months, there was continued cardiac improvement with BNP down to 1066 pg/mL and normalization of renal function. Overall, despite a nontrivial postoperative course, perioperative levosimendan support and tailored hemodynamic and nephroprotective strategies were associated with successful kidney transplantation, progressive recovery of LV function, and stable, normal allograft function at short-term follow-up.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 51-year-old man came to us with sudden, painful vision loss in his left eye for three days. His right eye could see clearly (20/20). His left eye could only see hand movements. The back of his left eye showed swelling of the seeing nerve, a bulge in the layer under the retina, several patches of fluid under the retina, and wrinkles in the thin lining there. An MRI scan with contrast dye of the eyes and brain showed a small lump behind the eye where the eye nerve meets the white part of the eye. Tests for cancer and immune diseases were normal. The doctors diagnosed inflammation in the back part of the eye’s white coat that forms a small lump (nodular posterior scleritis). They started high-dose steroid pills by mouth (prednisolone).", "literacy_label": "low_health_literacy"}
{"generated_text": "A 19-year-old woman went to the emergency room. Her heart was beating fast and uneven. Her body showed signs that her heart was not pumping enough blood. A heart tracing test showed she was not having a heart attack. A heart MRI did not show a disease of the heart muscle. A special heart CT scan then looked at her heart arteries. It showed the normal opening to her right heart artery was missing from birth. She was sent to a center that treats heart problems people are born with. Doctors did an electrical test inside her heart. They found a small hot spot on a tiny muscle that helps a heart valve. That spot was starting the bad rhythm, like a faulty spark. The team gently burned that spot to stop it. She has had no symptoms since.", "literacy_label": "low_health_literacy"}
{"generated_text": "This story is about a 49-year-old woman who had lupus for many years. Over time, her kidneys and her heart got weaker. She needed dialysis to do the work of her kidneys for 4 years until she could get a kidney transplant. Her heart pump was very weak before surgery. To help her heart get through the operation, doctors gave her a heart-helping medicine called levosimendan. The time after surgery had some ups and downs. But she got through it. At about one month after surgery, her heart started to work better, and her new kidney worked normally. At about five months, her heart kept improving, and her kidney function stayed normal.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 10-year-old boy receiving chemotherapy for acute lymphoblastic leukemia developed a brain abscess during induction therapy. He had a severe headache, and brain scans (CT/MRI) showed lesions that looked like an infection. Tests on his spinal fluid directly detected Bacillus cereus, confirming the cause. He was treated with antibiotics (such as meropenem and vancomycin). His symptoms resolved, follow-up imaging showed the abscess shrinking, and he recovered well.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 28-year-old Moroccan man developed about a month of liver-area pain along with fever, night sweats, and weight loss, which are symptoms that can suggest tuberculosis. CT and MRI showed multiple non-specific nodules in the liver. An initial needle biopsy was not conclusive, so doctors performed a laparoscopy to obtain better tissue samples. Pathology showed granulomas with caseous necrosis, confirming focal hepatic tuberculosis. He started standard anti-tuberculosis therapy: two months of four drugs, then four months of two drugs. He improved quickly, both in how he felt and in his lab results. A follow-up scan at three months showed that the liver nodules were fewer and smaller.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 10-year-old male with high-risk early T-cell acute lymphoblastic leukaemia (initially treated per LAL SEHOP-PETHEMA 2013) experienced an early CNS relapse two years after diagnosis and began InteReALL HR 2010 induction with bortezomib. After four weeks of profound neutropenia (20 neutrophils/µL) on prophylaxis (cefepime, cotrimoxazole, fluconazole) and acyclovir for HSV-1 skin infection, he developed a severe, analgesia-refractory headache. Head CT revealed a right temporal hypodense lesion. Suspecting infection, a lumbar puncture was performed and cefepime was switched to meropenem plus vancomycin. Despite being afebrile, he showed signs of septic shock on day 1 and required PICU admission for inotropic/vasoactive support; antimicrobials were broadened with gentamicin and caspofungin. Inflammatory markers rose (CRP 312 mg/L, procalcitonin 47.58 ng/mL by day 3), with pancytopenia attributable to chemotherapy and no other major biochemical abnormalities. Blood, urine, and fecal cultures were negative; viral serologies were negative. CSF biochemistry was normal (glucose 63 mg/dL; protein 16 mg/dL; leukocytes 1/µL), but microbiology detected Bacillus cereus, susceptible to meropenem, vancomycin, linezolid, and ciprofloxacin; CSF PCR/assays were negative for HSV-1/2, HHV-6, CMV, VZV, enterovirus, parechovirus, Toxoplasma, Neisseria meningitidis, Listeria monocytogenes, Streptococcus pneumoniae, and Cryptococcus. EEG showed diffuse slowing without epileptiform activity. On day 4, once off haemodynamic support, brain MRI demonstrated two T2/FLAIR hyperintense subcortical lesions in the right temporal and parietal lobes; the parietal lesion exhibited ring enhancement post-gadolinium, both lesions had peripheral diffusion restriction, and scattered parenchymal microhaemorrhages were present—an appearance suggestive of bacterial abscess due to an atypical pathogen. Integrating imaging with direct CSF detection established the diagnosis of B. cereus cerebral abscess. After two weeks of therapy, his headache resolved with no focal neurological deficits; interval MRI showed lesion size reduction. Vancomycin and acyclovir were discontinued after three weeks, and meropenem was continued to complete six weeks, with a favourable clinical course.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 16-year-old girl has a sunken, gray patch on her left thigh. A special scan that looks at blood vessels showed a blood vessel problem in the skin and in the layer just under the skin.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 4-year-old boy with metastatic neuroblastoma received intensive treatment, including chemotherapy, an autologous stem cell transplant, and then an allogeneic cord blood transplant. About a month after he developed upper respiratory symptoms and tested positive for RSV, he presented on day 194 post–cord blood transplant with worsening breathing problems and was ultimately diagnosed with pulmonary veno-occlusive disease (PVOD), a rare form of pulmonary hypertension caused by blockage of small lung veins. Lung biopsy not only confirmed PVOD-related changes but also showed lung injury patterns consistent with a recent viral infection. Taken together, the timing of his RSV infection and the biopsy findings suggest RSV may have contributed to the onset of PVOD.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 40-year-old man with HIV on treatment presented with intermittent fevers for two years. Over the prior two months, he developed progressive, diffuse abdominal pain and generalized lymphadenopathy. Laboratory tests showed pancytopenia, coagulopathy, hypoalbuminemia, and elevated inflammatory markers. CT of the chest, abdomen, and pelvis revealed only hepatosplenomegaly and widespread adenopathy. Broad infectious workup, including mycobacterial cultures from multiple specimens, was negative except for a positive HHV-8 RT-PCR. A left iliac lymph node biopsy was consistent with Castleman’s disease. Despite restarting antiretroviral therapy, his condition worsened, so clinicians initiated corticosteroids and ganciclovir. After one week he developed multiorgan failure with anasarca, making those medications unsafe. Repeat chest CT showed right upper lobe tree-in-bud infiltrates with bilateral pleural effusions; abdominal imaging showed worsening hepatosplenomegaly and new ascites. He was transferred to the ICU 48 hours later for fulminant hepatic failure and died shortly afterward. Postmortem testing grew Mycobacterium tuberculosis from a tracheal aspirate, and liver biopsy showed non-necrotizing granulomas.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "Case summary: A 67-year-old woman with a six-year history of recurrent left lower limb swelling presented with one month of progressive dyspnea and fatigue consistent with acute exacerbation of chronic heart failure. She had no prior cardiovascular disease, trauma, or surgery; remote oral estrogen use occurred seven years earlier. Examination showed marked left leg edema, skin sclerosis, absent popliteal and distal pulses, and a palpable thrill/tremor in the left thigh. Echocardiography demonstrated cardiomegaly with moderate mitral regurgitation, severe tricuspid regurgitation, and LVEF 60%. BNP was 2853 ng/L. ECG showed sinus tachycardia (105 bpm) with left atrial enlargement. Chest CT confirmed cardiomegaly without pulmonary parenchymal disease. CTA revealed a left iliac artery aneurysm (max 32 mm), marked dilation of the CFA (27 mm) and SFA (22 mm), complex AVMs centered on the SFA with early opacification of an enlarged femoral vein, and nonvisualization of the popliteal and anterior tibial arteries. She was diagnosed with complex congenital lower-limb AVMs and acute exacerbation of chronic heart failure, NYHA class IV.\n\nRationale and strategy: Preoperative duplex showed CFA volume flow of 3400 ml/min, indicating a high-flow shunt. Given prior coil embolization (two coils, 20 mm x 40 cm) failed to reduce flow or swelling, the team prioritized rapid shunt reduction using a covered stent, with staged embolization to address the nidus. This approach repurposed an abdominal aortic stent graft to reduce AVM inflow and improve cardiac load while limiting operative time in the setting of heart failure.\n\nProcedure details: To minimize access complications in dilated vessels (iliac 32 mm, CFA 27 mm, SFA 22 mm), antegrade surgical exposure of the CFA was performed under general anesthesia, placing a 14 F sheath. Complex AVMs were visualized in the SFA and profunda femoris with early venous filling. Based on a preoperative SFA mid-segment diameter of 19 mm, a 20–12 mm/120 mm aorto-uni-iliac abdominal aortic covered stent graft (MicroPort, China) was advanced over a 0.035 super-stiff wire (after popliteal access with a single-curve catheter) and deployed at the distal SFA to span the highest AVM density. Completion angiography showed marked reduction of peri-stent venous opacification with clear visualization of the popliteal artery. The femoral arteriotomy was closed with 6-0 vascular suture. The patient’s heart failure symptoms improved postoperatively, and a staged embolization was planned to limit procedure time.\n\nSecond stage and outcomes: At one week, CFA flow decreased to 1600 ml/min and BNP to 1198 µg/L. Transvenous embolization targeted the nidus and draining veins via right CFA arterial access (5 F sheath/catheter) and ultrasound-guided puncture of the AVM drainage vein (5 F venous sheath). Embolic materials included one 18–20 mm x 40 cm coil, two microcoils (4 x 42 mm, 5 x 10 mm), 3% polidocanol (6 mL), and 99% anhydrous ethanol (10 mL). Completion angiography demonstrated near-complete disappearance of AVM/shunting. At one year, leg swelling and cardiac function improved substantially: CFA flow was 780 ml/min; echocardiography showed only mild biatrial enlargement, mild mitral and tricuspid regurgitation, and LVEF 71%; BNP declined markedly.\n\nPractical experience and limitations: In very high-flow, complex congenital lower-limb AVMs causing high-output heart failure, coil-only embolization may be insufficient to meaningfully reduce shunt volume. A covered stent can rapidly downregulate inflow and unload the heart, but often requires adjunctive embolization of the nidus and draining veins to consolidate results. Repurposing an abdominal aortic aorto-uni-iliac covered stent in the SFA is technically feasible but off-label, demands large-bore access (14 F) with surgical exposure, and may be limited by vessel size mismatch, landing zone adequacy, and the need to preserve distal perfusion. Staging is advisable in NYHA IV patients to shorten anesthesia time and manage hemodynamics. This case illustrates that an abdominal aortic stent graft coupled with targeted embolization can effectively address acute heart failure driven by complex congenital lower-limb AVMs, while highlighting device-selection and access considerations that may constrain its use.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 12-year-old boy with Down syndrome and motor disorders was referred to the Oral Medicine clinic. On exam he had a dysmorphic face and dry, cracked lips; a cervical collar prevented assessment of his neck lymph nodes. Inside the mouth there was an irregular ulcer on the right lateral border of the tongue measuring about 1 × 0.7 cm, with a firm (indurated) edge and a white-yellow base. A sharp remnant of tooth 55 was causing repeated trauma to that part of the tongue. Based on the history and exam, the team diagnosed a chronic traumatic ulcer that clinically looked like oral squamous cell carcinoma (OSCC). Other dental problems included caries and several tooth remnants (63, 55, 62, 74, 85) that were recommended for extraction and later space maintenance. Blood tests showed low sodium and a mildly raised lymphocyte percentage, and MRI revealed a cervical spine dislocation; the patient later had neurosurgery. Treatment in hospital included paracetamol and amoxicillin, and local oral care from the Oral Medicine team: saline rinses (0.9% sodium chloride), 1% povidone-iodine mouthwash as an antiseptic, and petroleum jelly for the lips. The mother was instructed to clean the mouth with gauze soaked in saline, apply the povidone-iodine compress to the ulcer three times daily, and use petroleum jelly to moisturize the lips. The oral lesions improved over follow-up visits at 3 days, 1 week, and 10 days. After neurosurgery the patient was observed in the pediatric intensive care unit but developed respiratory failure and died.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 25-year-old Sundanese male presented to the Dental Hospital, Faculty of Dentistry, Universitas Padjadjaran with a 4-day history of painful oral ulcerations that appeared intraorally first and extended to the lips 2 days later, exacerbated by eating and speaking. He initially self-treated with petroleum jelly without benefit, then applied triamcinolone acetonide 0.1% in orabase once daily from a pharmacy, with partial but incomplete improvement. One week prior to lesion onset he reported a febrile episode; he also reported heavy workload and approximately 1.5 months of suboptimal nutrition. He denied systemic disease, drug or food allergies, alcohol, and tobacco, but reported frequent lip-licking; childhood varicella was noted.\n\nGeneral examination showed normal vital signs and no lymphadenopathy. Extraoral findings: serosanguineous crusts on the lips that were painful and bled easily. Intraoral findings: irregular, diffuse-bordered erythematous lesions with pain on the upper and lower labial mucosa. Additional findings included a non-scrapable hyperkeratotic white plaque of irregular shape with diffuse borders on the left buccal mucosa near tooth 38; scrapable yellowish-white plaques on the posterior third of the dorsal tongue without underlying erythema; crenated tongue with dental impressions laterally; a painless, hard torus palatinus (~2 × 1 × 0.5 cm) at the hard palate midline; multiple teeth with caries, radix, and edentulous areas; poor oral hygiene.\n\nPsychological assessment (DASS-21): normal depression (0), anxiety (6), and stress (6). Working diagnosis: suspected HAEM, with concurrent findings of coated tongue, frictional keratosis, crenated tongue, torus palatinus, reversible pulpitis (tooth 18), irreversible pulpitis (tooth 47), chronic apical periodontitis et causa radix (tooth 15), and edentulous teeth 28, 37, 36, and 46. Differential diagnosis for the lip lesions included exfoliative cheilitis, which lacks herpesvirus involvement. Serologic testing (IgG anti–HSV-1) was indicated to support the diagnosis. Baseline OHRQoL (OHIP-14) was 35 (moderate).\n\nInitial management combined non-pharmacologic and pharmacologic therapy. Non-pharmacologic: oral hygiene instructions (brush teeth and tongue twice daily with a soft-bristled brush and non-detergent toothpaste), hydrate with ≥2 L water/day, consume a balanced diet, avoid acidic, spicy, hard, and MSG-containing foods, and cease lip-licking and peeling. Pharmacologic: topical lip compresses with 0.9% NaCl at least three times daily and triamcinolone acetonide 0.1% in orabase applied thinly to the lips three times daily; a daily multivitamin was prescribed.\n\nAt 2-day follow-up, pain had decreased though serosanguineous crusts persisted. Serology returned positive for anti–HSV-1 IgG, ratio 6.32 (positive >1.1). A definitive diagnosis of HAEM (herpes-associated erythema multiforme) was established based on history, clinical findings, and serology. Existing therapy was continued, and acyclovir 200 mg orally five times daily for 7 days was added.\n\nAt 5 days after the prior visit, there was significant improvement with excellent healing of all oral lesions. Final OHIP-14 was 4, and physical, psychological, and social conditions normalized after 7 days of treatment. The patient was referred for definitive dental and oral care in periodontics, dental conservation, oral surgery, and prosthodontics. Written informed consent and institutional approval were obtained; the case complies with the Declaration of Helsinki.\n\nContext: HAEM is an immune-mediated mucocutaneous reaction pattern commonly triggered by HSV-1. Positive HSV-1 serology in the appropriate clinical context, together with characteristic labial crusting and diffuse labial mucosal erythema, supports the diagnosis. Management typically combines topical corticosteroids and systemic antiviral therapy, along with supportive oral care and trigger avoidance.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 78-year-old woman enrolled in a community pharmacy personalised dosage system (PDS/SPD) presented at medication pickup reporting several months of asthenia, weakness, dizziness, and confusion, limiting her usual ambulation. There were no new medicines in the SPD register. On-site vitals with an Omron Complete device showed SBP 96 mmHg, DBP 52 mmHg, HR 69 bpm, raising concern for symptomatic hypotension possibly related to her regimen. Her active medications and doses were: doxazosin 2 mg q24h (0-0-1) for hypertension; losartan 100 mg q24h (1-0-0) for hypertension; manidipine 20 mg q24h (0-1-0) for hypertension; simvastatin 40 mg q24h (0-0-1) for hypercholesterolemia; acetylsalicylic acid 100 mg q24h (1-0-0) for secondary prophylaxis; omeprazole 20 mg q24h (1-0-0) for ulcer prevention; pregabalin 100 mg q12h (1-0-1) for neuralgia; torasemide 10 mg q24h (1-0-0) for edema; dulaglutide 1.5 mg weekly; insulin glargine 74 IU q24h (1-0-0); insulin lispro 20 IU q24h (0-1-0) for diabetes; brimonidine 1 drop q12h (1-0-1) for ocular hypertension.\n\nRenal function by CKD-EPI yielded eGFR 30 ml/min/1.73 m2. Dose appropriateness was assessed against product information and a consensus guideline for drug use in renal impairment from the University of Barcelona Faculty of Pharmacy practical pharmacy group (ATC-organised, with overdose symptom summaries and risk stratification by eGFR). Based on eGFR 30 ml/min/1.73 m2, antihypertensive agents losartan and manidipine required dose adjustment; pregabalin also warranted renal dosing, and torasemide was recognised as potentially contributing to low BP. The team prioritised adjusting antihypertensives first and proposed deferring changes to pregabalin until after reassessing response.\n\nIntervention: A report to the primary care physician recommended reducing losartan to 50–75% of standard dose for eGFR 30–59 ml/min/1.73 m2 and adjusting manidipine for eGFR 15–30 ml/min/1.73 m2. The PCP implemented losartan 50 mg q24h and manidipine 10 mg q24h. The PCP also substituted pregabalin 100 mg q12h with gabapentin 300 mg q12h.\n\nFollow-up over two months showed improved BP values and resolution of the initial symptoms. Gabapentin 300 mg q12h was verified as appropriate for eGFR ~30 ml/min/1.73 m2 (recommended total daily dose 300–900 mg for eGFR 30–60). Overall, the case suggests symptomatic hypotension related to cumulative antihypertensive effect in the setting of stage 3b CKD by eGFR, with clinical improvement after renal dose adjustment of losartan and manidipine and subsequent regimen optimisation.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A.P. is a 38‑year‑old woman who developed dilated cardiomyopathy at age 17, likely on the background of infectious myocarditis after a throat infection. She was hospitalized for 10 months and 10 days with severe heart failure and a very low ejection fraction while being evaluated for heart transplantation. There was no clearly dangerous arrhythmia. Treatment focused on heart failure care and on preventing arrhythmias and blood clots.\nHer heart function recovered—a remission seen in about 16% of patients—and that improvement lasted 4 years. She then had a two‑year worsening, followed by several stable years and a normal first pregnancy. During her second pregnancy, she experienced a flare in the second trimester with postpartum dilated cardiomyopathy that lasted a couple of months, then improved.\nAs of May 2017, she was stable on guideline‑based therapy (an ACE inhibitor, a beta‑blocker, diuretics, and an If‑channel blocker), reported no limitation in physical activity, and was a mother of two and unemployed.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 13-year-old male from Cusco with recurrent respiratory papillomatosis (RRP) since age two (tracheostomy at age three) and a maternal history of genital papilloma presented after 16 days of predominantly nocturnal respiratory difficulty, inspiratory laryngeal stridor, and moderate dysphonia. He had previously received azithromycin and supplemental oxygen without improvement. On exam, there was mild subcostal retraction, decreased vesicular breath sounds over the left hemithorax, and scant wheezes predominating on the right; he required 4 L/min oxygen via binasal cannula. Laboratory studies showed WBC 8.03 × 10^3/μL, platelets 209 × 10^3/μL, hemoglobin 13.2 g/dL, and CRP 36.6 mg/L. Imaging included a chest study and head and neck tomography; chest tomography visualized several pulmonary cysts. Forty-eight hours after admission, he developed worsening stridor and respiratory distress, prompting emergent OR transfer for tracheostomy, microlaryngoscopy, and excision of papillomatous lesions. Intraoperative findings demonstrated extensive papillomatous disease with appendicular tumor-like lesions and ventricular bands involving the epiglottis, glottic surface, vocal cords, subglottis, and trachea to ring 5. Histopathology showed koilocytotic atypia consistent with HPV and mild focal dysplasia. Postoperatively, he was managed in the PICU with respiratory monitoring and was weaned off oxygen within 48 hours. He received a single intravenous dose of bevacizumab 400 mg and showed prompt clinical improvement. He completed a seven-day hospitalization with normalization of oxygen saturation and progressive oxygen weaning, then was transferred for ongoing care. He also received respiratory therapy. On telemonitoring at eight months, there was no evidence of recurrence or intercurrent events. Clinical context: RRP is typically HPV-related (often low-risk types) and can cause multifocal papillomas leading to airway stenosis; anti-VEGF therapy such as bevacizumab is used off-label to reduce angiogenesis and disease recurrence, and in this case was associated with a favorable short- to mid-term outcome.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A full‑term male newborn, 2 days old and delivered by cesarean section, presented with a congenital right scrotal swelling. On arrival he appeared well perfused and stable. Examination showed the right testis was enlarged, tense, non‑tender, and visibly reddish with excoriated overlying skin. Transillumination was negative on the right and positive on the left; both hernia openings were normal. Doppler ultrasound showed the right testis was enlarged with a heterogeneous, darker appearance and no detectable blood flow; the left testis looked normal, with only a small amount of fluid. He was taken urgently to surgery. Intra‑operatively, the right testis was frankly nonviable due to intravaginal torsion, with minimal hydrocele. Surgeons removed the right testis (orchidectomy) and fixed the left testis in place (contralateral orchidopexy) to reduce the risk of future twisting.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "Patient: 27-year-old woman, 16 weeks pregnant, with beta thalassemia major on monthly transfusions. Iron chelation was stopped during pregnancy.\n\nPresenting concerns: Since early pregnancy she had swollen, bleeding gums and bad breath. Exam showed dry, exfoliative lips and generalized gingival enlargement with redness, soft tissue, dark red rounded margins, easy bleeding, pain, and true periodontal pockets on the labial, buccal, palatal, and lingual surfaces. She had never seen a dentist for these issues. No other systemic illnesses were reported. Hematology showed anemia with abnormalities and evidence suggesting infection.\n\nAssessment: Gingival enlargement and chronic periodontitis associated with pregnancy and beta thalassemia major.\n\nManagement: Multidisciplinary dental care included 3% hydrogen peroxide rinses, a chlorine dioxide spray mouthwash, a course of antibiotics, professional calculus removal (scaling/root planing), and oral hygiene instructions. Medical care continued monthly transfusions; iron chelation remained on hold during pregnancy.\n\nOutcome: After about three months of coordinated care, symptoms and clinical findings improved satisfactorily.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 71-year-old patient with untreated, long-standing vitiligo presented with a 6-month history of right-eye visual loss and bilateral hearing loss, right-predominant. During admission he endorsed chronic headaches, intermittent fever, significant unintentional weight loss, generalized asthenia, and skin thickening. Initial ophthalmologic assessment: RO visual acuity reduced to light perception with impaired color discrimination; LO visual acuity 20/200. There was an afferent pupillary defect in both eyes and hyperemic eyelid margins. Anterior segment (both eyes): hyperemic bulbar conjunctiva, ciliary injection, cornea with peripheral nummular subepithelial infiltrates, aqueous anterior chamber without cellularity, normal iris, and lenses with nuclear opacities. Fundus, RO: pale (++) optic disc with approximately 50% excavation, slightly blunted nasal margin, attenuated/“raised and thinned” vasculature, macular area with scattered pigment. Fundus, LO: 2+ vitreous haze; edematous, hyperemic optic disc with blurred margins; peripapillary streaked hemorrhages; excavation not assessable; thinned vasculature; macular area with scattered pigment. Impression at that time documented right optic atrophy and left anterior optic neuritis. Workup for ocular–neurologic disease included evaluation to exclude tuberculosis, herpes, ANCA and non-ANCA vasculitides, and sarcoidosis. Lumbar puncture: opening pressure within normal limits; CSF protein 54 mg/dL. Nerve conduction velocities showed a polyradiculoneuropathy with moderate–severe axonal degeneration involving all four extremities, greater in the lower limbs. Contrast-enhanced MRI of the brain and orbits showed no optic nerve enhancement and no intracranial masses, but did reveal sinusitis and meningeal enhancement. Sarcoidosis was further disfavored by a normal ACE level and a whole-body gamma scan without hypermetabolic foci. On repeat ophthalmologic evaluation, there was progression with persistent right optic atrophy and left anterior optic neuritis. High-dose pulse corticosteroids were initiated, followed by a taper. The patient experienced clinical and functional improvement, particularly in neurologic and ophthalmologic parameters.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "Who: A 20-year-old Arabic man who practices martial arts. Problem: Pain in the back of his left thigh for 5 weeks. He tried medicines and physical therapy, but they did not help. Doctors said it was not a trapped-nerve problem in the hamstring. He stopped all sports. Treatment: He did a gentle seated nerve-glide exercise four times a day for three days in a row. He also learned better posture. Pain before treatment: 5 out of 10 at rest. 7 out of 10 with activity. Pain after 3 days: 2 out of 10 at rest. 4 out of 10 with activity. Knee scores got better. Pain part went from 22 to 61. Function part went from 30 to 80. After 2 months, he felt fully recovered and returned to sports with no problems.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 67-year-old patient with no significant past medical history presented with declining overall health marked by progressive hoarseness (dysphonia) and difficulty swallowing (dysphagia). Imaging showed a large nasopharyngeal/neck mass. Biopsy confirmed grade 1–2 follicular non-Hodgkin lymphoma. CT of the neck, chest, abdomen, and pelvis found a nasopharyngeal mass measuring about 70 × 40 mm with extension to 60 mm. Bone marrow biopsy and the pre-treatment evaluation were normal. The patient received four cycles of rituximab plus CHOP without response, followed by three cycles of rituximab plus DHAOX, with persistence of the mass. Repeat biopsy then showed loss of B‑cell infiltration and the presence of AL amyloid deposits. Serum protein immunoelectrophoresis detected immunoglobulin M. PET imaging demonstrated a hypermetabolic nasopharyngeal process. The patient is currently being treated with bortezomib, prednisone, and bendamustine.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 77-year-old male with a history of moderate cognitive impairment presented after a tonic–clonic seizure at home. On arrival to the ED he was hemodynamically unstable in a postictal state with suspected intrapelvic bleeding, triggering activation of the polytrauma code (for physiology rather than mechanism). He was stabilized with intravenous fluids and transfusion of packed red blood cells, and a pelvic girdle was applied. Once stable, examination showed shortening of the lower limb compared with the contralateral side, external rotation, and joint blockage on log-roll testing in both limbs, with functional impotence of both hips. Neurologic assessment was initially limited. There were no external injuries; distal foot pulses were present, and he could move his upper limbs. Chest and AP pelvic radiographs were obtained; the pelvic film demonstrated bilateral femoral dislocation, and a reduction procedure was performed. Computed tomography angiography was then used to exclude vascular injury (none identified). 3D-CT reconstructions revealed bilateral transverse acetabular fractures per Letournel, bilateral longitudinal iliac wing fractures, and intrapelvic protrusion of both femoral heads. Bilateral supracondylar femoral traction was applied and pelvic traction was removed. The patient was operated on hospital day 8, in accordance with the service protocol to delay acetabular fracture surgery approximately 7 days to allow fibrosis at the fracture site and reduce intraoperative bleeding. Given anticipated operative duration, a staged approach was selected. Perioperatively, both procedures were performed under general anesthesia with tranexamic acid to limit bleeding and cefazolin prophylaxis (2 g pre-op, then 1 g q8h for 24 h). Postoperatively, enoxaparin 40 mg SC daily was administered for 7 weeks. The left hemipelvis was addressed first due to greater radiographic protrusion and concern that a soft-tissue hematoma could complicate femoral head extraction (risk of vascular injury/bleeding). With the patient in lateral decubitus, a posterolateral approach was used. A Moore’s autograft was placed in the acetabular background (fracture focus). A Burch-Schneider Reinforcement Cage (Zimmer Biomet) was implanted, anchored to the ischium and ilium; dissection of the gluteus minimus and medius was required to position the femoral head. The ischial fixation was secured with screws, and fluoroscopy confirmed component positioning. A cemented dual-mobility acetabular construct was then implanted, followed by a non-cemented femoral stem. Closure included the capsule and pelvic musculature with transosseous trochanteric sutures. Seven days later, the right side was performed in lateral decubitus. The longitudinal iliac wing fracture was addressed first via the first window of the ilioinguinal approach and fixed with a six-hole anatomical plate. The hip reconstruction then mirrored the left: anti-protrusion ring with a cemented dual-mobility acetabular component and a non-cemented femoral stem. The authors note that anti-protrusion rings are indicated for acetabular fractures equivalent to pelvic discontinuity (AAOS type IV acetabular defects), requiring ischial and iliac anchorage, and are not indicated for isolated anterior or posterior wall fractures without acetabular floor involvement. During admission, the patient remained in bed with mobilization to prevent pressure ulcers. After the second operation and as tolerated, he transferred using a wheelchair; in bed he had unrestricted range of motion. He was discharged at 4 weeks and remained non–weight bearing until 6 weeks, then progressed to loading with a cane. Loading was delayed to allow initial consolidation of the acetabular background graft to support the ring and because bilateral involvement precluded practical partial weight bearing. At 12 months, he was fully weight bearing with a cane, with Harris Hip Scores of 79 (left) and 77 (right), WOMAC 12, and no postoperative complications. He reported occasional discomfort and a mild right-sided limp, had full range of motion on examination, and no episodes of instability since surgery.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "This report describes a 49-year-old woman with long‑standing systemic lupus erythematosus (SLE) who developed progressive kidney and heart failure and was listed for kidney transplantation after four years on dialysis. Her SLE began in childhood with lupus nephritis and she had prior immunosuppressive treatments; she was also hepatitis B and C positive. She had early heart disease, including a heart attack at age 20, later developed ischemic and dilated cardiomyopathy, received an ICD, and underwent mitral and tricuspid valve repair with left‑ventricle surgery; after that operation her kidney function worsened and dialysis was started. Before transplant she had severe heart dysfunction (LVEF about 26%, high BNP) and signs suggesting possible pulmonary hypertension, so the team added perioperative cardioprotective therapy with levosimendan. Levosimendan infusion (0.1 µg/kg/min) began after a dialysis session when the donor match was confirmed and continued through the first 24 hours after surgery. Anesthesia and postoperative care focused on protecting the new kidney and careful fluid and hemodynamic management; invasive pulmonary artery catheterization was avoided because of her ICD and unstable rhythm history. The postoperative course was complicated: she experienced delayed graft function requiring hemodialysis for roughly six weeks, had a biopsy‑proven acute rejection episode with acute tubular necrosis, and developed leukopenia and cytomegalovirus infection that led to changes in immunosuppression. BNP rose after surgery but then gradually fell; she was discharged on day 67 with serum creatinine 1.4 mg/dL. By one month after transplant there was measurable improvement in heart size and function (EF up to ~30%, better strain measurements), lower pressures suggesting less pulmonary hypertension, and better exercise tolerance (NYHA III/IV to II). At five months she had continued improvement in heart function, BNP down to about 1066 pg/mL, and normal kidney function.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 23-year-old male with a 23 pack-year smoking history, no alcohol use, and no illicit drug use presented with 2 hours of sudden severe frontal headache, nausea, vomiting, and chest heaviness. He was distressed but alert and oriented. Vitals: BP 178/103 mmHg, RR 26/min, T 38.9°C, HR 87/min, SpO2 94%. Exam: normal vesicular breath sounds; cardiovascular and abdominal exams inconclusive; neurological exam notable for neck stiffness, dilated but light-reactive pupils, normal plantar reflexes, and no focal deficits. ECG showed ST-segment elevation >2 mm in V2–V5, consistent with STEMI; he received a 300 mg aspirin load and was urgently transferred for PCI. Troponin was elevated at 1.48 mg/dl (normal <0.16 mg/dl). Femoral-access coronary angiography demonstrated normal coronary arteries with TIMI 3 flow. Post-angiography ECG showed normal sinus rhythm with LVH; echocardiography revealed normal ventricular function without RWMA. Subsequent workup found lymphocytosis and mildly elevated CRP. Non-contrast CT brain demonstrated a cisternal subarachnoid haemorrhage with extension anterior to the right temporal lobe. Abdominal ultrasound was negative for polycystic kidney disease; cerebral CT angiography was planned to exclude aneurysm. Nimodipine 60 mg q4h was initiated with a BP target of 160/100 mmHg. On day 2, he acutely deteriorated with cardiac arrest; after CPR, GCS was 6, and he was intubated and mechanically ventilated in the ICU. Owing to instability, repeat CT brain and planned cerebral CTA were not performed. He received multidisciplinary ICU care with NG feeding, IV fluids, antibiotics, a proton pump inhibitor, and nimodipine. On day 8, he developed ventricular fibrillation and, despite CPR and more than five defibrillation attempts, could not be resuscitated and died.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "This child is 2 and a half years old and has a condition called NF1. She had diarrhea with blood. Doctors used a small camera to look inside her large intestine. The inner lining looked red and irritated from the bottom (anus) to the start of the large intestine (cecum). The usual fine pattern of tiny blood vessels was hard to see. Small tissue samples showed long-lasting swelling. This fits a disease of the large intestine called ulcerative colitis. A special lab test (PCR) on the tissue found a virus called CMV.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 69-year-old male with prior CABG presented with 2 months of severe dyspnea on mild exertion (NYHA III). ECG showed ST depression in II, III, aVF, and V4–6; NT-proBNP was 2640 pg/mL. Echocardiography demonstrated LV systolic dysfunction with LVEF 30%. His history included an inferior STEMI in 2009 with severe 3-vessel disease (proximal LAD CTO, 90% mid/distal LCx stenoses, 95% mid RCA stenosis) treated with CABG (LIMA–LAD; sequential SVG to OM1, OM2, and PL). Current angiography via 6 Fr left radial access showed patent LIMA–LAD and SVG–OM1/OM2, but complete occlusion of the sequential SVG to PL. The native LM was occluded at the ostium and the native RCA was occluded in the mid segment with bridging collaterals. The strategy was to treat the native RCA CTO. Dual arterial access was obtained with an additional 6 Fr right femoral sheath. The right and left coronaries were engaged with 6 Fr AL 0.75 (Launcher; Medtronic) and 6 Fr EBU 3.5 (Launcher; Medtronic) guide catheters, respectively. An antegrade approach from the left radial artery failed: neither a Fielder XTR nor a Gaia 3 with a Finecross microcatheter could enter the distal true lumen. A parallel wire technique with a Crusade microcatheter and two Gaia 3 wires also failed. The team then switched to a retrograde approach via septal channels from the LAD through the occluded left coronary system. A Gaia 3 crossed the occluded LM and LAD to reach the distal LAD true lumen. A Sion wire was exchanged via a Finecross into the distal LAD, followed by dilation of the LM and proximal LAD with a 2.0 × 15 mm balloon. Septal surfing technique (SST) was then used to identify a viable septal channel. A Sion wire, supported by a 150-cm Finecross, was advanced retrogradely through a distal septal branch into the distal RCA. A Gaia 3 traversed the RCA CTO retrogradely into the proximal RCA true lumen and was advanced into a Guidezilla guide extension catheter positioned in the antegrade guide. The Finecross was delivered to the antegrade guide and an RG3 wire was externalized. The CTO segment was predilated with a 2.0 × 15 mm balloon and stented with two overlapping DES (2.5 × 38 mm and 3.0 × 38 mm), achieving an excellent angiographic result with TIMI 3 flow in all distal branches. Dyspnea was relieved at discharge, and at 6-month follow-up there was no recurrence of dyspnea.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 67-year-old woman with years of left leg swelling developed new symptoms of heart failure and was diagnosed with complex, congenital arteriovenous malformations (AVMs) in the lower limb. These abnormal vessel connections create high-flow shunts that can overload the heart. After a prior coil embolization failed to help, the team used an abdominal aortic stent graft (repurposed in the leg) to quickly reduce blood flow through the AVM, then performed staged embolization to target the AVM nidus and draining veins. Her heart failure and leg swelling improved, with blood flow in the common femoral artery falling stepwise and heart function markers getting better over time. The article highlights real-world lessons and limits: coils alone may not control very high-flow AVMs; covered stents can promptly lower shunt flow but usually need follow-up embolization; and staging helps reduce risk in patients with severe (acute) heart failure.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 2‑day‑old term male neonate, delivered by cesarean section at a private hospital, was referred for a congenital right scrotal swelling and presented to our children’s hospital one day later. On ED arrival he was well hydrated, pink on room air with good perfusion. Physical exam: right hemiscrotum with an enlarged, tense, non‑tender, visibly reddish testis and overlying skin excoriation; transillumination negative on the right and positive contralaterally; both hernial orifices normal. Laboratory studies were obtained, and urgent inguinoscrotal Doppler ultrasonography demonstrated an enlarged right testis measuring 15.6 × 9.4 mm with heterogeneous hypoechoic echotexture, prominent rete testis, and absent intratesticular color Doppler flow. The left testis was normal in size, shape, and echotexture; there was minimal hydrocele. The patient underwent urgent scrotal exploration. Intra‑operatively there was frank necrosis of the right testis secondary to intravaginal testicular torsion, with minimal hydrocele. A right orchidectomy and contralateral orchidopexy were performed. Contextually, perinatal testicular torsion often presents at or shortly after birth and Doppler evidence of absent flow with heterogeneous hypoechoic parenchyma correlates with nonviability; salvage rates are low when presentation is delayed. Contralateral orchidopexy is commonly performed to mitigate future torsion risk.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A teenager was getting treatment for a blood cancer called non-Hodgkin lymphoma. He developed very high blood fats (triglycerides). This made a lab test say his sodium was low, even though his body sodium was okay. Think of it like the blood looked milky with fat, which can trick the test. Doctors thought this was a side effect from two cancer medicines: asparaginase and a steroid (prednisone). They used a standard checklist and decided the side effect was definitely from those medicines. He was treated with a low-fat eating plan and medicines that lower blood fats. The cancer drugs were not stopped because that part of his treatment had already reached its planned end. His blood fats went back to normal in about two weeks, and he had no problems.", "literacy_label": "low_health_literacy"}
{"generated_text": "This report is about a woman with abnormal blood vessel connections in her left leg that she was born with. Her left leg stayed swollen for a long time. She then started having signs of heart trouble. At age 67, doctors confirmed the leg problem was complex and present since birth. The team used a special tube made for the big belly artery, plus a blocking procedure, to slow the bad blood flow in her leg. This was done to help her sudden heart failure caused by the leg problem. The report explains what worked well and what did not.", "literacy_label": "low_health_literacy"}
{"generated_text": "At 32 weeks of pregnancy, a routine scan found one small lump inside the baby’s heart. It caused no symptoms. This was the only problem seen. Doctors watched it with clinic visits until 39 weeks plus 1 day. Then the baby was delivered by C-section (a surgery to deliver the baby). After birth, the child had checkups on day 1, day 7, day 30, month 7, and month 12. At each visit, the child’s growth and behavior were healthy for age. The heart lump stayed the same size; it did not grow or shrink. By 1 year old, there were no signs of a related condition called tuberous sclerosis complex.", "literacy_label": "low_health_literacy"}
{"generated_text": "A previously healthy 13-year-old male presented with 3 days of acute bilateral pleuritic chest pain, mild non-productive cough, no dyspnea, mild rhinorrhea, and a single febrile episode (38°C). Pain localized to the costal margins, was worse with cough, and improved with paracetamol. He denied constitutional symptoms, syncope, or exercise limitation and regularly canoed twice weekly. There were no reported infectious exposures, environmental/occupational inhalational exposures, or family history of cardiopulmonary disease. A prior chest radiograph 4 years earlier during an acute illness showed a marked interstitial infiltrate; he was presumptively treated with azithromycin and had no follow-up.\nOn admission, temperature was 37.8°C, SpO2 99% on room air, HR 93 bpm, RR 15/min, and BP 115/66 mmHg (85th percentile). Exam revealed diminished breath sounds in the lower two thirds of the chest without adventitious sounds; there was no respiratory distress, clubbing, cyanosis, or abnormal heart sounds. Chest radiograph again showed a marked interstitial infiltrate comparable to the prior film. Thoracic CT demonstrated multiple bilateral ground-glass opacities involving >65% of the lung parenchyma, suggestive of pulmonary alveolar proteinosis (PAP). Respiratory viral testing was negative, and he remained clinically stable in the ED. He was discharged on empiric amoxicillin–clavulanate and azithromycin with symptom resolution and referred to a pediatric respiratory clinic.\nOutpatient workup showed positive ANA at 1/89 (fine speckled) with other autoantibodies negative and immunoglobulins within normal limits. Bronchoalveolar lavage returned milky fluid with positive periodic acid–Schiff staining; microbiology including mycobacterial studies was negative. Spirometry demonstrated a mild restrictive ventilatory defect with reduced FVC 2.92 L (77% predicted) and FEV1 3.21 L (69.9% predicted) with a normal FEV1/FVC ratio (109%). DLCO (SB) was moderately reduced at 13.8 ml/min/mmHg (48.6% predicted). A surfactant dysfunction genetic panel identified no pathogenic variants. GM-CSF antibody testing was positive, supporting a diagnosis of autoimmune PAP (AI-PAP). At 20 months, he remains asymptomatic and physically active; repeat testing showed FVC 4.03 L (81.3%), FEV1 3.71 L (87.5%), FEV1/FVC 91.96%, and DLCO (SB) 25.54 ml/min/mmHg (83.7%). Given stable, improving physiology and absence of symptoms, treatment was deferred with ongoing surveillance.\nContext: AI-PAP is mediated by neutralizing anti–GM-CSF antibodies that impair alveolar macrophage–mediated surfactant clearance, producing intra-alveolar lipoproteinaceous material that is PAS-positive and radiographically manifests as diffuse bilateral ground-glass opacities (often with a “crazy paving” pattern). Standard therapies include whole lung lavage and GM-CSF replacement; however, observation is appropriate in stable, minimally symptomatic patients, as in this case.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 38-year-old male with a three-year history of exertional chest tightness and dyspnea re-presented with progressive orthopnea and decompensated heart failure. Three years prior, outpatient echocardiography had identified a left-sided intracardiac echogenic mass consistent with myxoma, prompting admission. Physical examination at that time noted auricular hyperpigmentation with multiple brown-black macules. Abdominal imaging reported extracardiac findings, and genetic testing revealed TTN and PRKAR1A mutations. The diagnosis of Carney complex (CNC) with cardiac myxoma was established by clinical findings, imaging, and genetics. He improved with symptomatic therapy but declined definitive surgery. \n\nOn re-presentation (September 20, 2023), exam showed jugular venous distension, cardiomegaly with leftward/downward displacement, an irregular rhythm, a 2/6–3/6 mitral murmur at the left sternal border (fourth intercostal space), bilateral mid-to-lower lung wet rales, hepatomegaly (firm liver palpable 3 fingerbreadths below the xiphoid and 2 fingerbreadths below the costal margin), and mild bilateral pitting edema. ECG demonstrated atrial fibrillation (average ventricular rate ~150 bpm) with abnormal Q waves in V1–V3. Transthoracic echocardiography showed global cardiac enlargement, dilation of the aortic sinus and main pulmonary artery, small-to-moderate mitral regurgitation, and an irregular echogenic mass measuring 54 × 43 mm in the left chamber attached to the atrial septum. LV systolic function was severely depressed (LVEF 23.1%, FS 10.9%). The working diagnosis was end-stage heart failure due to dilated cardiomyopathy (DCM) in the setting of CNC with a cardiac myxoma. Given concomitant end-stage DCM and intracardiac tumor, heart transplantation was pursued when a suitable donor became available.\n\nOperative course: Median sternotomy was performed with cardiopulmonary bypass. Exploration confirmed global cardiomegaly, most pronounced in the LV, with poor contractility. Diseased native right atrium, left atrium, right ventricle, and left ventricle were resected, revealing a gray-white mucoid mass consistent with myxoma. Standard orthotopic heart transplantation anastomoses were completed (including left atrial cuff, great vessels, and caval anastomoses) using continuous Prolene sutures (3/0 and 5/0), with meticulous hemostasis. After rewarming and aortic unclamping, the graft resumed sinus rhythm spontaneously. Assisted circulation was weaned uneventfully. Histopathology of the explanted tissues confirmed DCM and cardiac myxoma.\n\nPostoperative course: On postoperative day (POD) 1, urine output was 1200 mL; hs‑troponin T was 796.70 ng/L; NT‑proBNP 10,798 pg/mL; WBC 17.15 × 10^9/L. Echocardiography demonstrated normal ventricular wall thickness and morphology with LVEF 65% (FS 35%). Immunosuppression and anti-infective therapy included IV methylprednisolone sodium succinate 0.25 g, cefoperazone/sulbactam 2 g, supportive nutrition, and hepatoprotective therapy. On POD 3, steroids were transitioned to oral prednisone acetate 25 mg; mycophenolate mofetil 0.5 g PO was initiated for rejection prophylaxis; caspofungin acetate 50 mg IV was added for antifungal prophylaxis. Urine output increased to 2000 mL; hs‑troponin T decreased to 390 ng/L; NT‑proBNP decreased to 7877 pg/mL; WBC 12.15 × 10^9/L. On POD 7, tacrolimus 1 mg PO was introduced with therapeutic drug monitoring (blood level 10.90 ng/mL), and prednisone was tapered to 10 mg. Clinical status steadily improved. By late postoperative follow-up (October 20, 2023), echocardiography was unremarkable; hs‑troponin T was 85 ng/L; NT‑proBNP 210 pg/mL; other labs were within normal limits. The patient was discharged in excellent condition and has remained clinically stable on outpatient follow-up.\n\nInterpretation: This case illustrates CNC with PRKAR1A mutation manifesting as atrial myxoma and end-stage DCM, compounded by atrial fibrillation and severe LV systolic dysfunction (LVEF 23.1%). Orthotopic heart transplantation effectively addressed both the intracardiac tumor and the refractory heart failure, with prompt normalization of graft function and favorable early outcomes under standard triple immunosuppression.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 19-month-old boy came to the emergency department after falling from a highchair and hitting his head. On exam he had severe, unexplained breathing trouble that required tracheal intubation (a tube placed into the windpipe to help him breathe). The team suspected that the breathing problem had caused an altered state of consciousness and led to the fall and head injury. Imaging of the chest showed complete collapse (atelectasis) of the entire left lung and an abrupt cutoff of the left main bronchus about 12 mm from the lung hilum (the area where the bronchus enters the lung). Rigid bronchoscopy found and removed a 2 cm almond that was stuck in the left main bronchus. Earlier signs included very fast breathing and heart rate, low oxygen levels despite bag-mask ventilation, visible chest retractions, and decreased breath sounds on the left. The mother reported the child had an intense coughing episode a few days earlier that resolved without treatment; the child had never eaten almonds before and likely swallowed this one by accident. After the almond was removed the child improved steadily, was extubated 24 hours later, moved from intensive care to the pediatric ward, and made a full recovery of respiratory function.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 12-year-old boy presented with one week of acute-onset headache and polyuria–polydipsia. Past history was unremarkable. On first assessment: height 146.5 cm (M), weight 30 kg (−1.4 SD). He was at the onset of puberty with bilateral gonadal length 3.2 cm and penile length 6.2 cm (M). Visual assessment, including OCT, was normal. Polyuria reached 113 ml/kg/day with nocturnal enuresis and intake approximately 3.8 L/m²/day. Initial labs were consistent with central diabetes insipidus: serum sodium 140 mEq/L, plasma osmolality 287 mOsm/kg, urine osmolality 179 mOsm/kg. Basal pituitary axes were otherwise intact: IGF-1, PRL, free T4, cortisol, FSH, and LH within reference ranges. MRI with and without contrast demonstrated apoplexy within a Rathke cleft cyst (T1/T2 hyperintense lesion measuring 15 × 6 × 11 mm). The anterior pituitary enhanced homogeneously. The posterior pituitary bright spot was absent. There were no radiologic features suggestive of craniopharyngioma. DI improved significantly with vasopressin therapy. A multidisciplinary team (endocrinology, neurosurgery, radiology) elected conservative management given the absence of compressive symptoms, early pubertal status, and normal baseline endocrine testing apart from DI. Serial MRI over nine months showed stability (12 × 11 × 10 mm), and subsequent surveillance at two years remained stable (11 × 12 × 11 mm) with slight size reduction at three years (7 × 10 × 6 mm). Over three years, the patient maintained normal pubertal progression and a stable hormonal profile on routine testing, with persistently normal vision. Growth velocity declined from −0.8 SD to −1.1 SD, prompting evaluation for acquired GH deficiency. At 14 years 9 months, two GH stimulation tests demonstrated partial GH deficiency: propranolol–glucagon peak 19.3 µUI/ml and insulin tolerance test peak 10.0 µUI/ml. GH therapy led to improved growth velocity from −1.1 SD to 0.2 SD over one year. Overall, this case illustrates that RCC apoplexy in a pubertal child can present with abrupt DI due to posterior pituitary/stalk dysfunction, while sparing anterior pituitary function initially. In the absence of mass effect or broader hypopituitarism, conservative management with structured clinical, biochemical, and radiologic follow-up is appropriate; delayed, isolated partial GH deficiency may emerge, warranting dynamic testing and treatment.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 17-year-old male with no significant past medical or family history was referred from Dentistry after an incidental nasal foreign body (NFB) was detected during preoperative orthodontic planning with dental radiographs and cone beam computed tomography (CBCT) without contrast. He was entirely asymptomatic, denying nasal obstruction, rhinorrhea, epistaxis, foul odor, hyposmia, halitosis, facial pain, discomfort, or sleep disturbances. The parents recalled a prior event at age seven when he inserted an object into his nose; an anterior rhinoscopy was attempted at that time, and removal under sedation was recommended, but the family did not follow up and assumed spontaneous expulsion given the absence of symptoms. Nasal endoscopy of the right cavity showed a deviated nasal septum with inferior turbinate hypertrophy; the mucosa was erythematous and mildly edematous. A foreign body was visualized, lodged and adherent to the floor of the nasal cavity beneath the inferior turbinate, partially covered with mucus/crust, with a shiny surface suggesting a metallic nature. Lateral and frontal radiographs demonstrated a circular radiopaque object along the nasal floor consistent with a metallic snap button; adjacent bony structures were normal. CBCT confirmed the foreign body and mild surrounding inflammation, without significant bony erosion or sinus involvement. With informed consent, removal was performed under local anesthesia in a semi-sitting position to mitigate the risk of airway dislodgment. After decongestion with xylometazoline 0.1% and topical anesthesia with lidocaine spray (10 mg/spray) in the right nostril, a hook was used to disengage the foreign body, which was then extracted with bayonet forceps. The procedure was uncomplicated with minimal bleeding controlled by saline irrigation, and post-removal inspection showed no significant tissue injury. The retrieved object was a metallic snap button (1 cm diameter) with substantial corrosion and biological deposits, consistent with long-term retention—likely over a decade. The patient was discharged in stable condition with 0.9% sodium chloride nasal irrigations and had an unremarkable two-week follow-up.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 29-year-old gravida V para IV (3 spontaneous vaginal deliveries, prior cesarean for failed induction 4 years earlier) presented for ANC at 32 weeks by LNMP. Maternal labs: VDRL, HBsAg, and urinalysis negative; CBC within normal limits; blood group A Rh-positive. Obstetric ultrasound revealed normal fetal anatomy except the heart. Fetal echocardiography showed normal situs; atria of comparable size; normally positioned atrioventricular and semilunar valves with normal motion; ventricles comparable in size and contractility; left ventricle forming the apex; no ventricular septal defect. Two circumscribed, round, echogenic masses were noted on the left ventricular papillary muscles, measuring 18.2 × 8.3 mm and 13.5 × 8.3 mm. LVOT and RVOT anatomy and function were normal on 2D and color flow. Impression: cardiac rhabdomyoma. Given the association with tuberous sclerosis complex (TSC), detailed neurosonography and systemic evaluation were performed and were unremarkable. She continued routine ANC without complications to 39 weeks. At 39 weeks + 1 day, a cesarean section (repeat on request at term) delivered a 3200 g female, Apgar 10 and 10 at 1 and 5 minutes. Postoperative courses for mother and neonate were uneventful; discharge occurred on postoperative day 3. The neonate was evaluated on days 1, 7, and 30: physical examinations were normal; no seizure activity or new cutaneous lesions; mass dimensions were similar to the antenatal findings. At 7 months, development was age-appropriate; pediatric echocardiography showed well-circumscribed hyperechoic masses on both left ventricular papillary muscles measuring 21.8 × 9.2 mm and 14.7 × 8.5 mm, without left ventricular inflow obstruction. At 12 months, anthropometric and neurobehavioral development remained normal. Echocardiography again demonstrated well-circumscribed hyperechoic masses on both left ventricular papillary muscles with no size increment and no left ventricular inflow obstruction. Up to one year of age, apart from the persistent intracardiac rhabdomyomas, the child met none of the clinical diagnostic criteria for TSC. Notably, while cardiac rhabdomyomas often regress spontaneously in infancy, these lesions were stable through 12 months.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 19‑month‑old boy was admitted following a fall from a feeding highchair, landing on his gluteal region and striking the occiput. He had three episodes of vomiting, marked irritability, RR >60/min, HR >150/min, and SpO2 <80%. On exam, he was hydrated and conscious but irritable, with subcostal retractions and decreased breath sounds at the left base. Bag‑mask ventilation with supplemental oxygen and pulse oximetry monitoring were initiated; paradoxically, SpO2 fell below 70% with ongoing ventilation. Lung ultrasound demonstrated absent A‑lines and consolidation, visualizing the lung as solid parenchyma. Given the poor clinical condition, orotracheal intubation with a cuffed endotracheal tube was performed. Post‑stabilization chest CT revealed complete atelectasis of the left lung with interruption of the main left bronchus at 12 cm from the bronchial bifurcation. In the context of maternal history of an intensive coughing episode in the preceding days that resolved spontaneously within 24 h, foreign body aspiration was suspected. Rigid bronchoscopy identified and removed a 2‑cm almond lodged in the left main bronchus. The patient improved progressively, was extubated at 24 h, transferred from intensive care to the general pediatrics ward, and achieved full recovery of respiratory function. Based on the clinical course, the team hypothesized that severe respiratory compromise likely preceded the event, causing altered consciousness and subsequent head trauma.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 25-year-old man came to the oral medicine clinic with painful canker sores on his lips that started in the mouth four days earlier and involved the lips two days later. On exam there were blood-tinged crusts on the lips that bled easily, and diffuse, painful red lesions on the inside of the upper and lower lips. He had reported a fever about a week before the sores appeared, a period of heavy workload and poor diet, and a habit of frequently licking his lips. Initial tests showed a positive anti-HSV-1 IgG (ratio 6.32), supporting herpes virus involvement, and the working diagnosis was HAEM. Exfoliative cheilitis was considered but less likely because it does not involve the herpes virus. Other findings included poor oral hygiene and several unrelated dental problems. Treatment combined topical and systemic care: topical steroid ointment (triamcinolone acetonide 0.1% in orabase), warm compresses with 0.9% saline, oral acyclovir tablets (200 mg, five times daily for one week), and a daily multivitamin. Patients were also advised on non-drug measures: brush teeth and tongue twice daily with a soft brush and non‑detergent toothpaste, drink more water, eat a balanced diet, avoid acidic, spicy or hard foods (and foods with MSG), and stop licking or peeling the lips. Two days after the first visit pain was reduced but lesions remained; after starting acyclovir there was marked healing by the next follow-up and complete clinical recovery after 7 days. Oral-health–related quality of life improved (OHIP-14 score from 35 to 4). The patient was referred for further dental care (periodontics, restorative, oral surgery, and prosthodontics) and gave consent for publication.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "This is about a 13-year-old boy. He has had small growths in his throat since he was two years old. The growths were in his voice box and windpipe. They narrowed his breathing tube, so he had trouble breathing. It was like trying to breathe through a pinched straw. A chest scan showed several small cysts in his lungs. Doctors removed the throat growths. They also placed a breathing tube through a small hole in his neck to help him breathe. He got one dose of a medicine called bevacizumab (400 mg) through a vein. He also had breathing therapy. He got better. The problem has not come back during follow-up.", "literacy_label": "low_health_literacy"}
{"generated_text": "This report is about a 13-year-old boy. He came to the ER with sharp chest pain that hurt more when he took a deep breath. He did not feel sick otherwise. His oxygen level was normal at 98% on room air. The lower parts of his chest sounded quieter when the doctor listened. A chest X-ray looked like one he had 4 years earlier. A CT scan showed many hazy and crisscross areas in both lungs, covering more than half of the lungs. This pointed to a rare lung problem called PAP, where material builds up in the air sacs. Tests for viruses, including COVID-19, were negative. A gentle lung wash showed milky fluid, and a special lab stain was positive. Breathing tests showed his lungs held a little less air than expected and moved oxygen less well. A gene test did not find a known cause. A blood test found strong antibodies that mean the body’s own immune system is likely causing this problem. About 20 months later, he feels well, and his breathing tests are normal.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 69-year-old man with prior coronary bypass surgery presented with two months of severe shortness of breath with mild activity (NYHA class III). He was diagnosed with heart failure due to ischemia after failure of a saphenous vein graft to the right coronary artery. This was supported by an abnormal ECG, elevated NT-proBNP, and a coronary angiogram; echocardiography also showed reduced pumping function. The team reopened a chronic total occlusion in the native right coronary artery using a retrograde approach through septal channels (septal surfing). To enable that route, they first re-opened the totally occluded left coronary artery. After the procedure, his dyspnea improved before discharge, and at 6 months he had no recurrence of shortness of breath.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 5-year-old presented to the pediatric ED 13 hours after ingesting chlorpyrifos with abnormal jerks, severe dyspnea, tachypnea (RR 48/min with intermittent sighs), diaphoresis, salivation, polyuria, vomiting, and subsequent aspiration of a charcoal–palm oil mixture. On arrival: T 38.3°C, GCS 3/15, pinpoint pupils, generalized hypotonia, SpO2 88% with widespread crackles, HR 180/min, BP 120/80 mmHg, random blood glucose 14 mg/dl. Serum lactate and cholinesterase levels were unavailable. The working diagnoses were severe organophosphate poisoning (cholinergic crisis with type I paralysis), aspiration pneumonitis, respiratory failure, and impending shock. Because ICU care was unaffordable, NIV via bubble CPAP was initiated, improving SpO2 to 99–100%. Hypoglycemia was corrected with a dextrose bolus; 20 ml/kg normal saline was given for tachycardia. The patient received IV dexamethasone, mannitol, and atropine 0.02 mg/kg (discontinued after the first dose due to rapid tachycardia), plus empiric IV antibiotics for aspiration pneumonitis; pralidoxime was unavailable. Within 3 hours, a 500 mL fresh whole blood exchange transfusion (FWB-EBT) was performed, after which GCS improved to 9/15. Blood glucose fluctuated between 41–259 mg/dl during the first 15 hours and subsequently normalized. By hospital day 2, the patient developed thready pulses and hypotension; an additional NS bolus was administered and dopamine was started at 5 mcg/kg/min via a peripheral vein. Mannitol was discontinued. A second 500 mL FWB-EBT was performed. Over the first 30 hours, consciousness and respiratory distress improved, though rhonchi developed and were treated with nebulized salbutamol and budesonide; the patient was transitioned to oxygen via nasal prongs with SpO2 ~97%. A day-2 chest radiograph showed bilateral infiltrates consistent with pneumonia. Full consciousness returned by hour 39. Antioxidants (IV vitamins C and B; oral vitamin E and zinc) were started, and diet was advanced over 48 hours. The patient responded rapidly overall, did not develop intermediate syndrome, and was discharged on hospital day 10; follow-up was lost. Exchange transfusion was utilized as a detoxification strategy in the absence of oximes and may have contributed to clinical stabilization by reducing circulating toxin and replenishing cholinesterase activity, alongside atropinization, ventilatory support, fluids, and inotropic therapy.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 27-year-old man presented to the emergency department with a fracture at the base of the neck of the right femur after a low-energy fall that involved axial loading and a twisting motion of the right hip. He had a known history of fibrous dysplasia in the right proximal femur and, 20 years earlier, underwent curettage, bone grafting, and prophylactic fixation; the hardware was removed one year later, and biopsy at that time confirmed fibrous dysplasia. Given the pattern and pathologic nature of the current fracture, the team proceeded with a definitive treatment: wide resection of the proximal femur and a total hip replacement using a modular prosthesis, along with cerclage to secure the construct. An excisional biopsy performed during surgery confirmed the same fibrous dysplasia that had been treated in childhood. He recovered well: imaging at four weeks showed the components in good position, and he progressed from partial weight-bearing to full weight-bearing with a walker around day 20. He returned to daily activities with a mild, intermittent limp related to the gluteus medius incision and was able to do low-impact activities such as walking, reporting high satisfaction with the outcome.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A young man from Morocco had strong liver pain for about a month. He also had mild signs that can come with TB infection. Scans of his belly showed small spots in his liver. Doctors used a small camera surgery to take a tiny piece from one of the spots. The test on that piece proved the spots were TB in the liver. He started TB medicines. He felt better, and his blood tests got better too.", "literacy_label": "low_health_literacy"}
{"generated_text": "Technique (TFD/PDT): The patient receives intravenous photosensitizer (Photogen, 1.5 mg/kg) 24 h pre‑procedure; peak absorption is 630 nm. Under general anesthesia, standard duodenoscopy (Olympus TJF‑180) is performed. After identification of the greater duodenal papilla and retrograde cannulation, a digital cholangioscope (SpyGlass DS, Boston Scientific) is introduced into the common bile duct. Cholangioscopy is used to identify the neoplastic stenosis. Under direct visualization, the illumination catheter (Medlight S.A., RD10‑323) is advanced through the cholangioscope. The catheter is a three‑way cannula: port 1 carries a 1‑cm cylindrical light diffuser with two black radiopaque markers denoting its limits; port 2 accommodates a 0.025‑inch guidewire; port 3 is an injection portal. Following cholangioscopic positioning, illumination is delivered at 90 J/cm² with power of 70 mW/cm², with 1‑cm stepwise repositioning to cover the entire stenosed segment. Completion cholangioscopy assesses immediate outcome and adverse events. Post‑procedure care: patients are fasted for 24 h; if no adverse events occur, oral intake is resumed. Discharge includes strict photoprotection instructions (avoidance of light exposure and use of sunglasses), especially during the first week after TFD. Results/Case: An 82‑year‑old man presented with a 2‑month history of obstructive jaundice and weight loss. EUS showed severe dilation of the common bile duct with choledocholithiasis; ERCP confirmed these findings but stone extraction was unsuccessful due to disproportionate ductal dilation, so a plastic biliary stent was placed. Cholestasis recurred 45 days later; two additional ERCPs failed to clear stones. During the third ERCP, a long irregular CHD stenosis was noted, prompting repeat EUS. Repeat EUS revealed a well‑circumscribed hypoechoic solid mass (1.8 × 2 cm) compressing the common hepatic duct, with apparent involvement of the common hepatic artery. Ultrasound‑guided needle biopsy confirmed moderately differentiated cholangiocarcinoma (Bismuth I). After staging, the lesion was deemed unresectable and the patient was referred for palliative therapy. Following multidisciplinary discussion, adjunctive PDT was performed to treat recurrent biliary obstruction. The procedure lasted 150 minutes without complications. A 10 Fr plastic stent was placed for biliary drainage (SEMS unavailable at that time). No photosensitivity occurred in the subsequent week. Early recurrence of cholestasis with cholangitis ensued; ERCP demonstrated stent occlusion by debris and biliary sludge secondary to tumor necrosis. A biliary scan and re‑drainage resolved the acute episode. He then remained asymptomatic for three months—the longest interval since symptom onset. At subsequent recurrence, a self‑expanding metal stent was placed. He continued systemic therapy and later required a duodenal stent for palliation of dysphagia. He died from complications of pulmonary metastases two years after symptom onset and 15 months after the TFD session. Mechanistic context: PDT activates the photosensitizer at 630 nm to generate reactive oxygen species, inducing localized tumor cytotoxicity and microvascular damage, which can debulk malignant biliary strictures and improve ductal patency.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 29-year-old woman, Para 1, presented with one month of abnormal vaginal bleeding to a level 2 hospital. She was HIV positive, had been commenced on antiretroviral therapy (ART) after diagnosis approximately one year earlier, but defaulted ART for one month when she became ill with vaginal bleeding, resulting in virological and immunological failure (viral load 37,400 copies/mL; CD4 26 cells/μL). On exam, there was an 8 × 8 cm friable cervical mass extending to the parametrium and bilaterally to the pelvic sidewalls, with contact bleeding and foul-smelling discharge. Ultrasonography showed a bulky cervix and bilateral hydronephrosis. She was clinically staged as FIGO stage 3B cervical malignancy based on pelvic wall involvement and hydronephrosis. ART was re-initiated with a switch from TLD (Tenofovir–Lamivudine–Dolutegravir) to a renal-friendly regimen (Lamivudine–Abacavir–Dolutegravir). A punch cervical biopsy revealed extra-nodal BL (Burkitt lymphoma). Immunohistochemistry and in situ hybridization confirmed the diagnosis: CD20, CD75a, CD10, PAX5, and Bcl-6 positive; CD44 and c-Myc positive; EBER-ISH focally positive. Ki-67 showed an almost 100% proliferation index, and PAX5 moderately positive BCL6. Baseline labs included WBC 2.67 × 10^9/L, hemoglobin 5.7 g/dL, platelets 71 × 10^9/L; creatinine 187 mmol/L, urea 11.1 mmol/L, albumin 21 g/L, AST 41 U/L, ALP 100 U/L. After histologic confirmation and multidisciplinary review, the plan was chemoradiation. She then waited 43 days to start treatment at the oncology unit due to a long waiting list—exceeding the recommended ≤48-hour window for initiating BL therapy. During this interval, further CT/MRI imaging could not be performed due to equipment dysfunction. Supportive care included ART, blood transfusion, and analgesia. She died on day 43 post-diagnosis while awaiting treatment and received no chemoradiation. No histopathological postmortem was performed because BL and HIV were established. Given BL’s rapid progression and high mortality in people with HIV and high viral load, the attending physician certified BL as the most likely primary cause of death, with multiple organ failure (including renal and hematologic) as a secondary cause.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 46-year-old man from Haiti now lives in Chile. He had wart-like bumps on the front of his shin for about a year. Tests showed a long-lasting skin fungus called chromoblastomycosis. The skin sample had special cells that prove this infection. The lab also grew dark-colored fungus from the sample. Under the microscope, the germ looked like a kind called Fonsecaea. He took antifungal pills and got freezing treatments on the spots. Treatment lasted six months. All the bumps went away.", "literacy_label": "low_health_literacy"}
{"generated_text": "This is about a 20-year-old woman. She had a kidney problem since age eight that made protein leak into her urine. The problem first showed up when a big blood clot blocked veins in her brain, and a clot also went to her lungs. She took blood thinners and steroid pills. Later she took a medicine that calms the immune system to help her use fewer steroids. Tests showed no inherited blood-clotting problem. She had several flare-ups of the kidney problem. Steroid pills controlled them until 2017. After that she had no relapses. Her doctors stopped the blood thinner and the immune-calming medicine. One year later she had sudden, very bad belly pain all over. She threw up after eating. Both legs were swollen. Tests showed the kidney problem was back. A special X-ray picture (CT scan) showed a new clot in the main artery that feeds the small intestine. It was like a plug in a pipe that stops water. Blood could not reach the intestines. In surgery, most of her small intestine was dead. Taking out that much bowel would not allow life. She died 48 hours later.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 52-year-old man had a seizure and was sent to a big hospital. X-rays showed a bad break-and-dislocation in his right shoulder. The same X-rays also found that his left shoulder had popped out of the socket in the back, which had been missed before. A later CT scan showed both shoulders had a break-and-dislocation, and the left shoulder got worse while he was in the hospital. Surgeons fixed both shoulders in one operation and held the bones with metal plates. The left shoulder needed two more surgeries: one because the repair failed, and another to free a stiff joint. Two years later, he was doing well. His arm disability score was 5% on QuickDASH. His shoulder scores (Constant) were 72 on the left and 76 on the right.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 19-year-old male with no significant history presented with an 8-month painful left scrotal mass unresponsive to antibiotics for presumed pyogenic infection, along with intermittent low-grade fever, night sweats, anorexia, and weight loss. Exam showed a large, painful, slightly warm left bursa and two firm, painful subcutaneous formations on the anterior thoracic wall (3–4 cm). CRP was 90 mg/dl; CBC, creatinine, glucose, and liver function tests were normal. Chest radiograph demonstrated bilateral reticulonodular infiltrates. Scrotal ultrasound suggested an epididymal tumor, and a left orchidectomy was performed. Histopathology revealed granulomatous epithelioid necrosis of the epididymis, consistent with active epididymal tuberculosis involving the body and tail and sparing the head and testis. The tuberculin skin test was positive. AFB studies of sputum and urine on 3 consecutive days were negative on direct smear and culture. HIV, HBV, HCV serologies and Wright's were negative. Thoraco-abdomino-pelvic CT identified miliary tuberculosis, coelo-mesenteric necrotic adenopathies, two thoracic parietal collections within the external oblique muscles (33 × 10 mm right, 45 × 10 mm left), and focal osteolysis of D11 and L5 suggestive of early spondylodiscitis; spinal MRI confirmed spondylodiscitis at D7, D11, L4, and L5. The diagnosis was disseminated tuberculosis with epididymal, pulmonary, parietal, ganglionary, and osteo-articular involvement. Treatment consisted of isoniazid, rifampicin, ethambutol, and pyrazinamide for 2 months, followed by isoniazid plus rifampicin. At month 4 of therapy he developed generalized tonic-clonic seizures; brain MRI showed multiple supra- and infratentorial nodular lesions compatible with tuberculomas. An anticonvulsant was added and anti-tuberculous therapy was continued. Evolution was favorable with early weight gain and disappearance of thoracic parietal formations, adenopathies, and miliary lesions on CT; there was no recurrence of seizures. Because the tuberculomas regressed slowly, therapy was prolonged; he was ultimately declared cured without sequelae at the end of the 234th month of treatment (as reported) with 2-year follow-up. Context: Epididymal tuberculosis can mimic neoplasm and may occur with negative AFB studies; CNS tuberculomas emerging during therapy are a recognized phenomenon, typically managed by continuing anti-tuberculous treatment with seizure control.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 57-year-old woman with a 14-year history of asthma and allergic rhinitis on salmeterol/fluticasone presented with two months of intermittent, dull abdominal pain, nausea, anorexia, malaise, and 5-kg weight loss. She was afebrile, hemodynamically stable, underweight (BMI 16.6 kg/m²) with sarcopenia, and had epigastric/umbilical tenderness without guarding. CBC showed leukocytosis with marked eosinophilia (WBC 26.8 G/L with 20.8 G/L eosinophils; 77.8%). Peripheral smear showed morphologically normal eosinophils. Bone marrow aspiration revealed 48% eosinophils without blasts or atypia. FISH for CHIC2 deletion (surrogate for FIP1L1-PDGFRA) was negative. Autoimmune/vasculitis screens (ANA, anti-dsDNA, p-ANCA, c-ANCA) were negative. Serum immunoglobulins demonstrated elevated IgG (2760 mg/dL) and IgG4 (1260 mg/dL), mildly elevated IgE (137.5 IU/mL), and high RF (144.4 IU/mL). Liver enzymes, BUN/creatinine, C3/C4, vitamin B12, cortisol, and NT-proBNP were within normal limits. ECG/echocardiogram were normal. Chest CT showed mild fibrosis and bronchiectasis. Bronchoscopy and AFB smears were negative; BAL cytology had 35% neutrophils and no eosinophils. Spirometry demonstrated severe obstruction with bronchodilator responsiveness; FeNO was 15 ppb. Stool leukocytes were present, but ova/parasite exams were negative. Serology was positive for Toxocara canis IgG (54.2 NovaTec-Units) and negative for other helminths and HIV. Empiric albendazole (400 mg twice daily for 5 days) was ineffective. Abdominal contrast-enhanced CT showed cholelithiasis without cholecystitis and no GI structural abnormality. Upper GI endoscopy was unremarkable. Colonoscopy demonstrated mucosal inflammation in the sigmoid, left, transverse, and right colon. Systematic colonic biopsies showed dense eosinophilic infiltration (>85 eosinophils/HPF in the left colon; >100 eosinophils/HPF in the transverse and right colon). Given the exclusion of hematologic neoplasms and secondary causes (including lack of response to anti-parasitic therapy and negative work-up for vasculitis/autoimmune disease), the findings were diagnostic of eosinophilic colitis. She was treated with oral methylprednisolone 16 mg and montelukast 5 mg. Symptoms resolved within two weeks with normalization of eosinophils to 0.3 G/L. Corticosteroids were tapered and discontinued, and montelukast was continued for three months with no symptom recurrence. This case illustrates eosinophilic colitis in an atopic patient with marked peripheral and tissue eosinophilia, elevated IgG4, negative myeloid neoplasm markers, and steroid-responsiveness, consistent with primary eosinophilic gastrointestinal disease after exclusion of secondary etiologies.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 2-year-old girl had a bulging left eye. The eye was pushed inward and upward. An MRI scan showed a clear lump. It looked dark on one kind of picture and bright on another. Tests on the tissue, including special lab tests, proved it was a teratoma (a type of growth). Doctors removed the lump through the inside of the lower eyelid and made small cuts at the outer corner to make room. One month later, the eye looked sunken. The white part was red. The clear front of the eye was inflamed. Doctors did a second surgery. They put donated eye-white tissue into the eye socket to add space, smooth the hollow, and help the eye surface heal. After one year, the growth did not come back, and there were no other problems.", "literacy_label": "low_health_literacy"}
{"generated_text": "This is a single-case report of a female third-grade student with developmental dyslexia (DD) and high abilities/giftedness (AH/S), evaluated pre- and post-phonological remediation. Ethical approval: CEP 1.012.635; informed consent/assent obtained. The first evaluation (T1) occurred at 8y2m (2018) and the second (T2) at 9y6m (2019). History: term birth; typical neuropsychomotor and language development; early bilingual exposure (French first words; Brazilian Portuguese at home); school transitions including French and later Portuguese–English bilingual schooling; interdisciplinary diagnosis of DD and AH/S at age 8; referral to LEIA/UFRN. Protocol: four assessment sessions at each time point (T1, T2) and 20 weekly 60-minute phonological remediation sessions (2H2018); limited parental engagement due to work. Assessments targeted phonological processing (phonological awareness, phonological working memory, rapid naming), reading, and writing. Measures: CONFIAS for phonological awareness; Phonological Working Memory Test (nonword repetition; digit span direct/reverse); RAN at T1 and TENA at T2 for rapid automatic naming; LPI (isolated word/pseudoword reading) and an expository text protocol (accuracy, oral/silent modes, comprehension, words/minute) for reading; spontaneous text plus dictation of LPI target words with Zorzi & Ciasca orthographic analysis for writing.\nResults—phonological awareness (CONFIAS): performance aligned with the writing hypothesis at each time point. T1 scores: syllabic = 35; phonemic = 14 (consistent with a syllabic–alphabetic writing hypothesis). T2 scores: syllabic = 37; phonemic = 20 (consistent with an alphabetic writing hypothesis). The 4-point gain at the phonemic level likely reflects the remediation focus on phonemic skills.\nPhonological working memory: At T1, nonwords were below expected (66 vs ET1 69) and reverse digits were below expected (4 vs ET1 6); direct-order digits were within/above expected (20 vs ET1 13). At T2, age-appropriate performance was documented with gains across categories: nonwords 69; reverse digits 12. The improvement in reverse span implicates executive mechanisms supporting rapid storage/manipulation, consistent with a strength often observed in high-ability profiles.\nRapid naming: T1 RAN performance was below normal across all subtests. At T2 (TENA), digits (41 vs ET2 35), objects (59 vs ET2 50), and colors (56 vs ET2 53) remained below expected; letters were within expected (29 vs ET2 32). Naming speed improved for letters (37→29 s), objects (62→59 s), and colors (60→56 s), but worsened for digits (37→41 s). Reduced naming latencies indicate more efficient access to the phonological/visual lexicon, though residual RAN deficits persisted—typical in DD.\nReading: T1 showed an alphabetic level with reliance on sub-vocal decoding, confusions for visually/phonologically similar letters, and very slow rate (≈20 words/min), well below grade expectations. T2 advanced to an orthographic level with oral reading ≈94.4 words/min, adequate prosody, rhythm, global reading, interest, and comprehension; low speech intensity suggested residual task-related insecurity.\nWriting: T1 reflected a transition from syllabic–alphabetic to alphabetic, with maladaptive pencil grip, imprecision, letter substitutions/omissions, hyper-/hyposegmentation, word repetition, and limited cohesion. T2 remained qualitatively imprecise with low intelligibility, visual letter confusions (e.g., b/d), and limited punctuation; however, the sample was consistent with an alphabetic phase, with a broader vocabulary repertoire (visual input lexicon). Overall, alphabetic writing consolidated but orthographic accuracy lagged.\nConclusion: After phonological remediation, the child demonstrated gains in phonological processing (awareness and working memory) and progressed from alphabetic to orthographic reading, while consolidating alphabetic writing. Nevertheless, characteristic dyslexic features persisted, particularly reduced efficiency in rapid access to the mental lexicon (RAN) and ongoing orthographic/spelling errors (confusions, omissions, hypersegmentation).", "literacy_label": "proficient_health_literacy"}
{"generated_text": "We describe a rare case of euthyroid, single-muscle thyroid eye disease (Graves’ orbitopathy) in a 50-year-old man who smoked and had dyslipidemia. He developed a very rapid and severe loss of upward movement in the right eye, producing constant, uncorrectable double vision and major quality-of-life impact. Thyroid function was normal, and TSH receptor antibodies were only slightly elevated. Imaging showed isolated enlargement of the right inferior rectus muscle; the other eye muscles were normal. Intravenous steroid pulses reduced inflammation but did not improve the diplopia or eye position. He ultimately required two orbital decompression surgeries. A biopsy of the right inferior rectus confirmed massive fibrosis with fat infiltration, consistent with single-muscle involvement.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "One day before the treatment, you get a light‑activated medicine through a vein. During the visit, the doctor slides a flexible camera through your mouth into your gut. They find the small drain where bile comes out. They thread a tiny camera up into the main bile tube. They look for a tight spot caused by a tumor. They slide a thin light cable to that spot while watching on the screen. They turn on the light and move the cable a small step, about 1 centimeter, each time to cover the whole tight area. At the end, they look again to see how it went and to check for any problems. This treatment was used for an 82‑year‑old man who had yellow skin from blocked bile for two months. Tests showed the main bile tube was very wide and had stones. They also found a firm lump about 1.8 by 2 centimeters pressing on the liver’s main bile tube. Surgery could not fix it. He got this light treatment to ease the blockage. He felt well for three months. He died from complications 15 months after the light treatment.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 51-year-old man presented with 3 days of sudden, painful vision loss in the left eye. Visual acuity was 20/20 in the right eye and hand motion in the left eye. Left fundus findings included optic nerve head swelling, choroidal bulging, multiple areas of subretinal fluid, and RPE corrugations. Orbital/brain MRI with gadolinium showed a retrobulbar nodular mass enhancing at the junction of the optic nerve and sclera. Oncology and rheumatology evaluations were unremarkable. The clinical diagnosis was nodular posterior scleritis, and oral prednisolone was started.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 70-year-old man had a bad leak in his main heart valve. Doctors placed a new valve through a small opening near the tip of his heart. Four weeks later, his heart got worse again. Doctors added a heart pump to help move blood. About a year later, a heart scan showed the valve was leaking badly through the middle. The team put a second valve inside the first one, like stacking one cup inside another. They turned the heart pump down to its lowest setting during the procedure. They also made his heart beat fast at 140 beats per minute to keep the new valve steady. The result was excellent. One year later, he felt well and the valve leak was no longer a problem.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 15-year-old boy had bad belly pain and was throwing up. A CT scan showed his small intestine was blocked because a loop slipped through a small opening deep in the upper belly. Doctors first tried surgery with a small camera. They could not see well. They changed to a bigger cut down the middle above his belly button. They moved the trapped intestine back where it belongs. The intestine looked healthy, so nothing had to be removed. They did not do an extra step to try to stop this from happening again. After surgery, he got a pocket of fluid in the lower belly. It was treated with antibiotics. He is going to follow-up visits in the children’s surgery clinic.", "literacy_label": "low_health_literacy"}
{"generated_text": "This newborn had a very serious genetic condition called neonatal Marfan syndrome. It badly affected his heart. His fingers and toes were very long like spider legs. Some fingers and toes were stuck in a bent position. His elbows and knees could not fully straighten. His face looked old for a baby. His eyes were deep set and tilted downward. His ears were soft and not well formed. His mouth sagged. His head was short and wide. The clear lenses in his eyes were out of place. A DNA test found a new change in the fibrillin-1 gene in a spot linked to the newborn form of this condition. Doctors tried medicines to lower the heart’s workload, kept him deeply sedated to reduce strain, and gave water pills to help him pee and move extra fluid. Even with this care, the heart valve leaks and high pressure in the lungs got worse, and the heart grew weaker. Surgery would have been needed to help him live longer. Because the disease was getting worse very fast, the family chose comfort care. A few months after birth, his heart failure worsened and he died.", "literacy_label": "low_health_literacy"}
{"generated_text": "You are 78 and take many medicines in a pre-packed pill system (SPD). For months, you felt very tired, weak, dizzy, and confused. We checked your medicines. We looked closely at pills that the kidneys help clear, using your kidney filter number (eGFR). We wrote a note to your family doctor. We asked to lower the dose of two blood pressure pills: losartan and manidipine, based on your eGFR. Your doctor lowered the doses. We kept an eye on you. Your symptoms went away.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 56-year-old Italian woman with transfusion-dependent beta-thalassemia major (with prior splenectomy and cholecystectomy) underwent MRI to measure iron in the heart, liver, and pancreas. At the time of imaging, she had no significant endocrine, cardiac, or hepatic complications and was taking deferasirox, vitamin D, and luspatercept. The MRI incidentally revealed a lobulated mass in the prevascular mediastinum. PET showed only mild FDG uptake, and chest CT identified multiple thin-walled cysts throughout both lungs, a pattern consistent with lymphangioleiomyomatosis (LAM). After multidisciplinary review, she had thoracoscopic thymectomy and a lung wedge resection. Pathology confirmed type B2 thymoma and pulmonary LAM. Based on these findings, adjuvant radiation therapy was recommended for the thymoma, and sirolimus was advised for LAM.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 5-year-old developed severe organophosphate poisoning after ingesting chlorpyrifos and then aspirated a charcoal–palm oil mixture. The illness progressed to respiratory failure, shock, coma, and acute (type I) paralysis. In the emergency department, the child received noninvasive ventilation, repeated exchange transfusions, intravenous atropine, and an inotrope infusion to support blood pressure, along with antibiotics and steroids. The child improved rapidly, did not develop intermediate syndrome (the delayed muscle weakness sometimes seen after organophosphate poisoning), and was discharged after a 10-day hospitalization. Additional context: the child arrived about 13 hours after ingestion with heavy secretions, pinpoint pupils, fast breathing, low oxygen, and crackles on chest exam. Pralidoxime was unavailable. Blood sugar was low at first and then fluctuated before stabilizing. A chest X-ray on day 2 showed pneumonia. Consciousness returned by about 39 hours, oxygen was weaned to nasal prongs, and recovery continued to discharge.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 70-year-old man with severe aortic regurgitation was treated with a transcatheter aortic valve implantation (TAVI) through the tip of the heart (apical approach) because he was high risk for open surgery. Four weeks later, he developed recurrent heart failure, so a left ventricular assist device (LVAD) was implanted. He remained stable for about a year, but echocardiography then showed severe central leakage through the valve. The heart team chose a valve-in-valve TAVI to fix the problem. During the procedure, they reduced the LVAD flow to a minimum and used rapid pacing at 140 beats per minute to stabilize the new valve during placement. The outcome was excellent: at 12 months, he was doing well with no significant aortic valve leak.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 45-year-old man was hospitalized with COVID-19 pneumonia and had no prior neurologic history. On hospital day 16, he suddenly developed reduced consciousness, his eyes deviated to the right, and he had jerking movements on the left side of his face and chest, followed by a generalized tonic–clonic seizure. After the seizure, he was left with persistent weakness on the left side (left hemiparesis). Brain CT was normal, and a spinal tap showed slightly elevated protein but no increase in white blood cells. Importantly, the cerebrospinal fluid tested positive for SARS-CoV-2 by RT-PCR, making viral involvement of the brain (encephalitis) likely and bacterial meningitis unlikely. An EEG did not show clear abnormalities, and later MRI was also unremarkable. He improved gradually, his condition stabilized, and his overall outcome was favorable.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 56-year-old female with CTD-PAH secondary to Sjogren’s syndrome (diagnosed 2013) complicated by ILD initially presented with dyspnea. Early studies showed interstitial changes and cardiomegaly on chest X-ray; echocardiography demonstrated PASP 99 mmHg, RA/RV enlargement, D-shaped LV, and severe TR. Chest CNYCT showed no filling defects to suggest PE, with enlarged pulmonary trunk, RA, and RV, consistent with PH. Sjogren’s was confirmed by sicca symptoms with Schirmer’s <5 cm OU, positive minor salivary gland biopsy, impaired salivary gland function on nuclear medicine scan, and positive anti-Ro. She began Revatio (sildenafil) 20 mg TID in 2013; Tracleer (bosentan) was added in 2016. Right heart catheterization in 2017 showed mPAP 39 mmHg, PVR nearly 15 Woods, and wedge 4 mmHg, indicating pre-capillary, group I CTD-PAH; Opsumit (macitentan) 10 mg QD replaced bosentan. From 2017 to 2020 she required repeated steroid hospitalizations for Sjogren’s control. Her risk status was low-to-intermediate on dual therapy until October–November 2020, when she developed worsened dyspnea and signs of infection, then severe decompensation on November 10 with SpO2 70% requiring 100% O2 via face tent, lactate 5.2 mmol/L, and BNP >10,000 pg/mL, consistent with cardiogenic shock. She was intubated in the ICU, started on four PH agents, stabilized, and improved; heart–lung transplant evaluation began November 12, vasopressors were discontinued November 13, she was extubated November 14, and transferred to the ward November 21 on nasal cannula 2 L/min. Follow-up RHC showed persistently elevated PA pressures attributed to chronic PH with right heart strain. She was reclassified as high risk; Ventavis (iloprost) 10 mcg/ml 2 ml was added in 2020. In May 2023, molecular hydrogen was initiated as adjuvant therapy: 1 capsule/day (PURE HYDROGEN; HoHo Biotech, Taipei, Taiwan), each containing 170 mg of hydrogen-rich coral calcium with 1.7×1,021 molecules of hydrogen, equivalent to 24 cups of water at 1,200 ppb H2 or 0.6 mM H2 per 200 ml water. Flow cytometry and serology (standard fluorescent dye preparation; dried reagent kits, Beckman Coulter; immunophenotyping and gating per prior methods) before and after hydrogen therapy demonstrated increased CD127+ Treg populations and decreased B cell subsets; anti-Ro antibody levels declined. Clinically, signs and symptoms stabilized following the addition of hydrogen therapy, and no adverse reactions occurred. The case adheres to CARE reporting guidelines (2013 CARE Checklist).", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 45-year-old male (Pakistan-born, 7 years in Portugal) with grade 3 obesity and no neurologic history presented with 4 days of fever, dry cough, dyspnea, chest pain, dysgeusia, headache, and myalgia. Admission exam: no focal neurologic findings; tachypnea; bilateral rough vesicular murmur; otherwise unremarkable. Labs showed mildly elevated inflammatory markers; on room air (FiO2 21%) arterial gases were consistent with type 1 respiratory failure. Chest teleradiography: extensive bilateral, predominantly peripheral and basal opacities. Nasal/oropharyngeal RT-PCR for SARS-CoV-2 was positive; influenza A/B, Streptococcus pneumoniae, and Legionella pneumophila tests were negative, confirming COVID-19 pneumonia. Respiratory status worsened over 48 hours, escalating from supplemental O2 to noninvasive ventilation, then high-flow nasal cannula without response. He was transferred to a level III ICU for sedoanalgesia, orotracheal intubation, and invasive mechanical ventilation.\nBy ICU day 11, he was on remdesivir, dexamethasone, enoxaparin, and empirical amoxicillin/clavulanic acid plus azithromycin for suspected bacterial superinfection. He had sustained fever with poor antipyretic response; inflammatory markers improved by ICU day 3. A sepsis workup included line changes; blood, catheter tip, bronchial secretion, urine cultures; urinalysis; and transthoracic echocardiography. Only blood cultures were positive (Klebsiella pneumoniae), sensitive to amoxicillin/clavulanic acid already in use. Echocardiogram: no valvular vegetations; hypokinesia of the lateral wall and LV apex with poor biventricular function. Troponin was mildly elevated (1.8 ng/mL) with ST-segment depression in leads I and aVL, raising concern for ACS vs septic cardiomyopathy. Noninfectious fever causes (e.g., neuroleptics, thyroid dysfunction) were excluded. He required dobutamine during ventilatory weaning and needed noninvasive ventilatory support post-extubation; first extubation occurred on hospital day 15.\nOn hospital day 16 (day 19 of illness), he developed an acute alteration in consciousness with conjugate rightward gaze deviation and left facial and thoracic myoclonus, progressing to a generalized tonic–clonic seizure that terminated after midazolam. Hypoxic-ischemic seizure etiology was deemed unlikely: he remained normotensive, without peri-event hypoxemia, had normal serum lactate, and preserved diuresis. No ionic or glycemic disturbances were identified. Postictally: no eye opening, no verbal response, no localization to pain (GCS 7), and persistent left hemiparesis (3/5). For airway protection, he was resedated, reintubated, and started on anticonvulsant therapy. Head CT was unremarkable. Lumbar puncture yielded turbid CSF with mild proteinorrachia, no pleocytosis, and normal opening pressure. CSF studies included panels for neurotropic viruses, VDRL, acid–alcohol resistant bacteria, cultures, and RT-PCR for SARS-CoV-2. EEG performed 1 hour after propofol discontinuation (under fentanyl; single 13-minute recording) showed no significant abnormalities. CSF RT-PCR returned positive for SARS-CoV-2 RNA, and in the absence of CSF pleocytosis, bacterial (but not viral) meningitis was excluded; encephalitis was considered the leading diagnosis. Brain MRI on hospital day 17 was limited by motion artifacts. After withdrawal of sedoanalgesia, his mental status improved (GCS 14); left hemiparesis improved to 4/5; no recurrent involuntary movements; he was safely extubated within 24 hours. Given the favorable trajectory, brain biopsy was not pursued. He was transferred to the ward on day 21, remained afebrile with stable mentation, had no further seizures or myoclonus, and a repeat MRI on day 26 was normal. He was discharged home on day 31 without antiepileptic drugs, with internal medicine follow-up. This case highlights COVID-19–associated encephalitic presentation with a generalized seizure and persistent unilateral deficits, supported by detection of SARS-CoV-2 RNA in CSF despite absent pleocytosis, and a favorable clinical outcome with gradual recovery.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 46-year-old Haitian man living in Chile developed wart-like plaques on the front of his right shin for about a year. Doctors diagnosed chromoblastomycosis after a skin biopsy showed the characteristic cells of this infection and a fungal culture grew dark (dematiaceous) colonies; direct microscopy suggested a Fonsecaea-type fungus. He was treated for six months with itraconazole taken twice daily and cryotherapy to the thickened areas. The lesions cleared completely. Additional context: The problem began as a small bump that slowly enlarged, later causing itch, pain, shallow ulcers, and yellowish drainage. Routine blood tests and screening for syphilis, HIV, and tuberculosis were negative. Local wound care was provided, including antibiotic ointment when signs of bacterial infection appeared. After therapy, there has been no relapse, with only mild lightening of the treated skin, which is expected after cryotherapy.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 36-year-old man had a tender lump at the junction of the penis and scrotum for five years. Surgeons removed the mass. Under the microscope, it was a spindle cell tumor, and special staining supported a diagnosis consistent with synovial sarcoma. He then had a second, wider surgery. Despite these aggressive steps, the cancer spread to other parts of the body and kept progressing even after multiple chemotherapy treatments.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 32-year-old male baker from Bamako presented on 27 April 2023 with a 1-month history of chronic productive cough, otalgia, and chronic right-sided purulent otorrhea. He had been treated elsewhere for confirmed malaria and acute otitis media with artesunate, paracetamol, and unspecified antibiotics without improvement. He is HIV-1 positive, started on TDF/3TC/DTG 7 months prior but was non-adherent due to denial of illness.\nOn exam: T 38.2 °C, altered general condition, right foul-smelling purulent otorrhea and otalgia, right basal pulmonary condensation syndrome; neurological exam normal with no cranial nerve involvement (VII, VIII intact). ENT: right EAC inflammation with purulent secretions and a single tympanic membrane perforation in the anterior-inferior quadrant; left ear normal. Rinne and Weber favored right conductive hearing loss.\nImmunovirology: at HIV diagnosis CD4 118 cells/µl, VL 12,370 copies/ml; at 6 months on ART CD4 193 cells/µl, VL 9,460 copies/ml; at TB diagnosis (month 7) CD4 89 cells/µl, VL 10,230 copies/ml.\nMicrobiology: Ziehl–Neelsen bacilloscopy positive (one cross) in gastric washings at admission; due to persistent otorrhea, repeat testing 19 days later showed a positive smear on the right ear swab. Xpert MTB/RIF detected M. tuberculosis without rifampicin resistance. Chest radiograph: accentuated bronchovascular markings at the right lung base. Diagnosis: tuberculous otitis media (middle ear TB) with concomitant pulmonary involvement in the context of HIV-1–related immunosuppression.\nTreatment: first-line anti-tuberculosis therapy for 6 months—intensive phase 2 months of isoniazid, rifampicin, pyrazinamide, ethambutol (2RHZE), then 4 months of isoniazid and rifampicin (4RH); fixed-dose combination, 3 tablets each morning fasting; pyridoxine (vitamin B6) 1 tablet daily. Two sessions of adherence reinforcement for ART. ART was restarted 4 May 2023 with tenofovir/lamivudine/dolutegravir 1 tablet daily plus supplemental dolutegravir 50 mg daily per protocol. Cotrimoxazole prophylaxis 960 mg daily. Local ear care included suctioning of the external auditory canal and ciprofloxacin ear drops, 2 drops three times daily for 14 days.\nOutcome: by day 14 there was clinical improvement with resolution of cough and otorrhea, and smear conversion to negative in both the gastric aspirate and the right ear swab. End-of-treatment status: complete clinical healing with normal ENT and neurological exams. Serial bacilloscopies with Xpert MTB/RIF at the end of month 2 (intensive phase), during month 5, and at the end of month 6 were negative. HIV viral load after 3 months of resumed ART was 329 copies/ml.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "She was 29 years old and had one child. She had HIV and a very weak immune system (CD4 count of 26). She had abnormal vaginal bleeding for one month. A tissue test from her cervix showed a blood cancer called Burkitt lymphoma in the cervix, outside the lymph nodes. Doctors also said the cervical cancer was stage 3B because it reached the pelvic wall and caused the kidneys to swell from blocked urine. A team of cancer doctors said she needed chemotherapy and radiation together. There was a long waiting list for this treatment. The start of care was delayed. She died 43 days after the diagnosis. She did not get the planned treatment.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 2-year-old female with a 1-year history of painless, progressive left proptosis and no systemic disease or family history presented with light perception only in the left eye. Examination showed proptosis with inward and upward globe displacement; restricted extraocular movements in downward and outward gaze; a palpable, irregular, well-defined soft mass in the inferior orbit; left lower lid ectropion; a 4 mm mydriatic, nonreactive pupil; and otherwise unremarkable anterior segment (fundus view limited by age). Hertel exophthalmometry: OD 10.5 mm, OS 18 mm. MRI demonstrated a well-circumscribed mass, hypointense on T1WI and hyperintense on T2WI; contrast-enhanced imaging demonstrated no significant improvement. The lesion was excised via a transconjunctival approach through the inferior fornix with canthotomy and cantholysis. Intraoperatively, a grayish-white cystic mass with a distinct boundary was identified; posterior dissection revealed tight adhesion to the optic nerve. Due to lesion size and limited exposure, volume reduction was performed with aspiration of approximately 12.5 mL of fluid, followed by complete excision. Histopathology showed a fibrous capsule lined by squamous and glandular epithelium with visible brain tissue and cartilage-like matrix, consistent with orbital teratoma; immunohistochemical examination corroborated the diagnosis. One month postoperatively, the patient developed enophthalmos, conjunctival hyperemia, and keratitis, attributed to prior orbital cavity enlargement by the mass leading to postoperative volume deficit; corneal nonapposition to the lids created a gap and corneal inflammation. After guardian consent, a second operation implanted allogeneic sclera to augment orbital volume, alleviate fossa pitting, and normalize keratitis. At 1-year follow-up, there was no recurrence of the teratoma. Residual findings included minor enophthalmos and outer canthus abnormality; visual acuity remained at preoperative levels. Hertel measurements were OD 10.5 mm and OS 8 mm; the remaining anterior segment examination was unremarkable.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 36-year-old man presented with a 5-year history of a tender left penoscrotal mass attached to the left side of the bulbar urethra at the penoscrotal junction; on exam it was a deep, smooth, tender, partially mobile cystic lesion (~20 × 20 mm) without skin tethering and not involving the spermatic cord. Doppler ultrasound showed a well-defined hypoechoic mass (2.7 × 3.1 × 2.0 cm) with marked vascularity. Pelvic MRI demonstrated a mass at the left inferolateral base of the penis with a clear fat plane, isointense to the testes on T1, T2, and diffusion-weighted sequences, connected to the vas deferens, without lymphadenopathy. Serum AFP and β-hCG were normal. The mass was excised for diagnosis and symptom control. Pathology revealed a cellular spindle cell tumor arranged in interlacing fascicles with spindle-to-oval vesicular nuclei, evenly dispersed chromatin, and inconspicuous nucleoli; mitotic activity reached up to 3/HPF. Immunohistochemistry was positive for TLE-1, CD99, and BCL2 with focal cytokeratin and focal EMA, supporting synovial sarcoma. FISH demonstrated SS18 gene rearrangement at 18q11.2, confirming the diagnosis. Margins were difficult to assess due to specimen fragmentation. Two weeks later, a wider re-resection was performed; the specimen (6.0 × 6.0 × 3.0 cm), resected deeply to the corpus spongiosum with shaving up to the urethra, showed no residual tumor. Staging PET/CT was notable only for an incidental left thyroid nodule (29 × 27 mm, SUV 4.9; TR3 on ultrasound). After 16 months of surveillance, metastatic disease developed in liver segment VI and the L1 vertebral body. Systemic ifosfamide/doxorubicin (6 cycles) produced no response in the liver lesion. He subsequently underwent hepatic resection of segments V and VI with cholecystectomy. New pulmonary lesions later emerged; therapy included pazopanib and stereotactic body radiation therapy, followed by gemcitabine/docetaxel (3 cycles), dacarbazine (2 cycles), and pembrolizumab (2 cycles), with continued progression. He was transitioned to palliative care and was lost to follow-up. Overall, this case represents a primary penoscrotal synovial sarcoma with SS18 rearrangement and an aggressive, treatment-refractory course despite two surgical resections and multiple systemic regimens.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 28-year-old Moroccan active-duty military male, BCG-vaccinated and without alcohol or tobacco use or relevant comorbidities, presented after 5 weeks of progressive abdominal pain maximal in the epigastrium and right hypochondrium, accompanied by fever, chills, profuse sweats, anorexia, and weight loss. On admission, he had SIRS with T 39.1 °C, HR 124 bpm, RR 22/min, and right hypochondrial tenderness with hepatomegaly; pulmonary exam and superficial lymph node survey were unremarkable. Laboratory data showed neutrophil-predominant leukocytosis (17,800/mm3) and markedly elevated CRP (323 mg/L), with normal lipase (38 IU/L), troponin (4 ng/L), LFTs (ALT 22 IU/L, AST 17 IU/L, GGT 42 IU/L, ALP 115 IU/L, normal bilirubin), PT 78%, albumin 39 g/L, normal electrolytes and renal function, LDH 231 IU/L, and beta-2 microglobulin 2.28 mg/L. Procalcitonin was 4.1 ng/L. Infectious workup including blood and urine cultures during febrile peaks, HBV/HCV/HIV and syphilis serologies, Quantiferon, GeneXpert on biopsy material, and three consecutive morning sputum examinations for mycobacteria were negative. Chest radiograph and abdominal ultrasound were unrevealing.\n\nCross-sectional imaging demonstrated non-specific focal hepatic lesions. Thoraco-abdomino-pelvic CT showed hepatomegaly (liver long axis 17 cm) with multiple, well-circumscribed rounded hypodense lesions lacking post-contrast enhancement; largest lesions were in segment I (21 × 16 mm) and segment V (36 × 27 mm). No suspicious thoracic or pelvic lesions were identified. Initial echo-guided liver biopsies showed subacute fibro-inflammatory changes without specific histology or malignancy. Liver MRI revealed a dysmorphic liver containing lesions with heterogeneous T2 signal, a hyperintense T2 rim, and peripheral enhancement after contrast; the largest lesions were in segment I (20 × 22 mm) and segment V (33 × 31 mm). No deep lymphadenopathy was seen on CT or MRI. Diagnostic laparoscopy with targeted biopsies demonstrated epithelioid and multinucleated giant-cell granulomas of varying size with caseous necrosis, confirming focal hepatic tuberculosis.\n\nTreatment followed a standard anti-tuberculosis regimen: Phase 1 with isoniazid, rifampicin, pyrazinamide, and ethambutol once daily fasting for 2 months, followed by Phase 2 with isoniazid and rifampicin once daily fasting for 4 months. Clinical and biological improvement occurred within days, with resolution of the inflammatory response. At 3 months, control CT showed a decrease in both number and size of the hepatic lesions. This case underscores that focal hepatic TB can present with non-specific hepatic nodules on imaging and often requires histopathologic confirmation when microbiological tests are negative.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "An 18-year-old man came to the emergency department with new chest pain, fever, shortness of breath when lying flat (orthopnoea) and a dry cough for several days. Initial tests showed an elevated troponin, diffuse ST-segment elevations on ECG, and an enlarged heart on chest X-ray. Transthoracic echocardiogram (TTE) showed severe concentric thickening of both ventricles and a pericardial effusion; Coxsackie A and B antibody titres were also positive, so clinicians initially treated him for viral myopericarditis with anti-inflammatory medications. Despite treatment he acutely worsened on day four, becoming hypotensive and short of breath; repeat TTE showed impending cardiac tamponade and he underwent pericardiocentesis. The procedure was complicated by a pulseless electrical activity cardiac arrest, and he required intubation and venoarterial extracorporeal membrane oxygenation (VA-ECMO) for circulatory support. An endomyocardial biopsy did not show inflammation, and blood testing found a very high Epstein–Barr virus (EBV) PCR. A separate biopsy of a small painless mass on his right arm unexpectedly showed EBV-positive natural killer/T‑cell lymphoma. With a working diagnosis of lymphoma involving the heart and pericardium, he was started on systemic chemotherapy (initially an emergency regimen followed by modified lymphoma protocols). After treatment his heart function steadily improved: ejection fraction recovered to normal range, the pericardial effusion resolved, and the abnormal myocardial thickening decreased. He completed most planned chemotherapy cycles and continues follow-up with cardiology and oncology.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 59-year-old man with type 1 diabetes came to the hospital with heart failure. A heart ultrasound showed big clumps of germs stuck to two heart valves, the mitral and the aortic valves. His blood test grew a germ called Staphylococcus warneri. This is a kind of staph that usually lives on the skin and is normally harmless. Doctors found he had an infection on his own heart valves (native valve endocarditis). He later had surgery to replace both the mitral and the aortic valves. Looking back, small lab changes and weight loss that began about four months earlier may have been early warning signs. He had not been on immune-weakening medicines and did not have any implanted medical devices.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 52-year-old man was transferred to a tertiary center after a tonic-clonic seizure. Initial radiographs confirmed a serious right shoulder injury and also revealed a previously missed simple posterior dislocation of the left shoulder. Follow-up CT scans of both shoulders showed bilateral posterior fracture-dislocations, indicating that the left shoulder had worsened during the hospital stay. He underwent a single-stage open reduction and internal fixation of both shoulders using locked plates. The left shoulder later required two additional procedures: one to address failure of the initial fixation (osteosynthesis failure) and another arthroscopic procedure to release a stiff joint. At two years, his recovery was favorable: QuickDASH showed 5% disability, and Constant scores were 72 on the left and 76 on the right.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "We report a rare case of euthyroid unilateral GO with early massive mono-muscular fibrosis in a 50-year-old male. Family history included cardiovascular disease, type 2 diabetes mellitus, and myasthenia gravis, with no family or personal history of thyroid autoimmune disease. He smoked 20 cigarettes/day since age 30 and had longstanding dyslipidemia. Beginning June 2020, he developed rapid, progressive right orbital soft-tissue swelling, pain on ocular movements, eyelid redness, and diplopia; visual acuity was initially normal OU. In October 2020, examination showed active right orbital inflammation (CAS 3/7) with moderate eyelid edema. Palpebral fissure height was 14 mm OD and 10 mm OS. Hertel exophthalmometry was 24 mm OD and 18 mm OS. There was severe limitation of elevation, persistent depression in primary position OD, and constant diplopia per the Gorman score. GO-QOL was reduced in both subscales, with a greater decrement in function (12.5) than appearance (50) on a 0–100 scale. Color vision by Ishihara was 16/17 OD and 17/17 OS. CT (contiguous 1.25 mm slices, 200 mA, 120 kV, pitch 0.5) demonstrated severe enlargement of the right inferior rectus to the tendon insertion; all other extraocular muscles were normal OU. The muscle–orbit area ratio OD was 0.25 AutoCAD units (vn ≤ 0.20 ± 0.03). Thyroid function was normal with slightly increased TSH-R-Ab at 1.75 mU/L (n.v. < 1.5 mU/L). Electrophysiology showed a slight reduction in p100 amplitude OD. Thyroid ultrasound displayed a thyroiditis pattern. Hematologic and systemic evaluations were negative. Routine labs were unremarkable aside from dyslipidemia (total cholesterol 220 mg/dl, triglycerides 297 mg/dl, HDL 38 mg/dl).\n\nTreatment with intravenous corticosteroid pulse therapy (methylprednisolone; cumulative 4,500 mg over 12 weeks) resolved inflammatory signs and symptoms; however, GO-QOL, Hertel exophthalmometry, and diplopia remained unchanged, and both visual acuity and electrophysiology worsened. As second-line therapy, two-wall orbital surgical decompression plus parenteral glucocorticoids was performed. Intraoperative biopsy of the right inferior rectus revealed massive fibrosis with adipose tissue infiltration.\n\nThis case exemplifies euthyroid unilateral GO with isolated inferior rectus involvement and early fibrotic transformation despite only mildly elevated TSH-R-Ab, producing a profound motility deficit and constant diplopia that was refractory to IV steroids and required bony decompression.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "You developed a month of productive cough, ear pain, and a long-lasting pus discharge from the right ear. Tests showed tuberculosis bacteria: the direct smear for acid-fast bacilli (AFB) was positive in a gastric aspirate (stomach fluid) and in a swab of the pus from the right ear. This supported TB affecting the middle ear, with likely lung involvement.\nYou were treated with standard anti-tuberculosis therapy for 6 months, along with supportive care. The treatment cleared the infection, and you made a complete recovery.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "This story is about a 4‑month‑old baby girl from an Indigenous community in rural Panama. The nearest clinic was three hours away by canoe. She was not getting enough protein and calories. She suddenly had bad diarrhea. She got very dehydrated, like a plant without water. A probiotic medicine called Enterogermina was given at the start. She was moved to a large hospital. She arrived breathing hard. She was in shock, which means her blood was not carrying enough to her organs. A blood test found a hard‑to‑treat germ called MRSA. A stool test found a germ called C. difficile that can cause diarrhea. Later blood tests from her arm and from a central line found Bacillus clausii. Doctors tried many antibiotics, but the germs did not respond. Her organs began to fail. She died 12 days after she got to the hospital.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 19-year-old man had a painful lump in his left scrotum for 8 months. Doctors removed the left testicle. Lab tests showed the lump was from TB in the small tube behind the testicle that carries sperm. Scans showed the TB germs had also spread to his lymph nodes, lungs, chest wall, and his bones and joints. He started TB medicines. After 4 months, he had seizures. A brain scan showed small TB lumps in his brain. The doctors kept the TB treatment and added seizure medicine. He got better, and his scans looked better too.", "literacy_label": "low_health_literacy"}
{"generated_text": "A 20-year-old Arabic male martial artist had 5 weeks of left hamstring pain after a sports injury and did not improve with medications or physiotherapy. Hamstring syndrome was ruled out, and he stopped all sports during recovery. Intervention: a modified slump mobilization (a seated nerve-gliding technique) was performed with four repetitions on 3 consecutive days, along with postural retraining. Outcomes: Pain on the numeric pain rating scale improved from 5/10 at rest and 7/10 with activity to 2/10 at rest and 4/10 with activity by day 3. The Knee Society Score also improved: pain from 22 to 61 and function from 30 to 80. At 2 months, he reported complete symptom resolution and returned to sports without limitation.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 23-year-old man came to the emergency department with a sudden severe headache, nausea, vomiting, and chest heaviness. His initial vital signs showed high blood pressure and a fast breathing rate. An emergency ECG showed a heart attack pattern (STEMI), so he was urgently sent for percutaneous coronary intervention; the angiogram revealed normal coronary arteries. Further evaluation with a brain CT identified a cisternal subarachnoid hemorrhage (bleeding around the brain). Despite coordinated care by multiple teams, his condition rapidly worsened, leading to cardiac arrest and death.", "literacy_label": "intermediate_health_literacy"}
{"generated_text": "A 19-year-old woman presented with acute palpitations. The initial ECG demonstrated ventricular tachycardia with right bundle branch block morphology associated with left posterior hemiblock, and T-wave inversion in the inferior and precordial leads. Biomarkers were elevated (troponin 27 ng/L, normal <14 ng/L; NT-proBNP 2225 pg/mL, normal <130 pg/mL). She was admitted to the coronary care unit. Five years earlier, she had presented with cardiogenic shock due to fascicular ventricular tachycardia; CMR and a transoesophageal electrophysiological study at that time were inconclusive. She was discharged with a diagnosis of tachycardiomyopathy on ACE inhibitors, a mineralocorticoid receptor antagonist, and beta blockers, with an uneventful interval thereafter.\n\nDuring the current hospitalization, there were no further hyperkinetic arrhythmias. Basal 12-lead ECG was obtained. Echocardiography showed diffuse hypokinesia of both ventricles. CMR was again inconclusive, and an undiagnosed congenital cardiac anomaly was suspected. Cardiac computed tomography angiography (CCTA) was performed (GE Lightspeed, retrospective gating, 100 kVp, 696 mAs, gantry rotation 0.35 s, 0.625 mm slice thickness; 70 mL Iomeron 400 mgI/mL IV). The left main and left anterior descending (with a wide ramus intermedius and two diagonal branches) and a thin, non-dominant left circumflex showed no obstructive coronary artery disease. The right coronary artery ostium and proximal segment were absent (ostial atresia); the mid and distal RCA were supplied by a large collateral from the distal LAD that coursed around the lateral right ventricular wall, traversed the distal atrioventricular groove, and gave rise to thin posterior interventricular and posterolateral branches. A thin branch from the mid LAD to the sinoatrial node was also observed.\n\nIn the differential for cardiogenic shock in otherwise healthy adults, once acute myocardial infarction is ruled out on 12-lead ECG and cardiomyopathy is not demonstrated on CMR, CCTA is the modality of choice to evaluate for congenital coronary anomalies and other causes. In this case, an echo-stress test confirmed inducible ischemia in the inferior wall, concordant with the arrhythmic focus location. The patient was transferred to a specialist congenital heart disease center, where she underwent transcatheter radiofrequency ablation of sustained ventricular tachycardia arising from the posteromedial papillary muscle. She was discharged on acetylsalicylic acid and verapamil. At 6-month follow-up she remained asymptomatic, without recurrent arrhythmias.", "literacy_label": "proficient_health_literacy"}
{"generated_text": "A 36-year-old man had a painful lump where the penis meets the scrotum for five years. Doctors took the lump out with surgery. Lab tests on the tissue confirmed it was a tumor. He had a second surgery to remove more tissue. Even with these surgeries, the disease spread to other parts of his body. It kept getting worse even after trying different chemotherapy medicines.", "literacy_label": "low_health_literacy"}